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Home My WebLink AboutBuilding Permit #385-11 - 42 SUMMER STREET 11/4/2010 L TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: �c7 J Date Received Date Issued: ! IMPORTANT:Applicant must complete all items on this page LOCATION `) L 50 W\M-f _ S+ Print PROPERTY OWNER l�5 Print MAP NO:(�_C_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 _ Wetlands '� . g- - Se tick Welh 0 Floodpl�a W hed D strict . _ p t - �- _ � DESCRIPTION OF WORK TO BE PERFORMED: 94 W1Ov2 S,`d;1 V4 i n%ICI W Identification Please Type or Print Clearly) �t r V-s c t Phone: q- B' OWNER: Name: e at _;.. Address: 10 r'oAPv. �� sac� AIS CONTRACTOR Name: M f Phone: Q7 S23 e�s� Address: Cvnc®rA Qcc�,4 Al Supervisor's Construction License: Exp. Date: Home Improvement License: L) Exp. Date: ARCHITECT/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: $ / �d O FEE: $ C)/6) Check No.: Receipt No.: 3 6 Zi� NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund nature of contractor` 4:_,.? ; T) j Signature ofAgent%Owner .,r ,:3, w_ .--g -=---3_-- --- Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ I E WERAGE DISPOSAL ❑ Swimming PoolsTannin assa eBod Art ❑� g Y❑ Tobacco Sales ❑ Food Packaging/Sales ❑c 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: Comments Conservation Decision: i Comments Water & Sewer Connection/Signature&Date Driveway Permit j 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 COMMENTS -- - -- li 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.$10041000 fine NOTES and DATA— For department use 1 LJ r Notified for pickup - Date Doc:.Building Permit Revised 2008 ] r t 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 ❑ 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 d 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 j Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products 40TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit n all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals S that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording lust be submitted with the building application Doc: Doc.Building Permit Revised 2008mi Location No. Date r p NORTH TOWN OF NORTH ANDOVER F A 9 41 Certificate of Occupancy $ s''•°'t<�'MUS Building/Frame Permit Fee $ 611 U r AC Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # f �� 23658 Building Inspector NORTH TONM of nati .: nr� 6 Andover . P0 No. 15 o -o , dover, Mas � s., • 1 (� �J COCMICMEWICK �t�- LAK � '7 ADRATE D '9S V BOARD OF HEALTH Food/Kitchen Septic System 'PERMI T D BUILDING INSPECTOR THISCERTIFIES THAT.......... OI .. .. . .............................. ...... ...I.44.4l........................................... ........................... Foundation has permission to erect........... ......... ................ buildings on ...... ... i.......is%N11!.../.n!!!..................!�.................. Rough to be occu ied as...�.� %doos.... �1��.�........ Ih� �.....�.f�.1�! ... n p ..�.... . ............... ....... ....... J.......... provided that the person accepting this ermit shall in every respect conform to the terms of the application on 14wo Final 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final a, PERMIT EXPIRES IN 6 MONTHS ' . ELECTRICAL INSPECTOR UNLESS CONS N ARTS Rough Service ...... B SPECTOR Final Occupancy Permit Required t0 Occupy Building GAS INSPECTOR Rough I 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 ro Page# of pages Pposal q3 � Cori fi VA Pr poral Submitted To: eJob Name Job# �. -2V'i Addre s C Job Location Date Date of Plans Fax# s Architect We hereby submit specifications and estimates for: -.