HomeMy WebLinkAboutBuilding Permit #923-14 - 49 CHURCH STREET 5/14/2015(9�1< A4Je44L1--
PermitNo#: 01z�>—Ii
Date Issued:
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
IMPORTANT: Applicant must complete all items on this
LOCATION 4/
e�Al
RTH
F/100,
-------- R int
PROPERTY OWNER 7)z9Z 5h,:�,-
Print 100 Year Structure yes no
MAP 01 -//—PARCEL:. ZONING DISTRICT: Historic District yes no
yes
Machine Shop Village ip 0
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
El New Building
El One family
0 Addition
El Two or more family
El Industrial
El Alteration
No. of units:
El Commercial
El Repair, replacement
El Assessory BIdq
El Others:
El Demolition
0 Other
0 , Septic 0 Well
0 Floodp[ain 0 Wetlands
El W-atershed, District
El Water/$
DESCRIPTION OF WUKK I U tit FtK1-UK1V1tL).
or Print Clearly
OWNER: Name:
Address:
Contractor Name:
Email:
Address:
Supervisor's Construction License: Exp. Date:
Home Improvement License:
ARCH ITECT/ENGI NEE
Address:
one:
Date: I/ — '2' ,
Phone:
Reg. No.
FEE SCHEDULE: BULDING PERMIPM00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
FEE: $ Z- 2 2b+
Total Project Cost: $
Receipt No.:
Check No.: W
NOTE: Perso'n"Tcontracting with unregistered contractors do not have access to the guarantyfund
I
Location 1,&VA -
No. Date
Check # Ll� —
TOWN OF NORTH ANDOVER
V, W
Certificate of Occupancy $
Building/Frame Permit Fee $ /0
0
Foundation Permit Fee $—
Other Permit Fee F171 --
TOTAL
J-1buiding Inspector
Plans Submitted [I Plans Waived [I Certified Plot Plan [I Stamped Plans F1
TYPE OF SEWERAGE DIS�O-SAL
Public Sewer 11
Tanning/Massage/Body Art
Swimming Pools El
well El
Tobacco Sales El
Food Packaging/Sales 0
Private (septic tank, etc. El
Permanent Dumpster on Site El
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
Planning Board Decision:
Comments
Conservation Decision: Comments
Water & Sewer Con nection/S.ignature & Date Driveway Permit
]QPW Town Engineer: Signature:
Located 384 Osgood Street
:L
IR
ip
IMENT
Cit d
- - ' i
r
COMMN'NT�S - -
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
MGL Chapter 166 Section 21A —F and G min.$100-$1 000 fine
NOTES and DATA — (For department use)
LJ Notified for pickup Call Email
Date Time Contact Name
Doc.Building Permit Revised 2014
No
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
,6 Copy of Contract
4� Floor Plan Or Proposed Interior Work
,& Engineering Affidavits for Engineered products
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
4� Building Permit Application
�6 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
TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
.4, Building Permit Application
4, 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
2012 IECC Energy code
Engineering Affidavits for Engineered products
IOTE: 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 offlce 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
Doe: Building Permit Revised 2014
%0
I
00*1
W,
uj
LL
0
0
co
cli
=
u
-0
a
0
L.
E
0)
>.
(A
u
CL
cu
V)
0
u
CL
LA
z
z
D
co
c
D
0
LL
to
=
0
CC
ai
c
E
!E
U
LL
in
z
Q
co
CLO
:3
0
LL
0
z
u
u
ui
=
b.0
:D
0
2!
a)
V)
m
s
Ll-
cc
0
1--
u
0
W
L.L
z
LLI
2
LLI
LLI
:3
ca
V)
ai
ai
0
E
V)
�,M71
TF
v
E
(D
a.
0
.2
Al.,
cc
CY)
4)
0
N
4)
0
z
0
0
F,
Cl)
Cf)
o
cl) w=)
Lij
CL Cf)
x z
LU 0
Q
Cl)
cn
uj
LU -j
CL z
tj 14
43 40
Aftfto %fto
w
0
w
IL
Cl)
z
CD
z
�j
Z
*f -I
�6)
0
E
0
z
0
0
a.
