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Home My WebLink AboutBuilding Permit #360 - 452 WAVERLY ROAD 11/2/2006 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 0, "° 16o Permit NO: Date Received s iii �^ + Date Issued: 11- �495Fa,''o;; :��y* ,SSACNUS�� IMPORTANT: Applicant must complete all items on this page LOCATION a rint Se/rl PROPERTY OWNER ,e 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: ,KRepair, replacement ❑ Assessory Bldg ❑Commercial Demolition C Moving(relocation) ❑ Other ❑ Others: ❑ Foundation onl DESCRIPTION OF WORK TO BE PREFORMED le O� Identification Please Type or Print Clearly) OWNER: Name:Ao SSC Phone: 5 Address: CONTRACTOR Name: Phone: 39j Address: �r _ Supervisor's Construction License:_ G vv o � Ex y p• Date: 9 i3 — Ua ':7 Home Improvement License: 9— 6 "7 a Exp. Date:_/ ARCHITECT/ENGINEER Name: Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.•$11.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost :$ , Cd G Ci CJQ FEES Check No.: Receipt No.: Page 101'4 I TYPE OF SEWERAGE DISPOSAL Swimming Pools E Tanning/Massage/Body Art Public Sewer Tobacco Sales ❑ Food Packaging/Sales E Well Permanent Dumpster on Site Private(septic t , ank etc. ❑ Electric Meter location to project r NOTE: Persons contracting with unregistered contractors do not have access to tit guaranty fund Signature of Agent/Owner Signature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Pla s ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF- U FORM it I DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ ! COMMENTS i DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ I COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS FIRE DEPARTMENT - Temp Dumpster on site yes no Fire Department signature/date COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer connection/Sienature& Date Driveway Permit 1 L Building Setback ( Front Yard Side Yard Rear Yard Required Provided 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 DATA—(For department use) s Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM05 Created AW.Jan.3006 i BuildingDepartment p nt 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 PermitApplication ❑ Workers COMP Affidavl • • d/Or C.S.L. Licen ❑ or MO"roposed Interior Work Addition Or Decks a Building Permit Application ❑ 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) o Mass check Energy Compliance Report (If Applicable) New Construction (Single and Two Family) L3 Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit a Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract o 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 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:INSI'E('7'ION,►L SERVICES DEPARTM1IEN'r:BPFOR51o5 Page 4 of 4 Location N0, gzl�GO Date w HORTN TOWN OF NORTH ANDOVER F P Certificate of Occupancy $ SSACMUSE�� Building/Frame Permit Fee $ I Foundation Permit Fee $ Other Permit Fee $ k TOTAL $ r Check # 19762 U Building Inspector `.10 Town. of .. 4 RTH over No. 3 4 0 10, over, Mass. 10 0 LA COCHICHE WICK ORATED IsE BOARD OF HEALTH Food/Kitchen PER T Septic System BUILDING INSPECTOR THIS CERTIFIES THAT..... .........401r,04111 .............................................. .........................n... .......... Foundation has permission to ere%........................................ buildings on. ........ .......... ..&..*............... Rough 0 - 7:7-11 I'll to be Occupied as.A..... ....JL Chimney .......... . . ....................................................................................... provided that the person accepting this permit shall in every r act conform to the terms of the application an 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 T PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTR ... S S Rough - �T ............. Service BUILDING INSPECTOR 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 _jj Smoke Det. i NIABUILDING 'S . le o inn : REMODELING 17 CINDERELLA CIRCLE • DRACUT,MASS.01826 0 (617)957-1382 CABINETS PORCH ENCLOSURES -7ree 61imated ANTONIO J. MARTIN CONTRACTOR r � DATE / ! I 4,4 I Jo f s v ✓�teJr»nrnavatr t- a crLsa �ufetCii Y BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Pip Number: CS 000859 a� Birthdate: 09/13)1943 Expires: 09/13/2007 Tr.no: 4590.0 Restricted: 00 ANTONIO J MARTIN 17 CINDERELLA CIRCLE_ DRAGUT, MA 01826 Commissioner F ' 71. Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: .118072 :Expiration 1/26/2007 Type: DBA' MARTIN'S REMODELING ANTONIO MARTIN 17 CINDERELLA CIRC DRACUT MA 01826 Administrator 10/31/2006 14 :20 TEL 603 673 0500 Eaton & Berube Ins 0 001/002 Client#: 27 84 SORFA ACORD,. CERTIFICATE OF LIABILITY INSURANCEDATE( 06D�) PRODUCER r4 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Eaton/$Berube-CL 02 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 365 Nashua Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR P.O. Box 37 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Milford, NH 03055 INSURERS AFFORDING COVERAGE NAIC tl INSUR2D INSURER A; Western World Sorrell Family Construction Inc INSURER B: 215 So Broadway Suite 196 : INSURER C Salem, NH 03079.2414 INSURER C: 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 15 SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR LTR NSR TYPE OF INSURANCE POLICY NUMBERPOLICY