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HomeMy WebLinkAboutBuilding Permit #520-15 - 415 CHESTNUT STREET 12/3/2014+� Permit NO: 6v, Date Issued. I 11th LOCA PROF MAP Nu V 10PARCEL:UA � ZONING DISTRICT: Historic District Machine Shoo BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received IMPORTANT: Applicant must complete all items on this oaae yes no yes I no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 11 New Building .-..'One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement 0 Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed:' District ❑ Water/Sewer Sera A vV r / � 1 fl J G -- OWNER: Name: Address: CONTRACTOR Name: Identification Please Type or Print Clearly) Phone: Address: cl I V ��, L �� MGY)c s-tc'< �. 1 Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: �1 ARCHITECT/ENGINEER Phone: - Address: Reg. No. 'y FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ L FEE: Check No.: ��' Receipt No.: `3iL i NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund I I` BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received 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 thers:❑ ❑ Others.- ElDemolition ❑ Other ❑ Septic []Well ❑'Floodplain pWetlands ❑ 1N6tershed District ❑ WaterlSewer DESCRIPTION OF WORK TO BE PERFORMED: Identification - Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name:. _ ,,Phone:- Address- Supervisor's 'Phone:- Address:Supervisor's Construction .L-icense:._. _ Exp. Date: Home Improvement License: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BOLDING 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 Signature of Agent/Owner_ ' Signature of contracubr .� Location' 'S2�- 121�i No. Date t�l Check # 2,321 TOWN OF NORTH ANDOVER a Certificate of Occupancy $ _ Building/Frame Permit Fee $ Is 3'N Foundation Permit Fee $ Other Permit Fee $ TOTAL $ i� Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Type aF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature CONSERVATION COMMENTS HEALTH COMMENTS e Reviewed on Signature Reviewed on Signature S Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comm Conservation Decision: Comments a Water & Sewer Connection/Signature & Date Driveway Permit ,o' DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT Temp ,Dumpster on site yes no Located at 124 Main Street Fire`Department signature/date da COMMENTS Dimension Number of Stories: 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 fine NOTES and DATA — (For department use ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits o 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/Cross Section/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) o 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 o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Building Permit Revised 2014 v C y n O Z N CD O 'O CL = 5O cm to .a o vCD cD o CL c 2 CD CD O CD Q. O CD CC C I � v z (D O CD C C Z Z rm cn - X Z cn --1 X ;a m O Z N ro z G7 N M: 0 C 0 0� O O 2 O yam,°<� N N •a -Di O m n o 0=Q0 = z o' rt 0,0 rn N CD o : CD 2 3CL S. = 3 CL :! 0 Q (A r6 al , DCD CD � 'rt • °_�'�� O 0' c •� 3 n CD CL Ga.0°s' O C_ i � In ID n m s 2)D r�oj W�� D � O CD 0 O .r O O "'F �D CD Now. L m !dw o' QP A = n � _rt t11 O : A. CL O Z m ;a (n 7' m (Dti, NCo m `-r Z T :)o w 3 T m N c n = m S T °-' X T °- (") 7 m m wc S T a d p N n N v T a n m v D z O m fm1 700 r m M n vZi m 0 C W H n 0 C v z G1 Nv 11 0 rD 3 N 3 W A v O m r x 1 Department of Industria! Accidents Office of Investigadons ' 600 Washington Street Boston MA 02111 www. massgov/d11a Workers' Compensation Insurance Affidavit: Builders/Contractors/Electridans/Piumbers Applicant Information �„Ilease Prtnt�bl, 4 Name 'City/State/Zip: N c'-Gr�V,,0-C \A 06'Pho e #: Co3 - g6d " 7(35.5. Are you an empidyer? Check the appropriate boa: 1. ❑ I am a t:mployer,, ►ith 4. 0 I am a general t ontracmr and I employees (lits/ and/or part-time).* have hoed the mib-contractors 2. ❑ I aan a sole proprietor or parmer- listed ori the atmehed sheet t ship and have to employees. These sub-contracwrs have for me in any capacity. workers' comp. insurance. .working (No workers' camp. insurance- 5. 0 We are a corporation and its required.].. officers have exercised their- ) . ❑ I am a homeowner doing all worst right of exemption per hrIGL. myself. (No workers' comp. c. 152, §44), and we have no insurance required.] t employees. [No workers' comp. iastirance req*ed.] Type of project (required): 6. 0 New construction 7.- 0 Remodeling 8. 0 Demolition 9. (].Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13.N Other 7d V� *Any applicant that checks box i must also Sll out the sec don below showing thatrwottets' oetttpensption poiiayntfottnatioa . t Homaoweets who submit this affidavit indicatiug they an during all wvdt end then him outside wmteteots must submit a new affidavit indicating such. tContractots that cbeck this box mast atteched.bn additional sheat showing the name of the anb.00anacrora and their wotkets' map. policy Worts dos.. . I am an employer that is providing workers' c6mpens4don insurance for my empluyees:?Idow-is the policy and job site Information. Insurance Company Name: UC C hCA n S M �r CA' C11 . Lr) Policy # or•Self-ins. Lic. #: •y �� `�3�� Expiration Dhte: Job•Site Address: �1 �.