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Home My WebLink AboutBuilding Permit #96-15 - 439 WAVERLY ROAD 7/28/2014BUILDING PERMIT 0 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: ( �k U%1POkTANT: Applicant must complete all items on this page LOCATION ot tV_" NM-rvA Oft 0 t Print PROPERTY OWNER M 0 $4 A-� el el Phnt MAP NO: PARCEL: ZONING DISTRICT: Historic District yes 0 Machine Shop Village yes (�O TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential I New Building I I One family :1 Addition 0 Two or more family 0 Industrial ,6'Alteration No. of units: El Commercial 11 Others: :1 Repair, replacement 0 Assessory Bldg I Demolition I I Other D Septic E Well 0 Floodplain 0 Wetlands 0 Watershed District I _J Water/Sewer I I A "t t 4— Ix le r, Idendficadon Please Type or Print Clearly) OWNER: Name: (Y)0H*-n-qA-r Phone: '1-1 f -4 +4- - 4- -C Address: CONTRACTOR Name: jd1_711S__006:9'Phon I -q 7;? -c2 6 S- / 17 Address: Ll 307� Supervisor's Construction License: cy — Q -f 11SQ <� Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGI NEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT. $1Z00 PER $10oO.00 OF THE TOTAL ESTIMATED COSTBASED ON $125.00 PER S.F. Total Project Cost: $ —70, 000. 0 0 FEE: $ _3 60, 01) Check No.: It T12im ReceiptNo.: 2nKIL4- NOTE: Pei -sons contracting w*th unregistered contractors do not have access to the guaran fiund 7 signature of contractor "!3ignature of Agent/Owne,r.- BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received Date Issued: IMPORTANT: Applicant must complete all items on this LOCATION t%ORTH '0 ATED rED Print PROPERTY OWNER Print 100 Year Structure yes no MAP PARCEL- -ZONING DISTRICT Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Building 0 One family 0 Addition 0 Two or more family 0 Industrial 11 Alteration No. of units: 0 Commercial El Repair, replacement 0 Assessory Bldg 0 Others: 0 Demolition 0 Other El Septic 0 Well 0 Floodplain 11 Wetlands 0 Watershed District 0 Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification - Please Type or Print Clearly' OWNER: Name: Phone: Address: Contractor Name: Phone: I Address: Supervisor's Construction License: Home Improvement License: Exp. Date: Date: ARCH ITECT/ENGI NEER Phone: A 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 contraeting with unregistered contraetors do not have aeeess to tile guarantyfund — I- �, —1 9 3 )iqnature of Agent/Owner Si-qnature of contractor. f, Plans Submitted 11 Plans Waived El Certified Plot Plan El Stamped Plans F1 TYPE OF SEWER -AGE DISPOSAL Public Sewer Tanning/1\4assage/Body Art E] Swimming Pools El Well Tobacco Sales El Food Packaging/Sales El Private (septic tank, etc. El Permanent Dumpster on Site El 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 Planning Board Decision: Conservation Decision: ,Comments Comments Water & Sewer Con nection/signature & Date DrivewaV 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 Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensio hs. Total land area, sq. ft.: i 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 rnin.$100-$1 000 fine NOTES and DATA — (For department use LJ Notified for pickup Call Emai Date Time Doe.Building Permit Revised 2014 Contact N Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. I Roofing, Siding, Interior Rehabilitation Permits Building Permit Application Li Workers Comp Affidavit u Photo Copy Of H. 1. C. And/Or C. S. L. Licenses ci 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 u Building Permit Application ca Certified Surveyed Plot Plan u Workers Comp Affidavit Li Photo Copy of H. 1. C. And C. S. L. Licenses • Copy Of Contract • Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Pl' an And Hydraulic Calculations (If Applicable) • Mass check Energy Compliance Report (If Applicable) L3 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) u 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) Ej Copy of Contract u Mass check Energy Compliance Report Li 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 01f 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 43qLocation N o. 0 Date TOWN OF NORTH ANDOVER i Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $- TOTAL $ Check # ,27824 Building Inspector— Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 30,000.00 m $ - $ 360.00 Plumbing Fee $ 45.