HomeMy WebLinkAboutBuilding Permit #836-2016 - 49 KINGSTON STREET 1/26/2016i
/a ��,p�j� I �-, BUILDING PERMIT
T' lam" TOWN OF NORTH ANDOVER
�j APPLICATION FOR PLAN EXAMINATION �j�
Permit No#: r Date Received
Date Issued: 11 7-0 I u
.A,- ti
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
ne family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
epair, replacement
❑ Assessory Bldg
❑ Others:
Demolition
❑ Other
�: Septic C41Nell❑
Floodplain Wetlands
❑Watershed Qstnct
D WaterlSewer ,..
OWNER: Name:
DESCRIPTION OF WORK TO BE PERFORMED:
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016923
ARCHITECT/ENGINEER
Phone:
Address: Reg. No.
FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED CT BASED ON $125.00 PER S.F.
Total Project Cost: $ 1, a ?�. 30 FEE -.1, �% '-'-
Check No.:
NOTE: Persons contracting
Receipt No.
contractors do not have
of Agent/Owner Signature of contracto
rtV fund
7---
.W
.W
Permit No#:
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
Date Issued:
IMPORTANT: Applicant must complete all items on this page
V' �.�LED 16 N
2 6 t Q
LOCATION
Print
PROPERTY OWNER
Fr'inf 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
❑ New Building
❑ One family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
D :Septic 0 Well
❑ F.Lo°odlain Wetlands.
, ❑ 'U1/atershed District
❑ UVatelSewer _ ._ _ . ..;..
__ ___
c_
DESCRIPTION OF WORK TO BE PERI-UKMEu:
Identification - Please Type or Print Clearly
OWNER: Name: Phone:
Arldrace-
Contractor Name: Phone:
Email:
Address.:. .
Supervisor's Construction License: Exp: Date: .
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER
Phone:
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 contracting with unregistered contractors do not have access to the guaranty fund
S� attire o1dAaent70wner Signature of confractor _ �y:
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
Taming/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
PLANNING & DEVELOPMENT Reviewed On
COMMENTS
Signature.
CONSERVATION Reviewed on Sionature
COMMENTS
HEALTH
COMMENTS
Reviewed on
nature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEE
PARTMNT �.Ternp Du p in
t
�,
Located at 1►24 Main Streets
• 49. it ' ..
Fire Department gig at11 to
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.$10041000 fine
NOTES and DATA — (For department use)
❑ 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
4. 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
a. Engineering Affidavits for Engineered products
TOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
4� 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/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)
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
2012 IECC Energy code
Engineering Affidavits for Engineered products
TOTE: 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: Building Permit Revised 2014
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The Commonwealth of Massachusetts
_ Departinent of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
t www.mass.gov/dia
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information !Please Print LeLlibi
Name ln Cfr`ciro
Address: a �JimQj gA
Cite/State/Z1D:
8 3 4 Phone #: 7 $1 " 831- Joys.
Are you an employer? Cheft the appropriate box:
=t. 1 am a general contractor and I
I. 1'1111 a employer with _�❑
jj cmhloyccs (full and/or part -utile).:` have hired the suh-contractors
2. ❑ lam a side proprietor or paruter_ listed on the attached sheet.
ship and have no employees
workint for 111c in any capacity.
[No workers' comp. insurance
required.
❑ I am a homeowner iloine all work
myself. I No workers' comp,
insurance rcquircd.]
These sub -contractors have
employees and have workcrs
comp. tnSUra nce.*
5. ❑ We are a corporation and its
officers have exercised their
right of' exemption per Ni61-
c. 152. S 1(4), and we have no
employees. (No workers'
comp. insurance required.)
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
S. ❑ Demolition
9. ❑ Building addition
IO.D Electrical repairs or additions
l I.❑ Plumbing repairs or additions
12.Q Roof repairs
13.�tOther-D&C:'r
".1mapplicant that cheeks hox -:1 must also till oul the section helowshossuag their workers' compensation policv inlornialion.
+ Homcoe ncrs N%ho suhniit this affidavit indicating Ilie y are dieing adl work and theft hire outside contractors mutt submit it now affidavit indicating.uch.
:Contr.tctor, that check this ho_c must attached an additional sheet showhts the name ol" the suh -con tractors and stair whether or not those entities hair
emploscc>. if [tic still -contractors have.mplowes, (heti' most provide their workers comp. policy mmnlxK.
1 ant rut employer iliat is provitling is,orliers' contpettsatiott insurance ji,or my entpinyees. Below is the policy and. job site
it{fnrnratinn. �
Insurance Company Name: -Pra,Y d -m t rvP er}y f �V0.Ily
8
Policv # or Self -ins. Lic. #: 7'P,3 g E l g 16 "� Expiration Ditte:
Joh Site Address: City/State/ZipN - way r , tM Pr d td
Attach a copy of the workers' compensation police declaration page (showing the police number and expiration (late).
