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HomeMy WebLinkAboutBuilding Permit #040-13 - 49 BRENTWOOD CIRCLE 7/18/2012 BUILDING PERMIT of ttO oT bgti TOWN OF NORTH ANDOVER F APPLICATION FOR PLAN EXAMINATION 41 • Date Received 1 ° Permit NO. �Q'°°R,TEo#IPa'"•c5 I gSSgC14us�� Date Issued: IMPORTANT:Applicant must complete all items on this page ` fir f LOCATIOP4 f vn .+Tc,kr PROPERTYOWNV, PHr.- y rMAP NO �_ PARCEL 6k P 4�,ZONING DISTRICT Historic District , dyes # ^"�R. :'.�. -..' .�-, 4 ''a?"'"yk'^�s.�.� nit`^3'�aTl'�.�"' '"� �s�` -,r � Machine:Sho ~Villa a es no h TYPE OF IMPROVEMENT PROPOSED USE Residentia Non- Residential New Buildingne family Addition Two or more family Industrial ation No. of units: Commercial epair, replacement Assessory Bldg Others: Other Septic Well ',: , x. Floodplain Wetlantls _ q •T F"r'�s', fir a�,..rn.� e a ,k lk', *`'y� r '�"'�,' r. f ! �. `,t.+:v` �,,- r �. ��,.,*. � � � � '' a� ���x� Y'. _ ; .Water/Sewer�a� > �� F,t', c•.r� � ����,�.�'�.-�..� �:���' *:� -x���'..« �.,�r,..��:��� :�S�r`�� �': SCRIPT N OF WORK TO BE PREFORMED: Identification Ple se Type or Print Clearly) OWNER: Name: Kok r\ I c� e� Phone: �?L q07 0 Address: 'C a'�a. p jCONTRACTORNamt.e _�' .,%, Phone 4 ���-:"Se'`����" ,��'�'' � �'��.+�,*�`,'#�� �••��7E°��^+t. `��'�k���°"$'•'�i.,.���.* `�.t9r=�-�.,� n'y� i .�+�'�T�''����'��'-`�-��'�,`� "`sem-,. - 4P<Ye 70 MIT-.�,_.i`+r » d�g� 'FMnT ta-Y .e+.4 �..'. Superviso.ras iConstruction�Ltoense= ¢Exp a ate USX, , ° tya •,� ,` _ a? C"r '�`ti` "�3 rr2.. 5d-- s'r=` '��" C '�` 's s �' ^'*;, n- t'# eft"+` k ',gwh i s.?t' � �� ��i``irk yk{i'+ ,s� �� d�.�,.'t� �;_'s r'��+ �;Y�S�n� �}.�' t .3.yt r.f g � .�.> - i����� s-�fr/�°` -`'°�✓� M.,t ARCHITECT/ENGINEER Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.-$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 1'G 000 , FEE: $ ( +� • � ff Check No.: 1� 59 Receipt No.: '7 X11 NOTE: Persons contracting with unregistered contractors do not have access to th arantyfund nSoAeSgnature of contractosr ° Location_ 4q ?wA�mj No. Date �- • ' TOWN OF NORTH ANDOVER • :rt tf L`p� ' • `r" Certificate of Occupancy Building/Frame Permit Fee $ � � _ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ k N I'. I Check# ko 25517 Building Inspector 5: 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes PlanningBoard Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature&Date Driveway Permit i DPW Town Engineer: Signature: Locate 4 Osgood Street <�FIRE`DEPARTMENT Temp Dumpster=on site es 3 = s o �, j k _ : ;dna`-rnx";'-bas F �s.s; i .T.-=atetl at,124 Mam Street "� ..F ;-kiS'! a_.riG' € #�„-b�., - 5 _ FIreDe artment SI nature/date: .4, Wy '� P g _ , •,+ �.ti,� m� �- y. - fir;. � -+�� � .z , 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 NOTES and DATA— (For department use) ❑ Notified for pickup - Date 1)"-Bu"ding Permit Revised 2008 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/Crossection/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 g NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New ConstructionSin le and Two Family) � g ❑ 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:INSPECTIONAL SERVICES DEPARTMENTMFORM07 Revised 2.2008 NORT�y own o ndover o - �+ No. - h ver, Mass 1�. O LAME COC KICKl WICK V S Ll BOARD OF HEALTH Food/Kitchen DSeptic System THIS CERTIFIES THATPERM .. .. .. .1� . . ��Vw BUILDING INSPECTOR �.. f� Ce � Foundation has permission to erect .Re"'E'RM-4 ..... uildings on .... .... 1 ...0 .. ..... Rough to be occupied as .......... ....................... ..... ......................................... Chimney provided that the person accepting this permit shall in every respect confor o the terms of the application 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 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI T 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. SEE REVERSE SIDE q. Page of pages Proposal Submitted Ta Job Name Job# Address Job Location , Date"" �t 4 Date of,Plans Phone#., F,"#'..: 3 _ Architect 1-2 We hereby submjiit{}specifications and estimates for _ { r _ rj � .w7 .. '" ".+.'..