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HomeMy WebLinkAboutBuilding Permit #53-15 - 40 PATRIOT STREET 7/16/2014TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO:6�� I / Date Received Date Issued: -I-- r / (4 IMPORTXNT: Applicant must complete all items on this page LOCATION qa /-a4 T/L 7 s z- Print PROPERTY OWNER �i' 047-J P1./ Print 100 Year Old Structure yes no MAP NO: PARC ZONING DISTRICT: Historic District yes no Machine Shop Village yes _ o TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building Vr ne family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: . '11Z1 /0 ®I�� � �' � ��/��' �5- jelr- 4ga F US;,Aa4�g, Zed t� Identification Please Type or Print Clearly) ' OWNER: Name: 1 J4 ,01- co in7zu Phone: 92V F.A TO-rrtz M CONTRACTOR Name: N,12', CU��'x-r. VIS -57 AIZi-- Phone: Address: �L2t/e J4 bvILLG i''7- 144Z-- s7,4 . Supervisor's Construction License: ©J ©o/;? -Ig Exp. Date: Home Improvement License: 7 Exp. Pate:%` ARCHITECT/ENGINEERS Phone: Address: Reg. No FEE SCHEDULE: BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASEDD�ON $125.00 PER S.F. Total Project Cost- $ FEE: $ Check No.: Receipt No.:�" NOTE: Persons contractin# withlynregistereA contractors do not have access to the guaranty fund Signature of A 6 6 of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE_OP SEWERAGE DiSPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc... ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM ..DATE REJECTED DATE -APPROVED PLANNING & DEVELOPMENT' ❑ ❑ COMMENTS _CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: - Com Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Tow; Engineer: Signature: FIRE -DEPARTMENT -Temp Dumpster on site Located at 124 Mair Street Fire Departinerit signature/date COMMENTS Located 384 0 no Street Dimension Number of Stories: 7t— Total square feet of floor area, based on Exterior dimensions._ Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A -F and G min.$100-$1000.fiine NOTES and DATA — For department use EI Notified for pickup - Date i Doc.Building Permit Revised 2010 Building Department The following i94 list of the retluired.forms to be filled out for the appropriate. permit to be obtained. Roofirg, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses o- Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) o Building Permit Application o Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses Li Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o Mass check Energy Compliance Report ❑ Engineering. Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cans if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the aprn>al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.tted with the building application Doe: Doc.Bui?ding Permit Revised 2012 E i J LLI = LL cc Q co L L L1 y—i "a O LL ate+ N N i -r O0 a)_ N cl: O 1.1 CL Z a m O O a+ m C 7 LLL to O o W T N :E U LL O CL Z Z co G d Op O w LL cc O CL Z o NJ Op O K U i V) LL 0 IA N Q L t10 �' LL W Q w LU LL N L m 6 Z �-+ N N a+ Q Y O Ln (x W Q V V • _ Q h 1NG' ���Q� j V y S 21 w H � C 00 O CL CL ca S .� J � Z v CL ^N^ i..� L H Q : p0 M.0 •� L 4 CL (L) ma O, . (� E N d (x W Q V V • _ Q h 1NG' ���Q� j V y S 21 w H � C 00 O CL CL ca S .� J � Z v CL ^N^ i..� The Commonwealth of.114"assach.useft , ` - �]►e�aY€�nen�o�'Xnc��c,��rccrAcczc�en�� Office o, flnvestigateons< 600 Washington. Street Noston, MA 02111 avww.mass govldia wo rkexs' Compewation Ymuurance Affidavit: BuRdergiContractors)Electr icians ltbI nbex.0 .Applicant WoranPlease Prim Legibly ' Nama (Bust essiorgani'zaiionli &idud):�. f CUs Toll-" .Address' City/Statc[Z p: W L _ r2l A 0 / 0'd 7 Phone 4:, ( 7 61Z Ar yo an exngloyer? Check the appropriatehOM Type oifproject (required): f 1.�/f I am a ex�aployex VMh / 4• ❑ 1 am a general contractor and 1 6• Q Now construction, _ r employees (fullandloxpattthne) * have 19redthe sub -contractors listed on the attached sheet. 7• Remodeling 2. Q I am. a sale proprietor or paxiner ship and`havena•employees These sub -contractors have 8. [] Demolition worldug forma lamcapacity. workers' comp, insurance, 5. ❑ We are a corporation audits 9. ❑ Building addition ENO workers' comp. insurance officers have exercised.their 10 1( Electrical repairs or additions required.] 