-_ _ 4C:X kk III We propose hereby to furnish material and labor —complete in accordance with the above specifications for the sum of: 'i $ cz�d 0Dollars with payments to be made as follows: Any alteration or deviation from above specifications involving extra costs will Respectfully \�►� be executed only upon written order,and will become an extra charge over and submitted above the estimate.All agreements contingent upon strikes,accidents,or delays \ beyond our control. Note—this proposal may be withdrawn by us if not accepted within 3 U days. &Aruptaurr of Proposal The above prices,specifications and conditions are satisfactory and are l hereby accepted. You are authorized to do the work as specified. Signature Payments will be made as outlined above. i Date of Acceptance d ' Z¢Z - 6 Signature I NC3819 ACORD. CERTIFICATE OF LIABILITY INSURANCE 1DATE( NYYY) 0/2 MIDD 10/27/2010010 PRODUCER (978) 686-2266 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION NORTH ANDOVER INSURANCE AGENCY INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR M.J. FOSTER INSURANCE SERVICES ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 163 MAIN STREET NORTH ANDOVER MA 01845-2508 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A MERCHANTS INSURANCE GROUP M & P Siding, Inc. INSURER B:HANOVER INSURANCE 43 Concord Street INSURER C: INSURER D: Dracut MA 01826— INSURER E: COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DULPOLICY EFFECTIVE POLICY EXPIRATION LTR NSRD TYPE OF INSURANCE POLICY NUMBER DATE MMIDD DATE(MMIDDIM LIMITS A X GENERAL LIABILITY CCPI041467 09/10/2010 09/10/2011 EACHOCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED ce 500,OLIO PREMISES Ea occurten $ CLAIMS MADE Fx--1 OCCUR / / / / MED EXP oneperson) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY JECT Loc B X AUTOMOBILE LIABILITY ADR8634388 03/16/2010 03/16/2011 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 1,000,000 ALL OWNED AUTOS / / / / BODILY INJURY $ X SCHEDULED AUTOS (Per person) X HIRED AUTOS / / / / BODILY INJURY $ X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ RANY AUTO / / / / OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY / / / / EACH OCCURRENCE $ OCCUR FICLAIMS MADE AGGREGATE $ $ DEDUCTIBLE / / / / $ RETENTION $ WC $ WORKERS COMPENSATION AND / / / / TORY ATH7 ER EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNER/EXECUTNE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? / / E.L.DISEASE-EA EMPLOYEE$ If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION (978) 688-9500 ( ) — SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT TOWN OF NORTH ANDOVER FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE 120 MAIN STREET INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE NORTH ANDOVER MA 01845- UTHO �T\�a�� J� ommomzwaa Office of Consumer Affairs and Efusiness Regulation 10 Park Plaza - Suite 5170 M Boston, Massachusetts 02116 Home Improvement C n�;tr ytor Registration Registration: 143178 Type: Private Corporation Z Expiration: 6/22/2012 Tr# 299673 M + P SIDING , INC. M PETER GAMACHE 43 CONCORD RD DRACUT, MA 01826 Update Address and return card.Mark reason for change. lfJ Address r-] Renewal [-] Employment F-] Lost Card DPS-CAI 0 50M-04/04-GG11001216 �� OfficeYoum r"ffair�s" Bri�incs" 'li°on License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: .143178 Type: Office of Consumer Affairs and Business Regulation Expiration: 6/22/2012 Private Corporation 10 Park Plaza-Suite 5170 -- - Boston,MA 02116 SIDING, IN7r a! PETER GAMACH€,, 43 CONCORD RD -`Yx., -= % DRACUT,MA 01826'-�'e'J i-;e% Undersecretary Not valid without signature 9090£ :#J1 �auoi�snuiun, Z I.OZ/9Z/9 :uogendx3 �� £9160 VVY '11383dd3d 1S alb'3H OL 38f1�13e 2j a313d i Z6L SO :asuaal-1 asue.adl josflAjadlGnS uoa;arnijsuoO sp.rr.purls pill.. suoilrin„ali ,Wippnfl jo