EFFECTIVE PO C DATE MM DD DATR MM LIMITS A GENERAL LIABILITY NPPI CS4967 08/29/06 08/29/07 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGEISE TO RENTED $50,000 IF ocrunnancnI CLAIMS MADE Q OCCUR MED EXP(Any one person) $5,000 X BI/PD Ded:1,000 PERSONAL&ADV INJURY $110001000 GENERAL AGGREGATE s2,000.0.00 GEN'L AGGREGATE LIMIT APPLIES PER; PRODUCTS-COMPIOP AGG $1,000,000 POLICY 7 PRO- LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Par accldeni) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA AGC S AUTO ONLY; AGG S EXCESWUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR FICLAIMS MADE AGGREGATE S $ DEDUCTIBLE $ RETENTION $ E WORKERS COMPENSATION AND WC STATU- OTH- EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNERtEXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? II yye6,describe under E.L.DISEASE-EA EMPLOYEE S 5PECIAL PR VI NS below E.L.DISEASE-POLICY LIMIT 13 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Tony Martins Remodeling DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL ,,D- DAYS WRITTRN 452 Waverly ad NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 HO SHALL N Andover MA 01845 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER.ITS AGENTS OR FX 878■957-0547 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2001108)1 p(2 #29925 Lp GDX (D ACORD CORPORATION 1988 10/31/2006 14: 20 TEL 603 673 0500 Eaton & Berube Ins 002/002 ,i IMPORTANT If the certificate holder Is an ADDITIONAL INSURED,the pollcy(ies)must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s), If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may II'I require an endorsement. A statement on this certificate ert cat® does not confer rights to the certificate holder In lieu of such endorsement(s). I DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does It affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon, i ACORD 25S(2001/08) 2 of 2 #29928 10/31/2006 TUE 13:00 FAX 603 883 6046 Sadler Insurance Agency 2001/002 J Client#:36502 SORFA ACORD- CERTIFICATE OF LIABILITY INSURANCE 1DATE(MMID 0/31/06DIYYYYI PRODUVR THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION THE SADLER INSURANCE AGENCY ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 24 Railroad Square HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 4 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, P.O. Box 2021 Nashua,NH 03061 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA: Liberty Mutual Sorrell Family Construction Inc. INSURER B: 215 South Broadway INSURER C: Salem, NH 03079 INSURER D: 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. IN RDD' POLICY EFFECTIVE POLICY EXPIRATION LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MMIDDIYY DATE(MMIDD/YYI LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 1 PREMISES Ea occurrence $ CLAIMS MADE a OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO- JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (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 EA ACC $ OTHERTHAN AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR ❑CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ A WORKERS COMPENSATION AND WC531 S355656016 09124106 09124107 ITORY WC STATU- 10TH. EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $100,000 ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBEREXCLUDED? E.L.DISEASE-EA EMPLOYEE $100,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $500,000 OTHER DESCRIPTION OF OPERATIONS!LOCATIONS I VEHICLES f EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Toni Barton Remodeling DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 1D_ DAYS WRITTEN 452 Waverly Rd NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Andover,MA 01810 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2001108)1 Of 2 #S446341M4463 1 0 AC ORD CORPORATION 1988 10/31/2006 TUE 13:00 FAX 603 883 6046 Sadler Insurance Agency 10002/002 IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer,and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. i ACORD 25-S(2001108) 2 of 2 #S446341M44631 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 '4t www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): N ( L5H4)121,E X / G Address: C City/State/Zip: DRX CG �7A SS Phone #: 97 T 9 5_> 13 { �-- Are you an employer?Check the appropriate bob: Type of project(required): 1.❑ 1 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.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 1 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 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions required.] officers have exercised their right of exemption per MGL 11.❑ Plumbing repairs or additions 3.El I am a homeowner doing all work myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#I must also till 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 5AP)-1-; )Q ) NS's / fi Policy #or Self-ins. Lic. 4:—W&F'3 /S:3 f(` 6—C 0 C'" Expiration Date: Job Site Address: �/ 5 `� k/5 R)_y 9 City/State/Zip: A(O, 440cj 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 tine 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 DIA for insurance coverage verification. /do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Q Date: /"f p 6 Phone#: �l ) ctf 5 7 l �� 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#: