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HomeMy WebLinkAboutBuilding Permit #834-15 - 49 LONGWOOD AVENUE 4/22/2015BUILDING PERMITo�_,UlD "ti\ TOWN OF NORTH ANDOVER 3? h 46 ` v APPLICATION FOR PLAN EXAMINATION _ h Permit No#: Date Received TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 9One family ❑ Addition ❑ Two or more family ❑-Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Ds eptic ❑'Well E. Floodplain EJ Wetlands ❑Watershed° District -QWater/Sewer __._ DESCRIPTION OF WORK TO BE PERFORMED: 5; �1! wti./I ,nS�1C4H014 bt!m -fe Docked Identification - Please Type or Print Clearly OWNER: Name: 7Q) -es Phone: Address: LJ ton i w t Contractor Name:of4c�,ce.i' '71tn3vla`r1�n� Phone: Email: PoICk bv%14 o 01 Address: o b- e Y- sT'8 n de r t/Ll t+4. Superviss Construction License. GSSL' " /o BOO 17 or'Exp. Date �l ��%dol 7-. Home Improvement, License:` : '? Exp. Date Z X0/6 ARCH ITECT/ENGINEE Phone: r 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: $ 31-& liS FEE: $ Check No.: Receipt No.: 2ke�o NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 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 4 Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses L�4 Copy of Contract Floor Plan Or Proposed Interior Work ,4 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 � Certified Surveyed Plot Plan 4. Workers Comp Affidavit 4 Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract 4. Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) 4. Mass check Energy Compliance Report (If Applicable) 4. Engineering Affidavits for Engineered products E: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) � 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 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 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 PLANNING & DEVELOPMENT Reviewed On COMMENTS Signature, CONSERVATION Reviewed on Signature COMMENTS HEALTH COMMENTS Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes a Planning Board Decision: Comments t Conservation Decision: Comments Wafter & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DERR@,� - mp ® reps t 1. Mam Stree ~` = MENT Te u ter on site s,y _oy' sated a r24 " Fire De . y Party, M, in situr�/ to 4 ; 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-$1000 fine NLN 1 tb ana UA 1 A — Notified for pickup Cal rtrment use mail M i Date Time Contact Name = Doc.Building Permit Revised 2014 2 --I 0 z 0 ,n z 0 m z m m Z r - p 0 0 0 ""Sc g �p m 0 C. CD =r C: CD $0, n CD 3. jD 3 0 — 0 CMD CD -n CD CD n c) CD (D --I 0 z 0 ,n z 0 m z m m Z r - p 0 0 0 ""Sc (paO $ O C' _ cr O (A _; < CD !D C O Ci • 0 O rt n ;mo Z O V1 S y' O y .0-► CDTI C o, O Q. 0 m �< CD W �' vs O _I N m CD 2 �• O �. as D r -L c ` �rt �D 0 Z O �' S m W "f � Z y A C =_. CD- CD 0-0 ;z Z C c < �. CL F)' " �rlm �o b N� CCDM 00cn: D ca n = -� 3 =_. �,CD O rn S S '" cn 0 � � < Q Q v, < O CD —1 ;aQ < 'D O U) a, CD CL �' C Cl) Q m Cr n Zcn ooCD CD h CD 0CD -� O Z " v, rt •r.� _L CD S' = O O O :: CD cn '0 Z c N s J CD v_ 8-0 O G) D C C Z: u _ < 0 CD 0 N O �^ 0 V �O m "M N CO T x T V7 x T ZI T r) � T (n T o P7 m CD m (D vc v c cm c s vs c crq c n 0 0 a o< o- n 7o o 'o z G) H p r- m 22 A > m m O 7p r- C G7 D O 70 W C Z G1 m m O m 3 s m coO 2 0 V �O m "M PERMIT AUTHORIZATION FORM . rel PARMPAMO CO s1 1, PITER 1ULES , owner of the property located at: (Owner's Name, printed) 49 Longwood Ave NORTH ANDOVER - (Property Street Address) (City) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. x Owner's Signature Dat FOR CSG OFFICE USE ONLY. Conservation Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date Offer for Office Use Only ...ev.1a �. 2132011 R ~ The Commonwealth of Nlassachusetts Depau•tinent of Industrial Accidents =. Office of Investigations Itt600 Washington Street x_ Boston, MA 02111 wtvw.►iiass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Information Prin Name (Business/Organization/Indii•idual): 1,0 1 4t CQ r" •L�j1 �j J 14 71)0 !n (. 0 `J'— Address: D. D_ ox f Phone #: Q % Are you an employer? Check the appropriate box: 1. AI am a employer with -- 4• ❑ I am a general contractor and I employees (fall and/or part-time).* have hired the sub -contractors 2. ❑ l am a sole proprietor or partner- listed on the attached. sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [\o workers' comp. insurance comp. insurance.