Loading...
HomeMy WebLinkAboutBuilding Permit #815-15 - 431 JOHNSON STREET 4/16/2015BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 1 Permit No#: I� Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION '"t3GY�YI PROPERTY OWNER a a-i,y 4A--...rnXr 1—' pV/Ag�; Print / 100 Year Structure yes MAP PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes V LED �0? b� r1' 6 Old oK *� no no no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building IS -One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial IN Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification - OWNER: Name: W�axU \C), Address: 931 S' a- +nu ne.. Contractor Name: 2 014i M Type or Print Clearly Phone: -)K 4:93-3�a-°__- 101 J Address: �t.3 I R � '�"Untk ,� Nd�-�-, �n dv�✓ � C1)�` � Supervisor's Construction License:. 9q 3D6 Exp. Date: I 16.1 Home Improvement License: 4 S wcl - Exp. Date: `1 µ ` ARCHITECT/ENGINEER Address: Phone: 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: $ 60.O C FEE: $-- Check No.:t_ Receipt No.: /__ 10 11 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor 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 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 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. ❑ Permanent 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 Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes F ','Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: FIRE DEPARTMENT - Temp Dumpster on site yes Located at 124 Main Street Fire Department signature/date COMMENTS Located 384 Osqood Street W 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 NU I t5 and UA I A — (1 -or department use ❑ Notified for pickup Call Emai Date Time Contact Name Doc.Building Pen -nit Revised 2014 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 NV I tJ and UA I A — (1 -or department use ❑ Notified for pickup Call Emai Date Time Contact Name Doc.Building Pennit Revised 2014 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. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS Reviewed On Signature_ Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes P `Planning Board Decision: Conservation Decision: Comments Commen Water & Sewer Connection/Signature & Date Driveway Permit 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 BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: I� /I Date Received I f Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION H3 I Joy\Mon S 3•Z y�,.�._ _ b OL o - � h 4_ riu < < PROPERTY OWNER - �� Print 100 Year Structure yesfMAPPARCEL: 6ZONING DISTRICT:Historic District yeMachine Shop Village ye TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building IN. -One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ,N Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑Septic ❑ Well ❑ Floodplain ❑ Wetlands 0 Watershed District ❑ Water/Sewer OWNER: Name Address: 431 DESCRIPTION OF VVOKK I U bl= trtrc1-UK1V1r-U: Identification - rt I \ o"% rouU Type or Print Clearly Stmt MIA W � 1 i'RtO nZ Contractor Name: Phone: C1_)Yb3 Address: 9t lJc nJ 3 N �f+t /t v�✓ �(� C}1 � 5 Supervisor's Construction License: Clq 3,N Exp. Date: Home Improvement License: 10 4 , V1 Exp. Date: —1 -14 ,1 b ARCHITECT/ENGINEER Phone: Address: Reg. No E FEE SCHEDULE: BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ 00 FEE: $ Check No.: C!'�" Y� Receipt No.: 1,--3 4 - NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor 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 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 Location 4 J 1 No.0(�-, 1,5 Date TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee $ Foundation Permit Fee $�_ Other Permit Fee $ M TOTAL $� i Check # �� v Building Inspector Z\. The Commonwealth of Massachusetts " = Department of Industrial Accidents Office of Investigations 9V- 600 Washin ton Street V., .: - floston, AIA 02111 ivww.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Orgaaizatiorr/Individual): D M 1 O C AJ S R I C6Vt RO b F UN 6 a J i A 1 N 6 INC_. Address: � 31 R Su -rr o N S-1 RE L 7 UN l i 5A City/State/Zip: No, A Nboti e r,, W 61W__ :Phone #: Are you an employer? Check the appropriate box: I am a employer with 1 4. F1 I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- ship and have no employees working for mein any capacity. [No workers' comp_ insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.1 5. F-1 We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees_ [No workers' comp. insurance required.] 1 03 &ado Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. F1 Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.,g] Roof repairs 13.❑ Other *Any applicant that cbecks 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. =Contractors 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: o p Y �12FlN 1TE ►A jC INJU ttiNcc Co Policy # or Self -ins. Lic. #: W CL) 0 39 19 q J 3 Expiration Date: I d 15 Job Site Address: `131 J o ku-s' S ISG r City/State/Zip: K - A [\L41Y M�i 0 If �Y 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 fonvarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Sigmature: C Date: Phone #: �A 3 A oW Official use only. Do not write in this area, to be completed by city or town official City or Town: Pcrmit/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 #: A&CERTIFICATE OF LIABILITY INSURANCE gilt)/20114 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 Susan Donnell NAME: Eastern Insurance Group LLC 233 West Central St PHONE(800)333-7234 'FA No: AE-MAODREIL r .sdonnell@easteninsurance.com INSURERS AFFORDING COVERAGE NAIL p Natick MA 01760 INSURER A Western World Insurance Co INSURED INSURER B.Commerce Insurance Company 4754 INSURERCGranite State Insurance Co. David Castricone Roofing b Siding Inc, DBA: INSURER 0: 231 Rear Sutton Street, Unit 3A INSURER E: /6/2015 North Andover MA 01845 1 INSURER F: COVERAGES CERTIFICATE NUMBERMaster 14-15 REVISION Nt1MRFR- 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. )NSR LTR I TYPE OF INSURANCE ADDL INSR SUER WVQ POLICY NUMBER POLICY EFF MWDO/YYYY) POLICY EXP IMWDDIYYYYI LIMITS GENERAL LIABILITY EACH OCCURRENCE S 1,000, 000 A X I COMMERCIAL GENERAL LIABILITY CLAIMS -MADE Fx_1 OCCUR NPP1388404 /6/2010 /6/2015 DAMAGE T ELATED PREMISES Ea occurrence5 50, 000 ME D EXP (Any one person) S 1, 000 PERSONAL d ADV INJURY $ 1,000,000 Lf—,I L GENERAL AGGREGATE $ 2,000,000 �N'L AGGREGATE LIMIT APPLIES PER: X I Fol-CY 17 JrCT PRG n LOC I I PRODUCTS - COMP/OP AGG b 2,000, 000 S B I AUTOMOBILE LIABILITY II 1 ' NY AUTO ALL OWNED SCH n1.ALr1OS X AUTOS X EDULED I NON -OWNED ;IREOAUTOS X AUTOS �I I /1/2014 8/1/2015 � „ EOMMBIINQ O SINGLE LIMIT S 1,000,000 BODILY INJURY (Per person) S BODILY INJURY (Per accident) S PROPERTY DAMAGE Per accident S S II UMBRELLA UAB EXCESS LIAR I OCCUR CLAIMS -MADE EACH OCCURRENCE S AGGREGATE $ I C i I I I i DEO I I RETENTIONS WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I N IvVY FROPRIc OR/PA.RTNER/EXECUTIVE os=;C_RAAEMSEA EXCLUDED) (Ma. -Crory in NH) II yes. oesaix under OESCRI?710N Or OPERATIONS below NIA WC003989723 /23/2010 /23/2015 , S WC STATU- OTH- I PR E.L. EACH ACCIDENT $ lOO OOO E.L. DISEASE - EA EMPLOYEE 3 100 000 E.L. DISEASE - POLICY LIMIT S 500,000 IDESCRIPTION OF OPEPAT1pNS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule. A more space is required) Roof:ing & siding contractor I TE CANCEL SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE astricone ftofing & Siding THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Unit 3A ACCORDANCE WITH THE POLICY PROVISIONS. 231 R Sutton Street AUTHORIZED REPRESENTATIVE North Andover, MA 01845 John Koegel /MET ACORD 25 (1010105) ©1988-2010 ACORD CORPORATION. All rights reserved. IAIS025nn:mvn, Tho Ar:ARn Ffnma an`I Innn oro roniglnror� mar4e of Ar.nQn Massachusetts - Department of Public Safety Board of Building Regulations and Standards tandards Construction Sulmr-N isur Slrcrialth License: CSSL-099358 �,,�_ DAVID T CASTRI�ONE �'- 31 COURT STREET NORTH ANDOVER MA�'O18 5 Expiration Commissioner 12/16/2015 n��e �anrrrrrrrarcrrll� a/C?/lj`rrdicir�u�e(rJ Office of Consumer Affairs & Business Regulation b OME IMPROVEMENT CONTRACTOR l' registration: 104569 xpiration: 7/14/2016 Type Private Corporatie DAVID CASTRICONE ROOFING, SIDING & David Castricone 231 R SUTTON ST SUITE 3A NORTH ANDOVER, MA 01845 Undersecretary Town of North Andover Building Department 27 Charles Street Noah Andover, Massachusetts 01845 (978) 688-9545 Fax (978) 688-9542 DEBRIS DISPOSAL FORM ,ao►:rh � 96 0 O .. L C'SAC Iu5e In accordance with the provisions of MGL c 40 s 54, and a condition of Building permit 4 the debris resulting from the work sliall be disposed of in a properly licensed solid waste disposal facility as defined by MGL cl 1, sl 50a The debris will be disposed of in /at: tS e, ,, AW Facility location Signature of Applicant Date NOTE: A demolition, permit from the Town of North Andover must be obtained for this Project tluough the Office of the Building Inspector,