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HomeMy WebLinkAboutBuilding Permit #119-14 - 41 CROSSBOW LANE 8/5/2013 (3) TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 3 L Permit N0: Date Received Date Issued: IMPORTANT: Applicant must com Tete all items on this page LOCATION Print PROPERTY OWNER Print 100 Year Old Structure yes no MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One 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: Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: CONTRACTOR Name: Phone: Add ress: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCH ITECT%ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt No.: NOTE` Persons contracting with unregistered contractors do not have access to the guaranty fund SignatureYof Agent/Nvner Signature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Location No. Date • - TOWN OF NORTH ANDOVER • ED Certificate of Occupancy $ Building/Frame Permit Fee $7- Foundation Permit Fee "' $ Other Permit Fee $ TOTAL $ Check#5 Building Inspector J i Plans Submitted❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped &ns fl c TYPE-OESEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBodyArt ❑. . 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 1 HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit lUI'VV To";! Engineer: Signature: Located 384 Osgood Street FIREDEPARTiV E-AT Temp Dumpster on site yes no Loc ed at 124 Mair, Street Fire Departmerit signature/date 3 COMMENTS Dimension Number of Stories: Totals square feet of floor area based on Exterior dimensions. q sons. 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-$1000fine NOTES and DATA— (For department use I I El Notified for pickup - Date E Doe.Building Permit Revised 2010 I Building Department The fol,,-awing is-a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ ` Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy'of Contract ❑ Floor',Plan Or Proposed Interior Work ❑ 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 ❑ 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) ❑ 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) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ 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 casts if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apw-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submAted with the building application Doc: Doc.Building Permit Revised 2012 Enter construction cost for fee cal - North Andover Fee Cakulation Construction Cost 4000.00 m $ - $ 456.00 Plumbing Fee $ 57.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 57.00 Total fees collected $ 670.00 I 41 Crossbow Lane 119-14 on 8/5/2013 Kitchen Reno, Bath Renos r I I I I NORTH own Of . t ndover 0 . - I rev No. _ t -�. I s h , • 3 h 1 ver, Mass, � l A- COC MICMl WICK 7�AERATED 0'P�`�,�5 S U BOARD OF HEALTH Food/Kitchen PER LD Septic System THIS CERTIFIES THAT .... ... .. .. .... .. �.�V, ,,,,,,........................... BUILDING INSPECTOR ....... ..... ........ ..................... has permission to erect . buildings on q.(.........C.. . � ,.., Foundation ............. ...... ... .... ................ • Rough on OeA to be occupied as .........C�. ... ......... 4 ..... ......................................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI STS Rough ' Service .............. ... .... ....... ............................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildin, Rough Display in a Conspicuous Place on the Premises — Do Not Remove _ _ Final No-Lathing-or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE di Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 152306 Type: DBA Expiration: 8/16/2014 Tr# 229906 JK CONSTRUCTION - JOSHUA KOLINSKY 24 WINSOR LANE TOPSFIELD, MA 01983 Update Address and return card.Mark reason for change. Address F-] Renewal F-] Employment F-] Lost Card SCA 1 0 20M-05/11 / VILG'�Q171.%JLQOLLl1G'CCGCIL Q�VGGCL.I9LGClLCGJG'LGJ Office of Consumer Affairs&Business Regulation License or registration valid for individul use only 0ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: 0JExpiration: egistration: 152306 Type: Office of Consumer Affairs and Business Regulation 8/16/2014 DBA 10 Park Plaza-Suite 5170 Boston,MA 02116 JK CONSTRUCTION JOSHUA KOLINSKY 24 WINSOR LANE TOPSFIELD, MA 01983 Undersecretary ANotali without signatu s � .o KOZ/L 1.190 iauolssiww00 i uol;ealdx3SL £t$610,VW Q'Ialdsclo L o I� 3N"2IOSNIIM bZ -� sxuiox r vamor — - 0601760-S3 :asua3r-1 — -- lost,uadnS uoqPni;suoj spiepue}S pue suol4eln6a8 6uipling;o pjeog kja1eS oilgnd 10 luaw1jeclaa- s:49snyoesseW i Ae�bP CERTIFICATE OF LIABILITY INSURANCE °A'E'M"'°°'y""' 7/30/13 THIS CERTIFICATE IIS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS 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 policy(es) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statemert on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER COT NEAC Water Street Insurance Agency PHONE 781 245-0888 Fax N 27 Water Street MAIL ADDRESS: Wakefield, MA I 01880 INSURERS)AFFORDING COVERAGE NAIC# INSURER A:Arbella Protection INSURED INSURERB:LibertV Mutual Joshua Kolinsky INSURER C: dba JK� Construction INSURER D: 24 Winsor Lane INSURER E: Topsfield, MA 01983 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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 AFFORDED 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. EV LTR TYPE OF INSURANCE AWL SUBR pOUCY NUMBER MUD EFF MN DCyWYYYY LIMITS A GENERALLIABILITY 8500043790 7/21/13 7/21/14 EACH OCCURRENCE $ 1,000,000 X COMMERCIALGENERAL LIABiLITY DAMAGE TO RENTED $ 100,000 CLAIMS-MADE FX-1 OCCUR MED EXP(Arryone person) $ 5 000 PREMISES(Ea occurrenC4 PERSONAL&ADV INJURY $ 11000,000 GENERAL AGGREGATE $ 2.000,000 GEN'L AGGREGATE LIMITAPPLIES PER PRODUCTS-COMP/OPAGG $ 2,000,000 }( POLICY PRO- LOC $ AUTOMOBILE LIABILITY Ca .INE�SINGLELI IT $ ANYAUTO BODILY INJURY(Per pehson) $ ALLOWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS ,AUTOS (P.'.. er aoddeM UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAO CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATIONWC231S349239028 7/27/13 7/27/14 WRC OTH- AN DEMPLOYERS'UABILRY y/N IM1I. _ ANY PROPRIETOR/PARTNER/EXECUTNEE.L.EACH ACCIDEW $ 100,000 OFFICE RMEMBER ExCLLDED? 7 N I A (Mandatory in NH) I E.L.DISEASE-EA EMPLOYEE. $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Rerre*s Schedule,if mors spew Is rsghlred) The Workers Compensation policy does not provide coverage for Joshua Kolinsky thong Pelusi 41 Crossbow In North Andover MA 01845 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood St North Andover, MA 01845 AUTHORIZED REPRESENTATNE Carmen Cocca ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: The Commonwealth of Massachusetts - Department of Industrial Accidents Office of Investigations U1 600 Washington Street Boston,MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organizationflndividual): Address: //I/%,b al- !h , Phone 1 one#: / 3 75 City/State/Zip: / 6l 7�8'a -96 71 Are�u an employer?Check the appropriate box: Type of project(required): 1.M I am a employer with 4. ❑ I am a general contractor and I 6. ew construction employees full and/or part-time).* have hired the sub-contractors � p )• 2.❑ I am a sole proprietor or partner- listed on the attached sheet.1 7• Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for in any capacity. workers'comp.insurance. g• E]Building addition [No workers comp.insurance 5. ❑ We are a corporation and its required.]' officers have exercised their 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. o workers'comp. c. 152, 1(4),and we have no Y [N p § 12.E]Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] 13.❑Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tcontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. I / Insurance Company Name:. / Y Policy#or Self-ins.Lie.#: //l �L�/- 9 �D Expiration Date: 7o'? Job Site Address: I W ef�®5'.S Di✓ 4/7< <City/State/Zip: r d � Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP.WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of&DIA.for insurance coverage verification. I do hereby certi un er the pai a penalties perjury tliat the information provided above ' true nd correct. Signature: Date: Phone#: PlAel / O? __�1 6 71 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - i Contact Person: Phone#: Information and Instruction's . Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,. express or implied,oral or.written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone numbers)along with their certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)withno employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial bAccidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should e returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be-sure-that-the affidavit-is-complete-and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.:Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a,dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please'do not hesitate to give us a call. The Department's address,telephone and fax number: I Tho CoMznOnmalthofJ\4assachvs#S Department ofZndustdal Accidents Office of Imstigations 600 Washington Street Boston,MA 02111 Tel,#617-,727-4900 ext 406 or 1-877,MASS.Ak'B Revised 5-26-05 Fax#617-727-7749 WWwanass,govfdla MASSACHUSETTS CON'T'RACT JIB CONSTRUCTION 44 Loomis Street, #305, Maiden, MA 02148 Federal Identification Number: N/A HIC Registration Number: 152306 CS Number: 94090 Salesperson(if applicable): Homeowner information (hereinafter"Owner"): i Q twrh v PGL41J (enter name,address,phone number&,"r of Owner) WORK TO BE PERFORMED AND MATERIALS TO BE USED The Owner hires the contractor to perform the following:� Ll�JQ M5 7� �L-' /-e mo Ve / / p A/�d Gc�tO�d �r�I?�S. xq l-/I.t G G �i Ct-n (� 4e)vlase S�iO�r" tvn � 7 jn MaS�"��` U�IAI ® / iQGp A, �� u�vr>d S �n /t�Ia Sft'r- ,d ti �i Gt�I� 4911-1�/dp/ 4 4- Materials"expected .Materials"expected to be used: Type: 1A 6IkU7f Brand: �'�S�/yt, Grade: A1,71 Type: Brand: Grade: Type: Brand: Grade: Type: Brand: Grade: The follovving schedule shall be adhered to unless circumstances beyond the Contractor's control shall arise: Work Scheduled to Begin: / 3 Expected date of Completion: 115-11a? (substantially completion) TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE The Contractor agrees to perform the work, furnish the material and labor specified above for the SUM of: $ W Payments will be made according to the following SCHEDULE: $ � 1) at signing oLhis ontact /$ 750 Due on or upon completion of dv h >° �GfT�' ,ou bin$ S"7l Due on or upon completion of n ,rA $ 50 upon completion of the contract In order to meet the completion schedule, the following material/equipment must be special ordered before the contracted work begins: ITEM: f-he At, Li /,�pof-S COST:$ _Due on_zA 5 ITEM: COST: $ Due on ITEM: COST:$ Due on DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES DOwner fonitractor Date: Date: 7MDII.3 You may cancel this agreement if it has been signed b a art thereto g g lace other than an address Y party p of the seller,which may,be his main office or branch thereof,provided you notify the seller in writing at his main office or branch by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing of the agreement. See attached notice of cancellation for an explanation of this right. Affiliated Law Offices of Michael Monteforte and Steven A. Grant I ' REQUIRED PERMITS The following permits are reiced. It is the oblig tion of the contractor to obtain such permits as the,owner's agent. d�`�''v, (- NOTE: Owners that secure their own permits or hire unregistered contractors shall be excluded from access to the Guaranty Fund provisions of MGL c. 142A. Is an EXPRESS WARRANT /YesY being provided by the contractor. No NOTE: All home improvement contractors and subcontractors shall be registered and any /C inquiries about a contractor or subcontractor relating to a registration should be directed to: Director, Home Improvement Contractor Registration, P.O. Box 871 Taunton, MA 02780-0871 508-821-9375. Unless otherwise noted in this document, the contract shall not imply that any lien or other security interest has been placed on the residence. ARBITRATION The contractor and owner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract, the contractor may submit such dispute to a private arbitration Oservice which has been approved by the Office of Consumer Affairs and Business Regulation and the c sumer shall be required to submit to such arbitration as provided in M.G.L. c. 142A. ontractor, Owner Date `3d�3 Date NOTICE: The signatures of the parties above apply only to the agreement of the parties to alternate dispute resolution initiated by the contractor. The owner may initiate alternative dispute resolution even where this section is not signed separately by the parties. ACCELERATION OF PAYMENT Homeowner's Financial Insecurity: A Contactor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. Contractor's Financial Insecurity: In instances where a contractor deems him/herself to be financially insecure, the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal from said account would require the signatures of both parties. No work shall begin prior to the signing of the contract and transmittal to the owner of a copy of this contract. No work will commence nor materials ordered prior to three days from the signing of this agreement. If payments are not made by the Owner and received by the Contractor by the due dates set forth in this agreement, the Contractor g shall charge interest on the balance overdue at an annual interest rate of twelve percent(12%). In addition, if said payments are not made when they become due, the Owner agrees to pay all costs and expenses of collection, including reasonable Attorneys Fees. tractor Owner ate 30 3 Date Affiliated Law Offices of Michael Monteforte and Steven A.Grant