U)
0
.2
CL
0
L)
cc
CL
U)
w
I.:
0
CL
U)
01—
co
0
CD
00
L- L-
0 CL
CL
cm
—J
0
z
CL
Cu O�
2.5
0
CD
E
U)
r—
(D
0
.6-
0
-
E
L-
0
--ftw
0
cn
(D
Cc
cn
r
U) CD
U)
0 >
-0 0
0
%—
0 0
z
(n
r_ 0
0
r_
A
tm > 0
0-0
CL
0
Cc cn
r-
0
W
a)
CL
0
cn
c CD m
c 4—
Lu
2
-0 Co
cv r
cn
:E .2
LU
E
0
L-
(D
0-0
C0
CL
U)
cc
o a 0
4w CL 0 U
E
(D
a.
0
.2
Al.,
cc
CY)
4)
0
N
4)
0
z
0
0
F,
Cl)
Cf)
o
cl) w=)
Lij
CL Cf)
x z
LU 0
Q
Cl)
cn
uj
LU -j
CL z
tj 14
43 40
Aftfto %fto
w
0
w
IL
Cl)
z
CD
z
�j
Z
*f -I
�6)
0
E
0
z
0
0
a.
U)
0
.2
CL
0
L)
cc
CL
U)
w
I.:
0
CL
U)
01—
co
0
CD
00
L- L-
0 CL
CL
cm
—J
0
z
CL
K&N General Construction
35 Ruth Ave
Dracut, MA. 01826
Tel: (978) 815-4544
HIC #129474
MA License #091242
Work to be Performed At
49 Church St
North Andover, MA 01845
617 — 407 - 2483
We hereby propose to finish the materials and perform the labor necessary
for the completion of the job.
1. Provide all necessary permits and Insurance Certificates to perform
work legally
2. Properly protect building and grounds during construction
3. Remove 1 layer of shingle roof
4. Install new drip edge
5. Install 15 pound of felt paper
6. Apply lead around chimney
7. Install 30 year shingles
8. Notify owner of any rotten wood. $35 per 4' x 8' board to replace
9. Use 1 1/4inch nails for nail gun to install shingles
10. Clean up all debris
11. Dumpstei/-Y��supplied by contractor
12. 5 years labor warranty
13. Should it become necessary for the Firm to file suit for the collection
of any sums due to the firm from the Client under this agreement,
the client shall pay in addition to the fees, costs, and/or expenses due
under this agreement an amount for reasonable attorney's fee
equivalent to 25% of the amount due
14. All accounts are due when they are presented. Those accounts not
paid within 30 days from the date of presentation shall accrue
interest at 18% per year on the unpaid balance
Total Cost for This Project $8,500
Deposit $4,500 Finish $4,000
Contractor Signature,
Customer Signature,
1 3 �_3E- �
aic oq Pgqr�
c7q \ (-,,A,,rm A -
co�-.
4
4clx The Commonwealth ofMassachusetts
Department ofIndustrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
. 6 www.mass-gov1dia ricians/Plumbers.
Workers' Compensation insurance Affidavit: Builders/Contractors/Elect
TO BE FILED WITH THE PERAUTTING AUTHORITY.
Name (Business/Organization/Individual):
Address:
City/State/Zip:,
Z� I
Phone#:
A;;y�ou n employer? Check the appropriate box:
I mployees (full and/or part-time).*
I am. aempl.yer with — 1�_-
2.FJ i am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3.FJ I am a homeowner doing all work myself [No workers' comp. insurance required.] f
4.F-1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5.FJ I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance.t
6.FJ We are a corporation and its officers have exercised their right of"exemption per MGL c.
152, § 1(4), and we have no e!riployees. [No workers' comp. insurance required.]
f
Type of project (required):
7. [] New construction
8. El Remodeling
9. F1 Demolition
10 E] Building addition
ME] Electrical repairs or additions
12. E] Plumbing repairs or additions
13.El Roof repairs
14. F1 Other,
*Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information.
r I and then hire outside contractors must submit a new affidavit indicating such.
I Homeowners who submit this affidavit indicating they a e doing al work
tContractors 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 insurancefor my employees. Below is the policy andjob site
information. Z&
Insurance company Name:
Policy # or Self -ins. Lic- #
Job Site Addre
��5T
I Compensation DOUCY
Attach a COPY VJL LAXV TV -1— c. 152, §25A is a criniinal violation punishable by a fine up to $1,500-00
Failure to secure coverage as required under MGL
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. A copy of this statement may be forwarded to the office of Investigations of the DIA for insurance
coverage verification. ve is true and correct.
hereby certify under thepains andpenalties ofperjury that the information provided abo
Z/17
Exp rat on
city/state/zip: 21,?M7�6 J��
page (showing the policy number a nd expiration date).