3. [] X am a hom eownex doing all work right of exemption per MGL 11. [(Plumbingxepairs or additions myself: �(o workexs' comp. c. 152, §1(`I), andwehaveno 12,Roofxepairs [] insuxauceregaixed.� i employees. [N'owoxkers' 13,[i Other comp. insurance required.] �!Auyapplicanitfiat checks box#�musialsoIlourthesecfionbeldwshowingtheirwbrkers'compensatzonpolzcymfomnataon. Homeowners Who submit this affidavit Indicating they go doing anwork and then ae outside contractors mus, submit a new affidavit indicating such. TCoutcactors tTiat cheAthis bei must attached an, additional sheet showing the name of the sub-eontractors and thekworkers' comp. policy information. I am an employer that isprovidiftg workers' compelasation insr�ra�tce, formy employees Be 0 as thepaXicy andjob site ire, fox�matior2. r _ Iusurance Company Name: 4kv�g exi-, Policy # or Selz ins. Lic. #: �U �- 3 `� �i0y 3 —Z'/yExpiration.Date: ` % 1/ lob Site Address: L/ D �A-T �� T S 7 Cityistateizip: Attach a copy of tie workers' coznpensatioxt-policy declaration gage (sbowing-tlte polfcy )nu:mber and eXpiratioa date). yailure to secure coverage as xequired.under Section M ofMGL o.152 cart lead to the imposition, of erhuIalpenalties of fine up to $1,500.00 andlor one�yeax hnprisoa�mexttx as well as civil penalties in the form of a STOP WORD ORDER. and a fma ofup to $250.00 a day agaiastthe =violator. Be advised that a copy ofthis statement may be forwarded to the Office oP- Investigations of the DTA for ibsurance coverage verification. .ado hereby certifyodV iiepaA andgnatties o perrury tltatMe infarmadon provided above zs true and eorrect _ a I Oficial use o 1y..Do not Iplite in 911s area, to be conWleted by city or toxin official. City or Town: PermitiLzcens€ # Issuing.Anthority (circle one): 1. Board of Health 2. guffdingDepartment 3. CitylTown Cleric 4. Electrical Inspector 5. Plumbing Inspector 6. Other - Information and Instructions Massachusetts General Laws chapter 152.req*es all employers to provide workers' compensation for thejx employees. Parsuarit io this statute, an ernployee is deffned as `°...every person iii the service of another under any contract ofhi a,• express orimplled, oral ovwrifien." .lin. ewwfayer js defned as "an individual; partnership, association, corporation or otherlegal entity, Or anytwo oxxnore of the foregoing engaged in a joint enterprise, and including fire legal xepxesentaiives of a: deceased employer,, or the receiver o ' ft2istee of au individual, partnership, association or other legal entity, employing employees. 1t6ever the owner of a dwelling house having notmore than thtee apartments and who xesides therein, or the o coupant of the, dwelling house of another who employs persons to do maintenance, Consfraction ox repair work on. such dwelling house or Onto grounds or building appurtenant thereto shallnot because of such, employment be, deemed to be an employes." MGL chapter 152, §25C(6) also states that "every state or to cal He -easing agency shall withhold the issuance or renewal of a license or permit to operate a business or to constmet buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required:' Additionally; MCL chaptex 152, §25C(7) states "Neitherthe eommonwealthnox any ofiis political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have beenpresented to. the coartracting authority." Applicants Please fiat out the workexs' compensaiion affidavit completely, by checlang ilio boxes that apply to your sitaation and, it A6cessary, supply sub-contractor(s)name(s), address(es) andphonenumber(s) along with their cerbixcate(s) of Insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees otTrer Chart the members orpartners, arenotrequiredto caxtyworkers' compensationinsurance. T, ,0. oxLLP doeshave employee9,apOJ1cyzsxequ1red. Be advised that-Ei affidavit may be submitted to the Department of Tudustial Accidents for confrmafion of insurance coverage. Also be sure to sign and date the affidavit. the affidavit should be.retunedto the city or town that the application for theperorit or license is being regao ted, zrot the Department of industrial Acoidents. Should you have any questions regarding trio law or if you are xequired to obtain, a *01kers' compensation policy, please