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HomeMy WebLinkAboutBuilding Permit #855-14 - 45 CHESTNUT COURT 5/20/2014 (3) TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received yo y Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION T/V U T �' T Print, PROPERTY OWNER Print 100 Year Old Structure yes no MAP NO: 066) PARCEL:f ZONING DISTRICT: Historic District yes no , Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family XAddition ❑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 WORK TO BE PERFORMED: /V£ LJ to t4n -) J•! Identification Please Type or Print Clearly) , OWNER: Name: Phone: Address: ' CONTRACTOR Name: `� :C ,_5 n/'L Phone: Address: /9 f/4 N- T 1 .5- Supervisor's .5Supervisor's Construction License: P�Pep y Exp. Date: Home Improvement License: Exp. Date: ` ARCHITECT/ENGINEER Phone: Address: Reg. No. r FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ �I, �y� FEE: $ Check No.: �-� Receipt No.-.- NOTE: o.:NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund Signature of Agent/Owner Signature of contractor -� Plans Submitted 11 Plans Waived ❑ Certified Plot Plan 11 tamped Plans 0 t? • W ,} TOWN OF NORTH ANDOVER ;> APPLICATION FOR PLAN EX:kMINATIUN !� Permit N0: Date Received: Date Issued: 4 ' r IMPORTANT: Applicant must complete all items on this page LOCATION 5' Print' Print'' PROPERTY OWNER �y�l�� �/i" %C�2� Print MAP NO.: PARCEL: � ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE.OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family - -- Addition Two or more family - Industrial Alteration No. of units: Repair, replacement Assessory Bldg Commercial Demolition = Moving relocation = Other Others: = Foundation only DESCRIPTION OF WORK TO BE PREFORMED (,r I-Je4J cep -------- Idetfiffication Please Type or Print Clearly) OWNER: Name: Phone• �3 .3 QQ.I Address: f�%J�r�s , & CONTIUCTOR Name: �o� ��/ i Phone: ;address: _ 1-11n-e � Sur erN isor's Construction License: 037 .3 T( Exp. Date: 2 / Li'15 Home Impro%ement License: /5-6 6 3f 5--" Exp. Date: .�RCHITEC T. E'NC ENE;ER \.ame: Phcne: Address: Reg. No. ----- FEE SCHEM LE:Bt LU1.l G PERMIT:-510.+i0 PER;;ii 00.00 CF THE TOT.IL EST1.41.-t TED COST BASED 0,N 51'S.'i0 PER S.E: Total Project Cost :$ �IG-o 6, a d x10.00-FEES 6 C't,eck tic,.: f 7 Receipt �,o.:�`� Pa:,.v it,i 4 . ._. -.;.- --. __ . - - .- ,:--- . . w - . . . .. . . . - , . . u ;:_ -. t `;` :....: -_.w , __ - 1. -. - . .: _- . , ., , - . _ t .. - . .. Location x G�. y✓. r-- No. Date G . �,. a ti' - ---. . O� MORT�y TOWN OF NORTH ANDOVER 11 . .. ? % , :•.,tiC - •_� • O � L . . I', i A ' s ° Certificate of Occupancy $ �'s„cM„s<�'s --1 Bui.lding/Frame Permit Fee $ �-- "" }/ w - ; Foundation Permit Fee $ Other Permit Fee $ t TOTAL $ Check # v :. 1 943 Building Inspector - _ 1. - - - - - .. ... . ._. -. ..... ... rt':= • ;: h , -. -_% - .- -. ,: .,. e _,_. _ --. _ - - ..._ _ '....' __ _ ... - .1 .. .. .. .- --. . .: .. -. .. _ . - ......... . - .. -. .. - - .. .- '� .._ 1. . . .. - - .:.. .. ., .. - - w . :. ...ry - . .. .. ...,..,:.. - Y .. 1 - T 'PE OF SEWARGE DISPOSAL _ Tanning'Nlassage y- Art SHimming Pouts _ Public Seger Tobacco Sales -- Food Packasinu Sales _ Well Permanent Dumpster on Site Private(septic tank,etc. _ Electric Meter location to project MOTE: Persons cnntrrr ting with unregistered contractors do not have access to the��uurrrnly J'und Signature of Agent,Owner A Signature of Contracto & Plans Submitted - Plans Waived Certified Plot Plan - Stamped Plans THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF- U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT i] ❑Vb ater Shed Special Permit G Site Plan Special Permit J Other COMMENTS DATE REJECTED DATE APPROVED CONSERVATION u !� COMMENTS DATE REJECTED DATE APPROVED HEALTH CO)vINIENTS i f Zoning Board of Appeals: ariance. Petition No: - - - Zoning Decision:receipt submitted cs _ i"nnnint, B-rird Lleci,sion: iscr�,Uicn Duci':ion: Camments i tv: Cl'f•`'G °'�'h(.r ;o rno.