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
PermitlLicense #
Issuing Authority (circle one): i Clerk 4. Electrical Inspector 5. Plumbing Inspector
1. Board of Health 2. Building Department 3. City/Town
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 defmed 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 (LLQ 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-insuranc*e 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 affidavft 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 bum leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
05-14-'15 13:00 FROM-Byam BrosMahony Inc 978-937-0745 T-807 F0001/0001 F-503
16� CERTIFICATE OF LIABILITY INSURANCE
m 'Y
DATE (MMIDOtYYYY)
Tfm 12015
1
0 5=1 14 2"0 1"!
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RI6HTS 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(ios) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statornont on this certificate does not confer rights to the
certificate holder In lieu of such endorsement(s).
PRODUCER Phone: 978-454-2926
B rn Bros Mahoney Ins. Agency
I V Pawtucket 1310 Fax: 978-937-0745
Lowell, MA 01864
CONTACT
NAME:
P"O F I.A X
IAIC.142� Fytl:
F -MAIL
APPRO156:
IN6URER(S) AFFORDING COVERAGE NAIC 0
Byarn Bros
INsuRrRA:Western World Ins. Co.
INSU�EO Peter Ngeth dba K -N Construcst
115 Amesbury St
Dracut, MA 01826
INSURER 2:
G
_.
_LNSURER
INSURE
INSkJRFR E:
INSURE9 F:
NPP9237331
Kl"Knman ft�V1_%1tJM MUIVJM�M_
THIS IS TO CERTIFY THAT THE POLICIES OF 114SURANCF: LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR TH15 POLIGY PERIOD
IN01GATED. NOTWITHSTANDINO 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 CLAIM&
—IN fR'
LTR
—
TYPE OF INSURANCE
ADDL
SUOR
POLICY NUMURR
POLICY EFF
�IYYYY�
PYL_1drffW_
IMMIDDrYYYY)
LIMITS
GFNERAL LIABILITY
EACH OCCURRENCE $ 300MO
A
X COMMERCIAL GENERAL LIABILITY
NPP9237331
11/2012014
1112012015
100,000
MED EXP (Any ona paftonj_ $ 6,000
CLAMS -MADE rx] OCCUR
PERSONAL & ADVINJURY $ 300,000
GENERAL AGGREGATE 5 600,000
GEN'L AGGRECATE LIMIT APKIIiS PER:
PRODUCTS - COMP/OP AGG $ 300,000
S
—1 J LOC
r POLICY r ',Rgi r
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
BODILY INJURY (Per person) S
ANYAUTO
BODILY INJURY (P-1
ALLOWNED SCHEDULED
AUTOS AUTOS
NON -OWNED
HIRED AUTOS AUTOS
4 !CLAIMS
PROPERTY DAMAGE
UMBRELLALIAB
OCCUR
EACH OCCURAPNOE $
',�GGREGATE -_ S
EXCr-$$ LIAO
-MADE
DED I I RETENTION,$
_FW_CSTA_TUF_JOTH- $
WORK91kS COMPIENSATION
AND EMPLOYER5'LIA1314ITY Y/N
ANY PROPMETOWPARTNER/EXECUTNE
T,., ''. T, �R
E.L. EACH ACCIDENT
EA EMPLOYEE $
Eka DISEASE � EA
OFFICERIMEMBER EXCLUDED?
(Mandakory In NH)
N/A
E.L. DISEASE - POLICY LIMIT
if yes 0
End scribovndar
o RiPTION OF OPERATIONS below
DEUCRIPYION Or OPERATIONS I LOCATIONS/ VEHIOLr;5 1.1tach ACORD 101, Additional Rdrnarkts Schedule, If more space lGrequirecl)
CERTIFICATE HOLDER CANCELLATION _ _
NOANDOV SHOULD ANY OF AIR VE FJESCRIBEJ,WWM&Q&JjJAlWLED 13EFORE
THE E IVFRED IN
Town of North Andover ACCO L'"IMPR-OVISI Al
Bldg 20 Suite 2035
1600 Osgood St AUT14ORIz7ED REPRESENTATIVE
North Andover, MA 01846 Byam Broa
Td 1U11:5111 -4)l V AL;VKUI UUKFUKA I IUN. An rignis reserved.
ACORD 25 (2010/06) The ACORD name and logo are registered marks of ACORD
al
o
0,
m
z
> z
x
CD
OD
3 vi m
0
CL
C)
(D
3
_4 Z
C)
0
LO
(ID
Is
03
CL
tA Vd
C)
C)
(D
3
C)
LO
(ID
CL
(J)
U)
0 rn
A"
C,
-hl 0