call the Department at the numberJistedbelow. Self-insured companies should enter thoir self insurance license number on the appropriate Iine. City or Town O£dclals Please,besuxethatiheaffzdavifiscompleteandpxintedlegibly. The, Department has provided a space at the bottom of the, affidavit fox you to flit out in the event the Office of Investigations has to contact you regarding the applicant. Please be -sure to fll in the permit/license number which-WM be used as a reference number; In addition, an applicant fhatanust submitmultiple permit/license appRoations is any given year, need only submit one afCdavit indicating current policy infoxmntion (ifnecessaMy) and under "Yob Site Address" the appiicant shouldwrite "01110 Ga9OM in (city or tawir)" .A copy o£the affidavit that has been offfcialty stamped or marked by to city ox town may be provided to the applicant as pt'oofthat a valid affidavit -is' on fiie fox future permits or licenses..A new aitxdavit must be filled out each Year, Where a.home owner or citizen. is obtaining alicense ox permitnotrelatedto anybusiness orcommercial ventuxe (i.e. a dog license orpermit to burn leaves eta.) saidperson is NOTmquired to complete this aftzdavit. The Office of In-vestigatfona would like to thank you in advance for your cooperation.and should you have any quesi'tons, please do not hesitate to give us a call. The Department's address, telephone and faxnumber.- na CQn moilw�a�t o Mas ac ?v lf� - J)PTaxtMOtt QVIIA11SWRI Accident.- ()fficc o j]rnve-diigaaova do Was gtot Stroa 13 ogon�, M -A 02111 Ro,*ed 5 26-05 � ACC>RD CERTIFICATE OF LIABILITY INSURANCE DATEIMMID000YYYYI 4/23/14 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER TMS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the poljcy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statment on thi s certificate does not Confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER lgore Insurance Agency N NAME: -- PHONE F►X 5 Centennial Drive nut E�a1 197 81 531-6550 i IA1C Not• (978) 531-9442 E ar1AiL ADDRESS; Peabody, MA 01960 ,,,____.INSUgER!$IAFFORDIN000VERAGE ._NAIC9 -_ i MED EXP (AMor* prlSQfl)...._..$ INSURERA_WQSteLTI 4TQr1Gi InLT eranne..... INSURED . INSURER,B:SafetvInsurance Compny a New England Custom Design - I SURFgc_Travelers.,Propert�r 6•.•Casualty Ron Weinberg . CEN'L AGGREGATE I -MIT APPOES PER POLICY PRO- I--'ECTi 226 Lowell Street / Unit S4 -A )NSy(tER off.. _..._._._.__....._._. .... ,�____ _. Wilmington, MA 01887 INSURER E: ---_--.._----...._.__..... ...... 13 bIIVCRAUtJ CERTIFICATE NUMSFR: I?wlclnu ulweee. - - -- ---- r• ,•VIS, VC. R. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFOROEO BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INYR'. TYPE OF INSURANCE IAOOLISUBRI POLICYWUMBER MMIppryEP I OdYEXP1 LIMITS A GENERAL LIABILITY Y NPP1349227 3/14/141 3/14/15; EACH OCCURRENCE S 1 ODO OOO r. X COMMERCIAL GE NE RALLIAB4ITY I DAMAGE TO RENTEDI ( PREMLSESIf:P.Qcwriow)_ . .r_._._ .. . I•,5 50.1.000_ CLAIMS MADE ;__. XJ OCCUR . I I i MED EXP (AMor* prlSQfl)...._..$ ---•1 —. -.. ._-- i 1 PERSONAL & ADV INJURY E 1,000,000 GENERAL AG GREGATE S 2,.0.0_0•`000_ . CEN'L AGGREGATE I -MIT APPOES PER POLICY PRO- I--'ECTi I PRODUCTS • COMPlOP AGG i _..._..._.�_. .E $ 2 , QOO OOO . `._.__._. L� j 13 AUTOMOBLLELLABIUTY y 5054921 4/5/14 4/5/15IN NGLELIMR I jEa_accipen) I E ANY AUTO NED AUTOS x AUTOS ` BODILY INJURY(Perperson)ALL BODILY BODILY INJURY(PerxnnengI - IE 250,000 l E 500 OOO NON -OWNED HIRED AUTOS AUTOS I r••_..... __.... epe __ _L _. _....... S _ i�tlaYnli�uJU+GE l•{ cc 1001 000 _ UMBRELLA LIAROCCUR EACH OCCURRENCE : E EXCESS LIAB CLAIMS•MAUE; _.....