-tion_iL laftirL &��atC .mp �umpster cn si!-c yes_ -'w re Department in;atur_ date — — -- _—.-- Building PUrnii .\pprc%�d and [SsuLd by: Building Setback (t.) Front Yard Side Yard Rear Yard Required ProN ided Required Provides _Required Provided DIMENSION Number of Stories: —_--Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: NOTES and DAT.\—(For department use) I; _ I t i c hll_lfn,"„'•.L',LI:�YI::, ,LI'.'G ".II.. L Building Department The fohowing is'a list of the required forms to be filled out for the appropriate.permit to be obtained. Roofivg, Siding, Interior Rehabilitation Permits o Building Permit Application o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses Li Copy of Contract u Floor Plan Or Proposed Interior Work u Engineering Affidavits for Engineered products ,I NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o 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 o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit Li Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Li Copy of Contract u Mass check Energy Compliance Report o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign offrom Fire Department prior to issuance of Bldg Permit In all casts if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apw-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submAted with the building application Doc: Doc.Building Permit Revised 2012 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 a Building Permit Application ❑ Workers Comp Affidavit Photo Co Of H.I.C. And/Or C.S.L.. Licenses � Copy Copy of Contract ❑ Floor Plan Or Proposed Interior Work Addition Or Decks Building Permit Application ------- ---- --- ---- -- - -- - - Surveyed Plot Plan Workers Com Affidavit ❑ Work p Photo Copy of H.I.C. And C.S.L. Licenses Co Of Contract Y p •drat - ith Sprinkler Plan And Hy ❑ Floor/Crossection/Elevation Plan Of Proposed Work W p Calculations (If Applicable) Applicable) � Mass check Energy Compliance Report (If New Construction (Single and Two Family) Building Permit Application Certified Proposed Plot Plan a 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 In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board o Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy ant. proof of recording must be submitted with the building application inc:I`.til'F.("I'It)\.11.til'.N\'f('L•;:i ilF,P'.IR'I 11F.`•!'al'FUn`!It5 VAORT#.f Town of Andover In No. 0 TP 1 4P dover, Mass, L A E COC MIC HE WICK 0RATED S E BOARD OF HEALTH Food/Kitchen PERMIT D Septic System 1% BUILDING INSPECTOR THIS CERTIFIES THAT .... ...............( ......................................... ................. ........... . ... ..................................... Foundation has permission to erect............... buildings o .....qSM....... ......C17m... Rough op...*....*'*'*"**'*' 41 1 ININOW 6 T)a 0 OW601 Chimney to be occupied as.... . ........ A10.....1101W. ..to........................................................... provided that the person accepting this permit­s"I'aill"in****e*very res conform to the terms of the application on file in 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 PERMIT IN 6 MONTHS ELECTRICAL INSPECTOR /000' C STARTS Rough /16 UNLESS CONSTR Service ....... ........... ............ ............. ECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. SEE REVERSE SIDE Smoke Det. //ze �nirz�nnnu�a��� o�.1r!rratac�zuae�a BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 038381 Birthdate: 01/04/1949 l Expires: 01/04/2008 Tr.no: 13097 Restricted: 00 DAVID H WAIN 14 ADAMS POND RD DERRY, NH 03038 �� Commissioner :✓/,e �ur�r,�norr{uea�l� c� :j�zs�acfurel7s �\ Board of Building Regulations and Standards •';:- _..:i. HOME IMPROVEMENT CONTRACTOR Registration: 150385 I Expiration: 3127/2008 Type: DBA DAVID WAIN CARPENTRY DAVID WAIN 14 ADAMS POND RD. - ' DERRY,NH 03038 Deputy Administrator The Commonwealth of Massachusetts Department of Industrial:lccidents Office of investigations ;¢ r ;�= 600 Washington Street Boston AM 02111 MWWW.nlass.govIdia t Workers' Compensation Insurance ,affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(l)usincss;Urganiialionilndivi�luul): ���� Gy,�,o� ;address: 1-7�q lbs, ,I/d — City:Stateizip: (7DJWV AIIJ 6363g- Phone #: 663 6661 ,%re you an employer?Check the appropriate box: Type of project(required): I.❑ 1 am a employer with 4. El am a general contractor and l 6. E] New construction ployees(.full and'or part-time).* have hired the sub-contractors Remodeling e1mam a sole proprietor or partner- listed on the attached2.X sheet. 2. ❑ ship and have no employees These sub-contractors have S. ❑ Demolition working for me in any capacity. workers' comp. insurance. q. ❑ Building addition [No workers' comp.insurance 5. [1 We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.[] 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.] ',\ny applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. y I lomeowners who submit this of idav it indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating:;uch. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. 1 um an employer that is providing workers'compensation insurance for my emplgyees. Below is the policy and job site inf armation. Insurance Company Name:_ _-- — ---.----__--- ---- --- Policy 4 or Self-ins. Lic. .`�: ----_ _ Expiration Date:_----- --. Job Site Address: City%State;/Zip:___— —. — 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 biGL c. 153 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 STOP WORK ORDER and a tine 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 DIA for insurance coverage verification. 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. _�e` nate: ti i%nature: _ --- Phony 663 — -- 660-1--- ------- --- — !)/fichd use only. Do nitif write in this greet, to be eomplcted b):r.-!ty or town gficiol. City or Town; :permit/License 4--_-- — Issuing Authority(circle one): I. Board of Health 2. Building Department 3.C;ty/Town Clerk d. F.!ectrical Inspector 3. F Iumbing Inspector 6.Other Colltaet Per-mn: ACORD. CERTIFICATE OF LIABILITY INSURANCE OP ID P DATE(MM/DD/YYYY) WAINDAI 4 06/05/06 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Benway-Johnston Insurance Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR PO Box 750, 35 Crystal Ave ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Derry NH 03038 Phone: 603-432-3357 Fax:603-432-9822 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Providence Mutual Fire INSURER B: David Wain Carpentry INSURER C: 14 Adams Pond Road INSURER D: Derry NH 03038 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. POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LTR NSR TYPE OF INSURANCE DATE MM/DD/YY DATE MM/DDA LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 500,000 A X COMMERCIAL GENERAL LIABILITY CPP 0059657 01 08/16/05 08/16/06 PREMISES(Eaoccurence) $ 50,000 CLAIMS MADE X❑ OCCUR a i t=' ?)e ^ MED EXP(Any one person) $ 5,000 . ._ .. PERSONAL&ADV INJURY $ 500,000 GENERAL AGGREGATE $ 1.000.000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 POLICY M PRO JECT LLOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO NOT APPLICABLE (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR F] CLAIMS MADE NOT APPLICABLE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND TORY LIMITS ER EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE NOT APPLICABLE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER NOT APPLICABLE DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PVISIONS t CERTIFICATE HOLDER CANCELLATION 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 FAILURE TO DO SO SHALL Muriel Picard 45 Chestnut Court IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR No Andover MA 01845 REPRESENTATIVES. AUTHO ED REPRESENT E Q ACORD 25(2001/08) ©ACORD CORPORATION 1988