Loading...
HomeMy WebLinkAboutBuilding Permit #706-15 - 5 GREENWOOD EAST LANE 12/9/2015NORTFt BUILDING PERMIT ro� TOWN OF NORTH ANDOVER °"'o - APPLICATION FOR PLAN EXAMINATION Permit NO: ? 0& Date Received Date Issued: _L./-- 1 — TYPE OF IMPROVEMENT PROPOSED USE Resid tial Non- Residential ❑ New Building ne family ❑ Addition ❑ Two or more family ❑ Industrial ❑ AI ration No. of units: ❑ Commercial Wl�epair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic ::❑ Well ❑ Floodplain ❑ Wetlands ~ ❑ Watershed"'District , ❑:.Water/Sewer - , �bher �W UJOd Identification Please Type or Print Clearly) 4 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BAS/ED�ON $125.00 PER S.F. Total Project Cost: $ UIP �i • FEE: $ `T Check No.: / -; 4W, Receipt No.: NOTE: Persons cont cting witl&Cnregrstered contractors do not have access toanty fund 4f. Plans Submitted ❑ Plans Waived.❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanniug/MassageBody 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 o U FORM PLANNING & DEVELOPMENT COMMENTS Reviewed On Signature. CONSERVATION Reviewed on Signature COMMENTS HEALTH COMMENTS. t Reviewed on _ Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments 'mater & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: FIRE NiTAI ;LocatebjaVvW Main Street rFir6E);bpartr enrA-►gn COMMENTS,` npObr on site yes Located 384 Osgood Street �2�r+� *a� �tvL- rjSy�lu 4. "t 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 ruse) Ll Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 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 o Copy of Contract o Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products 3TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses o 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) o 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 o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products )TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit n all cases if a variance or special permit was required the Town Clerics office must stamp the decision from the Board of Appeals hat the appeal period is over. The applicant must then get this recorded at the registry of Deeds. One copy and proof of recording oust be submitted with the building application Doc: Building Permit Revised 2014 Location s— No.—') "`% } ^" Date Check # f-- 2°797 TOWN OF NORTH ANDOVER, Certificate of Occupancy. Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ J�' Building Inspector CD 0 Z �D O Cr CL �. 'a c� O 00 CD C c CD O CD CL O cQ CCD CO) CD n r+ O Lwj n 0 CD C'1 O r� S CD CD tn' �D N O O 0 CD O y S C° a Cl) V > p• CL O 0 CD 0 m O a' z p ? =r -0 p O N CD T - rt o o .-« CL m CD CD , CD '!0- a O CL O a= a D 0o C o �« n to y � .r O C W � p CD A./) <D -a ' Z CL -i o � m rn to U)� CD ov,L CA � o o� rr :S 0mv�y� Q Z� Q0°' N X X Q < N� 0 C Cl) = CD y CL oo '-' 1 C Z @ v, 'COD 01 �, � ti a o - C1 —� Cncn CD S o Fx UO) .d z � =r -a Cn m o C rn Vl 3 O (D (D N Y (D �O-* O 0 W C O (CD �o v a z T j' Dl ::o O C- 7' G) N n T 3 Dl N O Z rD .T7 O C S r mc n f7 N v m T 5 DL Z7 O C S r- cl N m -� T j' R (••) S 7 �p O C 3 T O C DL 0 O O W C z M z H r^ 0 (A (D -O �• n fD 3rn T O O \ 3 N ' W o 2 m D 2 Service Information Matthew Carnevale 5 Greenwood East Ln North Andover MA 01845-4622 Contact: Matthew Carnevale Phone: (617)571-8238 Fax: Alt Contact: Alt Phone E -Mail: quaffro—ft-225@yahoo.com Job Name ❑ Call Ahead 0 Confirmed Carnevale, Matthew - 2497 Job Type # *p �ers 2 "permit ne Sweepnman, Inc. 108 Main Street Building H North Reading MA 01864 Phone: (978) 664-6642 Fax: (978) 664-1298 sweeanman0vahoo.com www.sweepnman.com Work Order Billing Information $250.00 Matthew Carnevale 5 Greenwood East Ln North Andover MA 01845-4622 $4,930.00 Marketing Campaign Wom Sales Rep Terms $0.00 Type Class TM Due on receipt Liner Route Scheduled Start End TimothyM 1 12/10/2015 08:00 AM 04:00 PM Item Quantity Rate Amount LINER - Liner for brick oven 6" hybrid 1 $2,390.0000 $2,390.00 Insulated at the bottom and around the top LINER - For wood stove insert Bricks will have to be removed from the back to fit the full 6" liner through the throat Permit - Permit Fee $2,290.0000 $2,290.00 $250.0000 $250.00 Job Subtotal: $4,930.00 $0.00 Account Balance: $0.00 Total Due: $4,930.00 System Info Home Heating Chimney Info System Chimney Cap Job Notes and Instructions TM estimated this job from his prior company, customer search him out, please go and provide estimate for liner work This report is the result of visual inspection done at the time of cleaning. It is intended as a I have read this form and understand the convenience to our customer, not as a certification of fire worthiness or safety. Since apparent condition of my fireplace, appliance, conditions of use and hidden construction defects are beyond our control, no warrantee is chimney, and / or vent system. Furthermore I made for the safety or function of any appliance, and / or system, and not is to be implied. understand the limitations of this report as given. 'c091510:21a Sweepnman, Inc. 978-664-1298 p.1 ;iWC>R0r CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYWY) 1i 12/9/2015 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 Scott Leavitt, CIC, LIA -NAMMTMBrainerd Inc PHONE(978) 667-9031 FAX AIC No:(978)667-1018 lA Andover Road _ADD scottl@brainerdinsure.com INSURERS AFFORDING COVERAGE NAIC fl MED EXP (Anyone person) $ Excluded Billerica MA 01621 INSURERA:Jame- River Insurance CO an INSURED INSURERB:Safety Insurance CompanV Sweepnman Inc. INSURER C : 108 Main Street Bldg H INSURER INSURER E North Reading NA 01864 INSURER F; 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, EXCLUSIONSAND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN8RR TYPE OF INSURANCE INSD POLICYNUMBER ! MMIDDIT'l POLICY LUAITS A X 'COMMERCIAL GENERAL LIABILITY i CLAIMS -MADE [i] OCCUR EACH OCCURRENCE $ 1,000,000 AMAGE TO RIENteu PREMISES (Ee occurrence $ 5D , 000 X Blanket Additional 1 000691690 11/18/2015 11/18/2016 MED EXP (Anyone person) $ Excluded Insured By Contract PERSONAL a ADV INJURY $ 1,000,000 i GEML AGGREGATE LIMIT APPLIES PER NXPRO- r�POLICY JECT [ j LDCPRODUCTS GENERAL AGGREGATE S 2,000,000 -COMP/OP AGG $ 2,000,000 OTHER: EmployseBenefts $ AUTOMOBILE LIABILITY COMBINED SINGLE 7LUT Ea accident' $ 1,000,000 BJ AUTO ALL AUTOS ED X AUTOSSCHEDU�D HIRED AUTOS XNONJIVED AUTOS AUTOS NQw #TBA 11/18/2015 11/18/2016 BODILY INJURY(Perperson) $ BODILY INJURY (Per accident)' $ X PROPERTYDAMAGE Per accident $ $ UMBRELLA UAB EXCESS LIAR OCCUR CLAIMS MADE I EACH OCCURRENCE $ AGGREGATE $ DED RETENTIONS I $ i :ANY ;OFFiCERIMEMBER WORKERS COMPENSATION_ AND EMPLOYERS' LIABILnY Y / N PROPRIETORIPARTNERIEXEGUTI VE EXCLUDED? C (Mandatory In N K yes, describe under NIA t STA UTE I ER" E.L. EACH ACCIDENT $_ E.E.L.DISEASE -EA EMPLOYE $ E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS below i DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (ACORD 101, Additional Remad(s.Schedule. maybe attachedif more space is required) This Certificate of Insurance represents coverage currently in effect and may or may not be in compliance with any written contract. Matthew Carnvale 5 Greenwood East Lane North Andover, MA 01645 ACORD 26 (2014/01) INS025 I2olanie 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 1S Leavitt, CIC, LIAiS ©1988-2014ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ACOR" CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 11/17/2015 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 D -JOHNSON INSURANCE AGENCY INC 7 GROVE STREET STE #201 TOPSFIELD, MA 01983 CONTACT NAME: PHONE No Ext)! FAX No E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC # INSURERA: LM Insurance Corporation 33600 INSURED SWEEPNMAN INC INSURER B : EACH OCCURRENCE $ 27 LOWELL RD INSURERC: INSURER D: NORTH READING MA 01864 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 27338068 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 LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MMiDD/YYYY POLICY EXP MM/DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY r EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS -MADE OCCUR Ea occurrence PREMISES $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: PRO - POLICY JECT LOC GENERAL AGGREGATE $ PRODUCTS -COMP/OP AGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ ANY AUTO ALL OWNEDSCHEDULED AUTOS AUTOS Per accident ( ) BODILY INJURY $ HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE $ Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N / A WC5-31S-388139-014 12/18/2014 12/18/2015 STATUTE ER _ _ E.L. EACH ACCIDENT $ 100000 E.L. DISEASE - EA EMPLOYE $ 100000 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Workers compensation insurance coverage applies only to the workers compensation laws of the state of MA. This certificate cancels and supersedes all previously issued certificates, only as they relate to workers compensation coverage. MATTHEW CARNVALE 5 GREENWOOD EAST LANE NORTH ANDOVER MA 01810 liAMlitLLA I IUN 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 LM Insurance Corporation ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD 27338068 1 1-388139 1 14-15 WC I yogeah.patil@libertymutual.com 1 11/17/2015 5:24:28 PM (PST) I Page 1 of 1 The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aaulicant Information Please Print Legibly Name (Business/Organization/Individual): �S%/, )P_& Yi --,L fY(� . Address: Are Are you an employer? Chec the appy 1.5 I am a employer with employees (full and/or part-time).* 2. ❑ 1 am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ 1 am a homeowner doing all work myself. [No workers' comp. insurance required.] t 6jl /Phone #:917 -- hate box: 4. 0 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.* 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] l /- Type of project (required): 6. 0 New construction 7. 0 Remodeling 8. 0 Demolition 9. [] Building addition 10.0 Electrical repairs or additions 1 I.0 Plumbing repairs or additions 12.0 Roof repairs 13.1,Other�j� *Any applicant that checks box #1 must also fill out the section below showingtheir workers' compensation ol"" ' p p y information. � 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 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 insurance for my employees. Below is the policy and job site information. , ._1 , , - p Insurance Company Name: Policy # or Self -ins. Lic. #: I� � —� 3�,5 ' _0z Expiration Date: Job Site Address:5 Orma walfd City/State/Zip: r '! 14 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 $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. I do hereby certi fy ant s and penalties of perjury that the information provided above is true and correct 44 II Official use only. Do not write in this area, to be completed by city or town official. City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Contact Person: Permit/License # 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Phone #• 11 __ Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supen-Asor Specialt-, License: CSSL-100886 DAVID A BANCROFT 27 LOWELL RD..` North Reading MA 01 Expiration Commissioner 0310912016 Commonwealth of Massachusetts Department of Public Safety Oil Burner Technician Certificate License: BU -026558 I rs DAVID A BANCR0FT 27 LOWELL gD.,- North Reading 1V A 0181 Commissioner Expiratioh: 03109=16 Office of Consumer Affairs& Business Regulation License or registration valid for individul use only 1.1 - -1 — F -i - 11.1 . ME IMPROVEMENT CONTRACTOR FA �a_ �V -. before the expiration date. If found return to: ��q registration: stration: 160389 Office of Consumer Affairs and Business Regulation 6 Ul Type: K piration: 7/161/2016 Private Corporatior 10 Park Plaza - Suite 5170 Boston, MA 02116 SWEEPNMAN, INC. DAVID BANCROFT 27 LOWELL RD. NO- READING, MA 01864 Undersecretary Not valid without signature