----....... __ . _ ..... AGGREGATE E DEO RETENTIONS C WORKERS COMPENSATI ON AND EMPLOYERS* LIABILITY 7PJUB-0239N23-•2-14 3/lA/16 3/14/15' WCSTATU• j01'N• I x. WC ST I Y /N ANY PROPRIETORIPARTNERIEXECUTTVE � OFFICER"EMBGRE%CLWED7 I NIAI MITS ER E_L_EACHALGOENf .. $ 100.00_0__ (Mardaarry .n NH) ':.j liyc:.deviocundcr I E.L:DISEASE • EA EMPLnYlG ZOO 000 L�_ DESCRIPTION OF OPERATIONS below I F L DISEASE . POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (AMaoft ACORD 101, Additional Ro(mrks Schedule, if more spore is reghi red) CERTIFICATE HOI nFR SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Kilgore (D 1988,2010 ACORD CCRPARATInu AC;OKD 25 (2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: (978) 774-0718 E -Mail; NEW ENGLAND CUSTOM DESIGN, INC. 226 LOWELL STREET WILMINGTON, MA 01887 #978-658-0881 Home Improvement Contract Registration No. 102467 ROOFING AND SIDING AGREEMENT This is a legally binding contract. Make sure you read this Agreement and understand it before signing it. Do not sign this contract if there are any blank spaces. NOTICE: All home improvement contractors and subcontractors, unless specifically exempted by Massachusetts law, must be registered with the Commonwealth of Massachusetts. All inquiries about registration should be directed to: DIRECTOR - HOME IMPROVEMENT CONTRACTOR REGISTRATION One Ashburton Place, Room 1301 Boston, Massachusetts 02108 Telephone: #617 727-8598 ds Agreement is made on ��oi % 20 IV by and between New England Custom Design, Inc. (hereinafter, "Contractor") J owner%�I/(7lit ��rT'n/ (hereinafter, "`Owner'), of v / Town 42N AtV Ear) Vr/Z State?77cf _ Zip (H) Phone )Address ("The Premises') -4 U �/i /D % �t (W) Phone sv Roofing will be on applied only on slope roof surfaces below, over present roofing shingles unless specified - under REMARKS. Z MATERIAL , /C� ( dYlto�-2 :;,C)l4 Color G �YJ (�� T_ Main Roof Ve.-S Bay Windows Al 71 Extensions fJ/air Porches:Front /TJ%ct e_ Side Its- -C Rear _JIV-" ° _- Other Roofs JLlC3411-r- NOTE: Roof board replacement cost 3. F -c1' per foot OR s39-0-1 per 4' x 8' sheet of inch CDX plywood. EN ARKS / EXTRAS: Missing or defective lumber is not included in any category of work unless specified here. J?r, Md L, j -S 7/ fi .ii'.v tlr .t•a, ✓�7 di fJs�'`Ii9�f S �tivrL�S-1kJp�/�C i/ S COSI �S ,Y� -� J t c II e P ly7iwec4 '778' The Conrractm-agreess to pet form in a good and workmanlike manner all work detailed above. CASH PRICE $ DOWN PAYMENT $ 2 O U -� Note All Roofing Customers PAYABLE ON START OF WORKS J -/ New England Custom Design Inc.,will not be held"responsible for dusrand debris falling to t PAYABLE S — attic areas diriiniroofrig installation. Please PAYABLE ON OMPLETION$%mI remove or cover valuables DATE:/off% 20� RIGHT TO CANCEL . 'he Owner may cancel this agreement if it has been signed by the Owner at a place other than the address of the Contractor, which maybe his main office or branch thereof, provided that the Owner .obfies the Contractor in writing at his main office orbranch by ordinary mail posted, by telegram sent orbv delivery, not later than midnight of the third business day following the signing ofthis Agree- nent. See attached Notice of Cancellation. A cancellation fee representing 30% of the contract price will be in effect if cancellation is requested after the legally allotted time has elapsed. "he Owner hereby certifies that he has read this Agreement, that the terms and conditions and the meaning thereof have been inedto him, and that he fully understands them and that there is no mderstanding between the parties, verbal or otherwise, than that which is contained in this Agreement, and agrees iha said Cont actor is not responsible nor bound by any representations not con - a, dint Agreement, mtb of its agents, unless the same be reduced to writing and signed by the Cont ctor. ON HO OD&NSIG�N���ANY BCZs��� 5o` % n 'sSignaturea[e N England Date owner's Signature Date a Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration NEW ENGLAND CUSTOM DESIG Val Lanza 226 LOWELL ST. WILMINGTON, MA 01887 SCA 1 G 20M-05/11 V le (pOWjin2o�ZlU6Clt�/2 O�C-/(�LCGIJCLCf2GlQe Q Office of Consumer Affairs & Business Regulation ME IMPROVEMENT CONTRACTOR egistration: .102467 Type: ,j xpiration - 7/2/201-6Private Corporation NEW ENGLAND CUSTOM DESIGN;41 `INC. Registration: 102467 Type: Private Corporation Expiration: 7/2/2016 Tr# 252411 Address and return card. Mark reason for change. tress F-1 Renewal F-1 Employment ❑ Lost Card License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, MA 02116 Val Lanza 226 LOWELL ST. WILMINGTON, MA 01887 " Undersecretary Not valid witho� nature Location 6C I No. �e— Date r v TOWN OF NORTH ANDOVER Certificate of Occupancy f. $ Building/Frame Permit Fee ` $r Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check#!2Q--%- I v 2. J J 0 V uilding Inspector