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 45.00 Total fees collected $ 550.00 439 Waverley Road 096-14 on 7/28/2014 Basement finish �md r L too MEMO I ui 0 0 ca ai -C u 0 0 Q) V) > Ln CL C) (A 0 F- u W z z co .2 m '0 C: = 0 L.L -C bo n o w (v a E -C U LL 0 u uj z z co tLo 0 -Fa U- cc 0 z -1 < u ui tio 0 CC W Y i� Q) Ln 0 u uj 0 z to z 0 w z ui ui LL co z (U a) Ln Q) 0 E tn a CL 0 0 E cn 0 0 0 (D Ajop r L od > CD 4) o r- (D > -0 0 0-0 E 0 0 z CL U) - = o w 0 > 00 CL -COL (D C-0 cn 0 r- E M-0 (D .2 co M: -03- o o 2 uj :E .2 w E C.) (D 0 -0 (D U) U) U) -0 04- c am YZ o " = 0 F- 4- CL 0 C.) E A) 0 0 0) (D 0 7 0 0 z 0 0 -7. cf) z 0 z Cl) Lu a- x Lu cn Lu LU -j CL z m oj c): uj IL (J)! Z.- 0 E 0 L- ce- 0 0 z 0 0 C 0 0 a. 0 CL CD < 0 CL 0 z 0 U) CL '7 141J.; Office of Consumer Affairs &' Business Regulation HOME IMPROVEMENT CONTRACTOR gistration: 51 Type: 22153 xPiration: 7/26/2016 LLC JOHN BERTHOLD CONSTRUCTION LLC John Berthold 15 POPLAR RD SALEM, NH 03079 Undersecretary Massachusetts - Department of Public Safety Board of Building Regulatlions'and Standards Construction Supervisor License: CS -054526 CHARLES E BE 10 PWEW00D Rb Salem NH 03079 Expi ration Commissioner 02117/2016 A ^^E2n r%%fW"L0,' CERTIFICATE OF LIABILITY INSURANCE r DATE (MM/DDNYYY) TYPE OF INSURANCE 1 07128/2014 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(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 E. 1. Wells Insurance Agency, Inc. Div of HUB International New England LLC 275 Great Road Acton, MA 01720 CONTACT -NAME: HONE FFAX _(PA N El): (978)392 -4567 (A/C, No): /C E-MAIL -ADDRESS: PRODUCER -CUSTOMER 10 INSURER(S) AFFORDING COVERAGE NAIC # INSURED _INSURERA: Acadia Insurance 11295 Target Construction, LLC -INSURER B : Union Insurance 14 Pinewood Road INSURER C: Salem, NH 03079 INSURER D: -INSURER E : AUTOMOBILE X INSURER F: COVERAGES CERTIFICATE NUMBER: 13-14 Still RFVIRION Nt]MRFR- 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 ADDLSUBR INSR WVD POLICY NUMBER POLICY EFF (MM/DDNYYY) POLICY EXP (MM/DDNYYY) LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY ICLAIMS-MADEFx_]OCCUR CPA 5133477-110 12/13/2013 12/13/2014 EACH OCCURRENCE $ 1,000,00( A AGE TO RENTED $ DREM MISES 2SO,00( MED EXP (Any one person) $ 5,00( PERSONAL & ADV INJURY $ 1,000,00( GENERAL AGGREGATE $ 2,000,00C GEN'L AGGREGATE LIMIT APPLIES PER: I—] POLICY [ X PRO- F JECT LOC PRODUCTS - COMP/OP AGG $ 2,000,00C $ B AUTOMOBILE X LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS CAA 5133479-10 12/13/2013 12/13/2014 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,00( BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ A — UMBRELLA LIAB EXCESS LIAB [X OCCUR CLAIMS_MADE CUA 5133480 -IC 12/13/2013 112/113/20114� EACH OCCURRENCE $ 5,000,00( AGGREGATE $ 5,000,00( — DEDUCTIBLE RETENTION $ $ 5,000,00( $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE _—] OFFICER/MEMBER EXCLUDED? r (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA OTH- ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ ICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) 7-28-14 Evidence of insurance CERTiFiCAT E HULUEM CANCELLATION Prem Shankar 439 Waverly Rd No., Andover, MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 1988-2009 ACORD CORPORATION. All riahts ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD \r ---2C2'0^- 22 O" ' - ---------''-------------�---22u-.--'' - --� ---�- - ' O C� O 4 1 ca A _ O E '. 0, * 0 0 m CL rt, oj� 0 0 m CL oj� 0 0 m CL Are yolx an employer? Check the appropriate Tbox: The Commonvealth ofHassachusetts LEI I am a employer with - 4. El lam a general contractor a -ad 1 6, New constractim Office ofInvesfigafions have ned the sub-confractors listed on the attached Bhoet. T 600 Washington Street ship and lava no - employees Boston., HA 02111 8. El Damolifim mmmuss.govIdla workeys, Compewation bsuxance Affidavit: ]3iiRderg/ContractorolElectricians�?li�mber,o kant W wation Apph o ENO workors, VOMP. jilsurauce Name pus�aosslorganizaflonadMduaD: 6 Address: �e- uty/Statelzip: J'r,. nolle w: Are yolx an employer? Check the appropriate Tbox: Type of project (reqidred): LEI I am a employer with - 4. El lam a general contractor a -ad 1 6, New constractim I employees (ffla�idloxpart-tima)-* 2. El I am a s oJD proprietor or p artner- have ned the sub-confractors listed on the attached Bhoet. T 7. Remodemig ship and lava no - employees These mlx- contractors have 8. El Damolifim worldng forma in, my capacity. woricors) comp. insurance. 5)1�rWeareacorporagonaudibq 9. El Building addition ENO workors, VOMP. jilsurauce officarshave extrcised.their 10.L] Electrical repaks or additions x quired.] I am a homoovinar dping aU work 3. Ela right of exemption P or MOL I.[] PImbiug repairs or addidons myself UT0Wqrk6!!8,,G0MP- c. 152, §1(4), andwahavano I E] Pwoft6pairs -2---- - hisurarlearegaired.1 T employe6a. [No workers, I is. n Oflier comp. insurance reqidred.] KAnyapplicaatthat below SJ1G-WMgMe.1rW0FKeM, compensationpuncymiounauuiL T-1romeownerawlLo sabmitlLgamdavitfiiffloattnitfieyk�dpingaUworKandthenWraout.-IderontractoramusLsubmiEano-waT:EdavitindicatffigtAich. TC0,rftaGt0rS that chcokthh box must attached p �Iddftlonal sheet Amingtho -nam ofthesu��-00&aGtorsandfheir-woikem'comp.poffoyfifonnation. I wn an emy foyer that isprovidhig workers' com a rm eW ees B iv epolle andl bsife ,pensationlusurane fo Y 10Y - c/o Y 0 infoxmadon. lusurance Company poliCy # or S Olf—iU. LIG. EXp1tat11D11DatG.. lob -Site Address, pityffitate/Zip: Attach a copy of (showing -the policynTauber and expiratlou date). yaijnrato secura coVaxaga.asxaqpredmdar SectlonZA ofMGL o. 152 can leadto thahnpositlon of of a line -up to $1,500.00 andl-aro'na.-Year im-orlsopment, as wellas chRponaffles inthe form of a STOP -WORK ORDER and a fho of -up to $250.()o a day against the wolator. Be, advised that a copy of this statementmaybe foxwardedto the Office -of. fhvestigations of ffio DU for ibsurance, coverage varifloation. I do it oreby cergfyAp�y fiz-441fl� that Me informationprovided above is ftue and correct, T, -�/ Y - Thone 4: J,,? tl - 7 C� �, Ofil-cialuSaMly. Do not 1prile !It &IS afea,10 179 colqjetedby city or town official City or Town: Permit[License 9 Issuing Authority (circle 6310): 1.)3oardofUealthL2.BuffdiugDe�artment3- CityHowa Clerk 4. Electrical Inspector 5.Numbluglaspector 6. Offier Information and Instructi ons Mass-ach"seft G0110ralLaws chapter 152r0q*8s all employers to providawarkers, compensationforifteir employees. Parsua to th1s statute, an ernployee is defined as evarypeisonhithosergcoof o e d ay o t Wross orhnplia� oral uvwxitten!, an th r un or n c n1rac oflilra,- An employWis defuied as "an individual,, partnership, assoclaff on, colvoration ar other lega t y 00 MO I en Ity, qT an tw X X0 Offt f6rO6'Pij engaged in ajoint enterprise, and includingthe legaliepxesentatives of a7daceased eppl �Ockflon or other legal Ot1tity, employing em�pjcyee, xOdelvir oi i��0'6fan fudividnApartuarghip, as g. Mwever ft owner of a dwelhg home having notmore, than three, apartraents and who resides therelp" or the, o coupant ofthe, dwelling liousD of another who employs p elsons to do