°".. ... f K Eg¢ yl env ! ^i Ch1 We propose Hereby to furnish material and labor—complete in accordance with the above specifications for the sum of 7) 77 $ 7D011ars - �. r with payments to be made as follows. At Any alteration or deviation from above specifications involving extra"costs'will Respectfully be executed only upon written order,and will become an extra charge over and s` r` ' submitted Is" above the estimate.All agreements contingent upon strikes;accidents,or delays ,~ ✓ beyond our control: , _ Note—this prdposal,M y be withdrawn by us if not:accepted within days. The aboverices,s ecifications and conditions are satisfactory and and are P P ' hereby accepfed:You areauthorized to do the work as specified. Signature Payments will be made as outlined above: Datetbf Aceentance Signature The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): A.T��:7 Address: &pq City/State/Zip:No J&� Q A6 Phone#: ��� 30C-)"4�* Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2. am a sole proprietor or partner- listed on the attached sheet. E]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 required.] officers have exercised their 10.ElElectrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plu ' g repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12. Roof repairs insurance required.]1 employees. [No workers' comp.insurance required.] 13T]Other *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. $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: �� C't �- 0 ��S l � S Policy#or Self-ins.Lic.#: W C G a O 0 (p - Q 2-0 12_ Expiration Date: 5 Job Site Address: I 3,0_ )0J r City/State/Zip: _�!'i✓�1 tom' © L Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requir d 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- .x imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day agains e violator. Be adv' at a copy of this statement may be forwarded to the Office of Investigations of the DIA pinsurance cover efification. [do hereby certify u tierl the pains an nalties of perjury that the information provided abov is trt a and correct. Si nature: j Date: l Z Phone#: 0— `{J Official us4 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the:permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-7274900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia ACOORID0® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 7/18/2012 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 NAME: M P Roberts Insurance Agency Inc PHONE g78-683-8073 FAx A/C No Ext: we No:978-683-3147 1060 Osgood Street ADDRESS:Paula@mprobertsinsurance.com North Andover Ma 01845 INSURER(S) AFFORDING COVERAGE NAICN INSURER A:WESTERN HERITAGE INSURED ARTHUR ALLEN CONSTRUCTION INSURER B: INSURER C: 369 WAVERLY ROAD INSURER D:ASSOCIATED EMPLOYERS NORTH ANDOVER, MA 01845 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 11000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 100,000 CLAIMS-MADE CI OCCUR MED EXP(Any one person) $ 1,000 A SCP0869779 10/17/11 10/17/12 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 17 POLICY PR) Loc DEDUCTIBLE $ 500 AUTOMOBILE LIABILITY C BI EDN LE LIMIT Ea accident $ ANYAUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY Per accident $ AUTOS AUTOS ( ) NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 71 EXCESS LAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION WCSTATU- 5TH- AND EMPLOYERS'LIABILITY YIN X TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE WCC5006462012011 09/05/11 09/05/12 $ 500 00 D OFFICERIMEMBER EXCLUDED? NIA E.L.EACH ACCIDENT 0 (Mandatory in NN) E.L.DISEASE-EA EMPLOYE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION CITY OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE BUILDING INSPECTOR THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 OSGOOD STREET ACCORDANCE WITH THE POLICY PROVISIONS. NORTH ANDOVER MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD25(2010/05) The ACORD name and logo are registered marks of ACORD i r%lra arrr�rer,rrue�r�/�,a/r r..irrc�t6c/( Office of Consumer Affairs&Bus►hess Regulation a OME IMPROVEMENT CONTRACTOR Type: egistration: 972406 h xpiration: 6/21/2014 DBA ARTHUR ALLEN CONSTRUCTION ARTHUR ALLEN 369 WAVERLY RD NO.ANDOVER, MA 01845 Undersecretary 99 i d 0R"; Btllid19 um- ; OC,B't $;'1!c$tESF'3 License: CS 86230 (y r ' « ARTHUf3 A AILEN ` u ` F 369 WAVERI !RD NOANOOVER MA 01845