�� C ��';_ Ciry/StatelZip: `' �'1cJ� U M C(. Attach a copy of the workers' compensation policy declaration page (showingthe police cumber and expiration dale). Failure to secure coverage as required undq Section 15A of NiGL c. -15Z can lead to the imposition of miminal penal ies of a fine up to S1,500.00 and/or ane -year imprisorgnent, as well as civil penalties in the form of a STOP WORK ORDER and a sine of up to 5250.00 a day against the. A-alamr. Be advised that a copy of this statement may be foiwardod.to the Office of Investigations of the DIA for insurance coverage verification. :I do hereby eertrft under the pains and penalties. of psdary that the information p ovfded%above- it &u- and correct Date: / J Of j kW use only. Do not write In this area, to be completed by city or town offleiat City pr Town: Permit/Ltcense.# . Issuing Authority (drde one): ' L.Board of Henittt. 2. Building-Departtaent 3. City/Town Clerk 4. Electrical Inspector S. Ptumbing Inspector 4. Other Contact Person: Pbane #t CHELMSFORD FIREPLACE CENTER, LLC 7 Summer Street CHELMSFORD, MA 01824 www.chelmsfordfireplace.com TEL (978) 256-6328 FAX (978) 250.9474 EMAIL chelmfire@aol.com TOAoa CUSTOMER EMAIL R�1 � I• � f"1 L �.. � h T E X30 D s� 21156 Cdr _ — � __ r'I J� 3�_�.___ S � ��--� R C.[��-2 5_ S.t i' t'ov h��—_— ______.-___ T — � J S• r 7SO, 217 TSL I\ No Refunds on Special Orders. No refunds after 30 days. Payment due upon time of order. — All dimensions given by customer are not the responsibility of C.F.C. permit!eesAQq additional pipe extra.Llj- Fireplace Width: 3"? % Height: aa- Depth: j i Rear Width: Rear Height: Customer Signature: .4CORor CERTIFICATE OF LIABILITY INSURANCE �� DATE (MM/DD/YYYY) 12/2/2014 THIS CERTIFICATE IS 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(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Germain Foy Insurance Group - Manchester PHONE(603) 641_8111 FAX (603)641-9869 1889 Elm Sto AIL INSURERS AFFORDING COVERAGE NAIC N Manchester NH 03104 INSURERAMerchants Mutual Insurance 23329 INSURED INSURER B: STEPHEN BRISSETTE INSURER C: 291 WEST ERIE STREET INSURER D: INSURER E: MANCHESTER NH 03102-5058 INSURER F: COVERAGES rFRTIFIrATF NI IMRFP-CL14117383RR 01:vleInkl Pit 110192GD• 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. INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MMIDD POLICY EXP MMIDD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1, 000 , 000 }{ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISE Ea occunence $ 500,000 A CLAIMS -MADE aOCCUR OP9097148 /11/2014 7/11/2015 M ED EXP (Any one person) $ 15,000 PERSONAL &ADV INJURY $ GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG $ 2,000,000 PRO -LOC T POLICY JFnT $ AUTOMOBILE LIABILITY dED SINGLE LIMIT 11000,000 (Ea BODILY INJURY (Per person) $ A ANY AUTO ALL OWNED XSCHEDULED CAPI040224 0/21/2014 0/21/2015 AUTOS AUTOS BODILY INJURY (Per accident) $ X X NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE Per accident $ x Comp $250 X Coll $500 Medical Expense $ 5 000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I I RETENTION $ A WORKERS COMPENSATION RVJCSTATU- 11T1- FIR AND EMPLOYERS' LIABILITYI YIN E.L. EACH ACCIDENT $ 500 000 ANY PROPRIETOR/PARTNER/EXECUTIVE A State NB OFFICERIMEMBER EXCLUDED? (Mandatory in NH) N/A KCAID33879 0/4/2014 0/4/2015 E.L. DISEASE - EA EMPLOYEE $ 500,000 If yes, describe under E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER rANcl:l I ATInN AGUKU 25 (TUTU/U5) 1 NS025 nm nn5i m ©1988-2010 ACORD CORPORATION. All rights reserved. Tho Arnpn n2mo znrt Innn aro ronictorart mnrlrc of Arnpn SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Paul Beasly ACCORDANCE WITH THE POLICY PROVISIONS. 415 Chestnut Street AUTHORIZED REPRESENTATIVE North Andover, MA Lisa Bisson/MM ACY AGUKU 25 (TUTU/U5) 1 NS025 nm nn5i m ©1988-2010 ACORD CORPORATION. All rights reserved. Tho Arnpn n2mo znrt Innn aro ronictorart mnrlrc of Arnpn Massachusetts -Department of Public Safety Board of Building Regulations and Standards comtructiun Supervisor Specialty License: CSSL-100468 ` �! Stephen A Brissette 291 W. Erie Street Manchester 1K O102 Altti i Expiration Commissioner 04/23/2016 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration STEPHEN BRISSETTE STEPHEN BRISSETTE 291 WEST ERIE ST. MANCHESTER, NH 03102 SCA t 0 2OM-05/71 V/te �panzo�ro�ztaerc�(�. af'��io:,ac�u�elt - Office of Consumer Affairs & Business Regulation ME IMPROVEMENT CONTRACTOR gistration: 152802 Type: xpi ration: 10/2/2016 Individual STEPHEN BRISSETTE Registration: 152802 Type: Individual Expiration: 10/2/2016 Tr# 258091 Update Address and return card. Mark reason for change. E] Address E] Renewal P Employment f—] 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 STEPHEN BRISSETTE 291 WEST ERIE ST. MANCHESTER, NH 03102 Undersecretary ' �� Not valid without signature