= required.]5. F-1We are a corporation and its 3. ElI am a homeowner doing all work officers have exercised their myself. [\o .workers' comp. right of exemption per MGL insurance required.] ` c. 152, 51(4), and we have no employees. ['No workers' comp. insurance reouired.l Type of project (required): 6. El 'New construction 7. ❑ Remodeling 8. Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 1 1.❑ Plumbing repairs or additions 12.❑ Roof repairs 13-MOther 1-:nsJ/4i416 $1 *Anv applicant that checks box 11 mutt also till out the section belo\e showing their workers' compensation police information. Homeowners who submit this affidavit indicating they are doing all irork and then hire outside contractors must submit a new affidavit indicative such. =Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have eniplo\ ees. If the sub -contractors have employees. they must provide their workers' conip. policy number. 1 ant an en►p/oyer that is providing ivorkers' compensation insurance for my e►np/gl.,ees. Beloty is the po/ici' and job site information. Insurance Company'Name: Policy # or Self ins. Lie. #: ttY 0 V►JG �$�—L�b (o �J Expiration Date: I Job Site Address: _X'fl l oyl9 wetb J9 --/c City/State/Zip: n_ enj it eel, 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 fine up to S 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 S250.00 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. ! ilo /►erehr c^ifj under the pains andpenalties of perjti ty that the infor►n«tion provided above is Erne and correct. Official use onh'. Do not write in this area, to be completed br cin, or town official. City or Town: 11'ermit/License # ;�r II s 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 #: OP ID: SS i4`�.�'RE'R CERTIFICATE OF LIABILITY INSURANCE �'�`��°° 15 o3r13r�,s 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(les) must be endorsed. If SUBROGATION IS WAIVED, subject to Me terms and conditions of the policy, certain policies may require an endorsemenL A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Durso & Jankowski Ins Agcy LLC 198 Massachusetts Avenue North Andover, MA 01845 Durso & Jankowski Ins. Agcy. CONTACT PHONE Fax E-MAIL ADDRESS: PRODDERCUMN POLAR -1 I AFFORDING COVERAGE NAIL i INSURERS INSURED Polar Bear Insulation Co. Inc. P O Box 958 Andover, MA 01810 INSURER A: Penn America 32859 INSURER 13: insurance Co. 33618 INSURER C : INSURER D: INSURER E : i RER F L:tJVr-KAUM5 CERTIFICATE NUMBER: RFVICIn1M NIIMRFR- 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. RSR LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFF MMIDminrm POLICY EXP (mumonnrm LIMBS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,0() A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR PAC7052023 0"4=5 03I24/2M6 PREMISES Ea occurrence $ 50,0014 MED EXP (Any one person) $ 5, PERSONAL & ADV INJURY $ 1,000, GENERAL AGGREGATE $ 2,00000,00 GEWL AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG $ 1,0,00 POLICY JECT PRO LOC $ B AUTOMOBILE LIABILITY ANY AUTO 100926 01/04/15 01104@016 COMBINED SINGLE UNIT $ 1,000,00 (Ea acceded) BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Pe ao ddent) $ X SCHEDULED AUTOS X HIRED AUTOS PROPERTY DAMAGE (PER ACCIDENT) $ X NON -OWNED AUTOS $ $ UMBRELLA LU1B X OCCUR EACH OCCURRENCE $ 11000,00 A EXCESSLuh cuJMS-MADE PAC6906385 0=4=15 0311412016 AGGREGATE $ DEDUCTIBLE $ $ RETENTION $ WORKERS COMPENSATIONWC ANDEMPLOYERS'WIBILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVE OFRCERIMEMBER EXCLUDED? D NIA STATU TH- Y M PER E.L EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ (Mandatory in NH) If yes, describe under EL DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101. AddMonal Remarks Schedule, B more apace Is requinaM I�lsulation �I�lor Mine al Corservat�t icerouNSTAR 8 National Grid are addititortno I insured on Gent a liy po cy. verage 11 rimary an Non-Corttrib ry Conservation Service Group Contractor Services Dept 50 Washington St Westborough, MA 01581 ACORD 25 (2009M) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 46-61PL ©1988-2009 ACORD The ACORD name and logo are registered marks of ACORD riahts reserved 9.2-e&omwwwweaa r =�_Office of Consumer Affairs a1 1" t 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 102726 Type: DBA Expiration: 7=016 Tr# 252249 POLAR BEAR INSULATION CO. - - Vincent LeBlanc P.O_ BOX 958 ANDOVER, MA 01810 - - _ Update Address and return card. Mark reason for change. -- Address [:] Renewal r-1 Employment ❑ Lost Card DPS -CAI 0 SOM44/04-G101216 Liassac husetts Board c u1.cii:. ;i,2 R29L Construction Supervisor Speciai0 PETER A LEBLA14C 2 EAST PINE STREET = Plaistow NS 03865 _ r