maintenance, construction or repair workon su6h dwelling house Or 011tho grounds or building appurtenant thereto shall not because of such ejuplo entbode dto p oy YM ame beanom I or.,, MGLchapterI52, §25C(6) also states that "every state or. Ideal licensing agency shall witlihold the issuance or renewal of a Reense or permit to operate a business or to construct buildings lu the commonwealth for any applicant Who has not produced -acceptable evidence of compliance with tlie insurance coverage required.11 Additionalty, MGL cfiap�ter 152, §-25C(7) states'Weitherifie commonwealthnor any of its political subdivilsions shall MtOx into any contract for the pDrformanca ofpublic work MW �Gccptabla ovidence of compEpce, with the insurance xeqairements of this chaptarhave, beenpresentedta Ifib cQntractiagauthority." Applicants Pleas-0:fill out thaworkors, compons4on affidavit completely, by chedingifio boxes that applyto your situation and, iE ji6cedsaty; supplys-ab-confrartor(s) name(q), address(es) andphonenmiber(s) alongwiththeir r ,ergeate(s) of fil=ance. Limited Liabfflty Companies (LLC) or Limited Liatflity Partao 8 (LLP Vd 11 eni I ee o he h�n the _rship ) th 0 p oy s t Xt members arp�ftars, aranotreqatedto can-ywoikers' If aULLC orLLP doeshave employaps,apolloyis:required. Ba advised thatthii affidavitmay be submitted to the Department of Judustial. Accidents for conffimation of insurance coverajo. Also be sureto sigu and date the affidavit. 1heaffidavitshould b 0 retumedto the GRY or tova thatlh� application for thapennit or license is batg reqao�to�)aof the DOP'artment of IndustrialAccidents. Shouldyou have, any questions regarding the law or if you are xquked to obtain a*cAers, co�apersatfonpolfqy, please call the Department at the. number listed below. Sclf-inswedcompaniosshoWdonterihDlr self-111smaRca Rcense number on the appropriate Eno. I City or Tovm Officials Pleasaba sure thatthe, affidavitis complete andpriatedlOgibly. The, Department has provided a space at the bottom of the affidavitfatyou to fffl out in the event the OfffcO Of hv6stigatiOns has to contactyouregarding ffio applicant. I mim e Pleasaba-sura to 0111thO POunit/11001190RUMbar Whichwill be used as areferance b 'r, In addition, an applicaiit thatraustsu'bmit-mulaplopemit/ilcemoappH ti Ga ons many given year-, need only submit one, affidavitindicaffig, cjirr�.ut PDRGY infoTmation (if necossaw) and under "lob Me Address; the applicant sliouldwx1te "all I * tov&):`A� ocationS 'or -OPY On OfflUallY stdwped or marked by the city or toym may be providW to the aPplicant as Vtbof that a valid affida&.1don MO�O-r Mure permits or licouses. . A new af ff davit must be MeLd out each Year. Where ahomo Omer or citizen is obtaining a license oibeirait not related to anybtisiness or commercial venture (i.e. a dog license 040tillit to bum leaves Oto.) said -Person is NOTrequired to complete this affidavit. T11G Office Of lnvesggations�WoUld Eke to Ifink you in advance for your cooperatf on and should yqu have any please do nothesititato givaus a call. The, Department's address, telephone, and fax munben ThO CQMMQII W-OaM of MQ4,�,q�V Offloe of )[AV"tfgR#0.4,% 6b o wamagon stce, ezt TO, # 617-72'�-4900 Q#406 Qx 1-877-MASSAM Re-vised5-26-OS F M. # 617-727-7749 J4 7-i IQV lu UALUMAXAAAAW LU ML I; 4 Ij UALUMAXAAAAW LU ML I; 4 0 0 "o co z LAAAAAAAAAAAAAW .0. ul (A CL 2 M N, z LAAAAAAAAAAAAAW .0. ul (A CL 2 NOW ftom PROPMAL A -it KAJUL* 1=53 od -,JIM awn" W.Nowma P%.— act— wkverl4 MOM .5 V4"1MNftVWMM 0 1 (OP4 �f_ CA -f 41r ec.�Lcl-.r A 4 'IftPoorom Affimoda 4or @monk A I wo" jo-.,ive_4_ e it 4c 7_0 dhu* PAVOW07 a a Paso PROPOSAL -t WAUc.# 12M BMMLD CANsrzRUC"M 22 7 YS - A RX V- a Lem P"M imix AIM V%bwftmbMqwdbm&m=d I I I= 117, 1,':,x Pc-ck- )A --o-.4 voo r S' I 1490a *#4 #40e4p .4e i A4 "vfo top C 6L ie C'OL vooee Lot . . ..... 4 -0 -L -AJ