Failure to secure coverage as required under Section 25A of MGL. c. 152 call 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 $250.00 a day against the violator. Be advised that a copy of this statement may be fbi-warded to the Office of
lmcstidaations of the DLA for insurance Covera -c verification.
I do hereby certif�t► er tltL pains 'and p alties of perjury that the information provided above is true and correct.
Date:
—1b
Q.ficial use only. Do not write in this area, to he completed b}' city or town gfficiat.
City or Town:
Issuing Authority (circle one):
1. Board of Health 2. Building Department
6. Other
Contact Person:
Permit/License #
3. Cityfrown Clerk 4. Electrical inspector 5. Plumbing Inspector
Phone #•
, r r- rw6n ira ur INZIUKANUI: LIS It[) tILLOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT
TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS
POLICIES. AUOREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
I 5R DD
AND CONDITIONS OF SUCH
POLICY NUMEIR
P 2,1 VFEC
P Y EXpJRA710N
LIMITS
GENERAL LIABILITY
r1I
I EACH OCCURRENCE S 1,000,000
X COMMERCIALOENERALUASIV
! MPU7994P
07-24-2015
07.24-2016
MAGE s 300.000
CLAIMS MADE F7X OCCUR
MED EXP rmn pvcvm_1 10,000
B
PERSONAL BADV INJURY Is 1,000,000
GENERALAOOREOATE is 2,000,000
jGENLAGGREOATELIMtTAPPIIESPER-
i 7 PR POLICY I F-1 LOC
I
PRODUCTS-COMP10PA00 S QQ OQQ
AUTOMOBILE LIABILITY
ANYAUTO
026008830
07-29-2015
07-29-2016
C000d M(1 08iNOLEUMrr
IED ctltl$ 1,000,000
ALL OWNED AUTOS
A
KSCHEDULED AUTOS
1 BODILY INJURY S
(pprpayp�j
,
X t HIREDAUTOS
K NON
i
009 LY
aGlntS
PROPERTY DAMAGE S
tPeraxldertq
OARAOILU,SSLrTY
AUTO ONLY -EA ACCIDENT E
ANY AUTO
j
OTl{ER THAN FAACC I S
AUTOONLr.. AGG I S
EXCE88!UMBRILLALIABILITY I EACH OCCURRENCE F S
OCCUR 17 CLAIMS MAOE
(
AOAO REGATE S
E
DEDUCTIBLE
)s
RLTRMTION
Is
WORKERS COMPENSATION AND
I TATtr• DTH•
5MPL0YERS' LIABILITY
(
Y
I ANY PROPRIETORIPARTtJERlEX!CUTIVE
-
E.L EACH ACCIDENT s
OFPICERMEMSER EXCLUDED?
C.L gbEA3E - EA EMPLOYEE E
Ny48, COW 06 undor
PECIAL PR Vl t BIDW !
EL. DISEASE I
OTHER
- POLICY LIMIT S
C Mass Workers Compensation 7PJUB-2E41618-1-15 8/23115 8123116
I
Employer Liability
I
100,000 / 100,000 / 500,000
DESCRIPTION OF OPERATIONS I LOCATIONS 1 VENICL62I EXCLUSIONS ADDED BYENDORSEMI!NTI SPECIAL PROVIVONE
Lowe's Companies, InC. and any and all subsidiaries are named as additional Insured as respects to General Liability And Auto
Llablllty
Lowes Companies Inc
Attn, IS Insurance
Post Office Box 1111
North Wilkesboro, NC 28856
Fax 877 689 9084
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES as CANCEL LEO eEFORE THE EXPIRATION
DATE THEREOF. THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LER, OUT FAILURE TO 00 90 SMALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, IT$ AGENTS OR
25 (2001108) ACORD CORPORATION 1988
2014-10-15 14:45 isoprt75.1979 1 >> isoprt75 P 112
ni�. office, of Consumer Affairs & Business Regulation
ffl,,-111@-i1FIME I rAPROVE ME NT CONTRACTOR
gistration: 160140 Type:
06A
?; expiration: 612512016
KEVIN CARREIRO CbNS7RUCTION
KEVIN CARRERO
2 SWES RD -
KINGSTON, Nh 03848 linki'seerctarY
Massachusetts - Department of Public Safety
90ard of Bz.;!dir%g Rcgu!--tions and Stan.dards
0in%truvtion Supcni-o,r
I
License: CS -074572
KEVINT C CARREJkO
2 SURES RD A
66389-4
KLNGSt6N NH
Expiration
Commissioner
09102F2016
Location A. 61
No. Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee s
A $
Foundation Permit Fee
Other Permit Fee $ k
ATM,
TOTAL $