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HomeMy WebLinkAboutBuilding Permit #360-16 - 431 BEAR HILL ROAD 9/21/2015 cSerf�✓�✓l,U y'Jzj/S� BUILDING PERMIT OF NORTH qw- LED /64 "YO TOWN OF NORTH ANDOVER 0_ y; '_ - o� APPLICATION FOR PLAN EXAMINATION Permit No#• D Date Received �gSSAc►+us���y Date Issued: ORTANT: Applicant must complete all items on this page LOCATION T ` �° /�/ 1�� �' i'I PROPERTY OWNER Print �QGIP��h P f� eall �— Print 100 Year Structure yes no MAP PARCEL: N ZONING DISTRICT--Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building X 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 WO TO BE PERFORMS :Arh�n C ( ., .11 9 &t'k-C L'4- T— /,LJ n Of fO b roy 2 7 l CA Identif]�catipn I- Please T e or Print Clearly OWNER: Name: Gt X�,1�_ �� - Phone: �� � � 4-C/ �t f Address: �L Contractor Name: SdA.,� IM k r-t?'') IfV Phone: Email: o1A DV,onPv ne Address: r J.&A-4 4 4 A c Supervisor's Construction License: f D ,� a '3 Exp. Date: 1 �_ Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT. $12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $-t ��� - FEE: $ 59 Check No.: u Receipt No.: NOTE: Persons contracting jWth unregistered contractors do not have access to',Lhe guaranty fund Signature of Agent/Owner ../ -tee_, ignature of contractor Location 2J No. , Date qb1hJ i . - TOWN OF NORTH ANDOVER • ��.�T,ED�6� e Certificate of Occupancy $ Building/Frame Permit Feer r Foundation Permit Fee $ ; Other Permit Fee $ TOTAL $ Check# to kZ- rt . '" � Building Inspector e, Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF 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_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS a ZPning 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 DPW Town Engineer: Signature: Street FIRE DEPARTMENT - Temp Dumpster on site yes Located 384 Osgood no Located at 124 Main Street Fire Department signature/date COMMENTS NORTH Town of Andover 0 10 No. h ver, Mass, a 1 45 OL^K§ 1• COCMICt1!WICK S U BOARD OF HEALTH Food/Kitchen PER IT T LD Septic System THIS CERTIFIES THAT ......... I4.0.. .k..4.0............. ... ......... BUILDING INSPECTOR y� 11 11'� Foundation has permission to erect ... .................. . buildings on ..: ..... ...:.!...1..!.1...... .... ....>..... Rough to be occupied as ........ 10...... �1 .. .........�........... Chimney provided that the person acce1pialhis ermit shal�fn eve res ect conform to the terms the a licationp p p p pp 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN MO THS ELECTRICAL INSPECTOR UNLESS CONSTRUC S S Rough Service ................................................................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. Page# of pages l. ---k ILA G r q- s '1J ( vi 4/aG s 7 L s PROPOSAL SUBMITTED T4< AC 1, ^� JOB NAME JOB# b ADDRESS /°J'n` G"(/ (/ f/r P JOB LOCATION t DATE DATE OF PLANS PHONE,# FAX# ARCHITECT e hereby submit specifications and estimates for: ....... _ .................... . ................... .... 7e propose hereby to furnish material and labor—complete in accordance with the above specifications for the sum of: Dollars LLwithpaymentsnts to be made as follows: d C U 6 / a v 6 /`i �� 11 or deviation from above specifications involving extra costs Respectfullyed only upon written order,and will become an extra charge submittedve the estimate. All agreements contingent upon strikes, delays beyond our control. Note—this proposal may be withdrawn by us if not accepted within days. Acceptance of Propoor The above prices,specifications and conditions are satisfactory and are , hereby accepted. You are authorized to do the work as specified. Payments will be made as outlined above. Signature Date of Acceptance Signature / A-NC3819/T-3850 09-11 The Commonwealth of Massachusetts Department of IndustrialAccidents d 1 Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le 'bl Name (Business/Organization/Individual): Cj<Z 4, f-(,/ V1 1) Address: r C CL<' C� .(` �� l /1�Q vim' /`�lc City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am.a employer with employees(full and/or part-time).* 7. 0 New construction 2.wl am a sole proprietor or partnership and have no employees working for me in 8. E Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t ❑ 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole ll.E]Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] *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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie./#: )/ / Expiration Date: Job Site Address: % ��H' �6i L/ 1N City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expi a ion date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify under the ains and penalties of perjury that the information provided above is true and correct. A Signature: 1A Date: X/<� Phone#: 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.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ® DATE(MM/DD/YYYY) AC� AC� CERTIFICATE OF LIABILITY INSURANCE 9/22/2015 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(ies) 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 Stephanie Morrissette NAME: p MTM Insurance Associates pHCN u Ext)a (978)681-5700 FAC Nol:(978)681-5777 1320 Os good Street E-MAIL ADDRESS: p ste haniem@mtminsure.com g INSURERS AFFORDING COVERAGE NAIC# North Andover MA 01845 INSURERA:Travelers Casualty Ins Co of 19046 INSURED INSURER B John Morrissey INSURER C: 57 Concord St INSURER D: INSURER E: North Andover MA 01845 INSURER F: COVERAGES CERTIFICATE NUMBER:15-16 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MMIDDIYYYY MM/DD/YYYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE �OCCUR DAMAGE TO RENTED 300,000 PREMISES Ea occurrence $ 680208957331542 6/18/2015 6/18/2016 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY FI PROCT ❑ LOC PRODUCTS-COMP/OP AGG $ 2,000,000 X JE OTHER: AIOI $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER _FT' TH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) This certificate of insurance represents coverage currently in effect and may or may not be in compliance with any written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood St. ACCORDANCE WITH THE POLICY PROVISIONS. N Andover, MA 01845 AUTHORIZED REPRESENTATIVE P MacDonald CPCU, CIC ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025 onl4rrn I y Massachusetts Department of Public Safety Board of Building Regulations and Standards Construction Superiisor License: CS-105236 JOHN MORRISS9-V 57 CONCORD Sl; 011068445, NORTH ANDOVER Expiration commissioner 11/26/2015 &Business-TOR Regulation Office of Consumer Affairs CTOR ( HOME IMPROVEMENT CONTRA Type: �. Registration: 169543 DBA (l Expiration: 7/512017 JOHN MORRISSEY REMODELING' JOHN MORRISSEY ` ___ 57 CONCORD ST Undersecreta NORTH ANDOVER, MA 01845 ry i 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 zi 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) ❑ 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 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