p.rrofloil iPJVS 311tlrnd .Irl lrraurl rncdad -sllatint{»ntir.l,, CERTIFICATE OF LIABILITY INSURANCE DATE(0/27/2 10 ioi27izoio THIS CERTIFICATE IS ISSUED AS A NATTER 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 HOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), 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 Albert A Daigle CompanyNAME' YMORE FAY 313 Willard Street 4A/C. No. Ent)° (NE•No): E-KAIL Dracut, MA 01826 ADDRESS: PRODUCER CUSTOMER IDN. INSUREDS) AFFORDING COVERAGE NATC A INSURED M & P Siding Inc INSURER A: A.I.M. Mutual Insurance Cc INSURER B: 43 Concord Rd INSURER C: Dracut, MA 01826 INSURER D: SII INSURER E: INSURER P: 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 IN, 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. POLICY NUMBER POLICY EFT POLICY EXP LIMITS OF INSURANCE ,n/aa/r*Tr, mna/rrn, GENERAL LIABILITY EACH OC CURANCE 6 �COMMIIIIAL GENERAL LIABILITY DANA PE TO DENTED CLAIMS MADE OCCUR 6 PRIMISCS(Ea.oceorrence) ❑ MLD E]IP (Any one pexaon) 6 PERSONAL G ADV INJURY 6 ❑ GEN'L AGGREGATE LIMIT APPLIES ER: GENERAL AGGREGATE 6 ❑POLICI PROJECT❑LOC PRODUCTS- COMP/OP AUG 6 6 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ❑ANY AUTO (ea acc idem) 6 � ALL OWNED AUTOS BODILY INJURY (Per Person) 6 F-15CHEDULED AUTOS BODILY IMJURY(Per amidmt) 6 HIRED AUTOS PROPERTY DAMAGE I Per—Id—t) 6 ❑NON-OWNED AUTOS ❑ 6 � 8 ❑UMBRELLA LIAD ❑ OCCUR EACH OCCURRENCE 6 DEXCESS LIAD CLAIMS MADE AGGREGATE 6 i �DPDVCTIBLE 6 ❑RETENTION S 8 WORKERS COMPENSATION ® vc srcn- OTIF AND EMPLOYEES LIABILITY ton LD[ITs 'ER THE PROPRIETOR/PARTNERS/ EXECUTIVE OFFICERS ARE E.L. EACH ACCIDENT 6 100,000 A ❑ incl ® excl 7015664012010 03/20/2010 03/20/2011 C.L. DISEASE -EA EMPLOYEE 6 500,000 E.L. DISEASE -EA EMPLOYEE 6 100,000 CGMMENTS DESCRIPTION OF OPERATIONS OR LOCATIONS: PETER GAMACHE IS NOT COVERED BY THE WORKERS' COMPENSATION POLICY MICHAEL LEVESQUE IS NOT COVERED BY THE WORKERS' COMPENSATION POLICY CERTIFICATE HOLDER CANCELLATION TOWN OF N ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE 1600 OSGOOD STREET POLICY PROVISIONS. N ANDOVER, MA 01845 AUTHORIZED REPRESENTATIVE I 3822 The Commonwealth of Massachusetts ' Department of Industrial.Accidents Office o fInvestigations 600 Washington Street Boston,MA. 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Colntractors/Flectricia>ns/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): 1A4 4 ? �j Th C, Address: 1_1 Cu r\c®.r City/State/Zip: Q se C-R, Phone#: q,f, 323 - `151 ( Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New,construction ,�(employees(full and/or part-time).' have hired the sub-contractors 2.LI 1 am a sole proprietor or partner- listed on the attached sheet.z 7 Remodeling . ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance S. ❑ We are a corporation and its 10.F1 Electrical repairs or additions required.] officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance -required.] employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 7 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lam an employer that isproviding workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: I�rr� OG`5I e Co Policy#or Self-ins.Lie.#: -7 0 15 a I ZO 10 Expiration Date: �5- 2 0 1 It Job Site Address: "I Z 43t)(A rn'r City/State/Zip:A r Ax f�m-1c r Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under 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 the DTA for insurance coverage verification. X do hereby certify under the pains andpenalffes ofperjury that the information provided above is true and correct. A44Si ature: � V�'Vlr, Date: Phone# l $ i2. 9 5 b 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.City/Town Clerk 4.EIectricaI Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: