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HomeMy WebLinkAboutBuilding Permit #371 - 5 WALKER ROAD 11/12/2009 TOWN OF NORTH ANDOVER 2 APPLICATION FOR PLAN EXAMINATION Permit N0: ✓ Date Received Date Issued: -/ 2-05 IMPORTANT: Applicant must complete all items on this page LOCATION ( 1ALgt0 1 : N, AN-60VL-tZ 0 t&'-AS Print PROPERTY OWNER M-\gMtjs ROY en 07 Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes (:0)_ 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 Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: fkmoy= a- Ro oF d J`O 30Y2 12bj- F Identification Please Type or Print Clearly) OWNER: Name: TJJo/�A-5 Phone: 17&4 g2: 3�Cyl Address: 5 tiALI(K RC) CONTRACTOR Name: Phone: (Rf 7 3 3� Address: 142. ROYAL- Ctf-cLr- I- M Nd d3a75 y Supervisor's Construction License: Exp. Date: 0&t t y J 2-c 1 C Home Improvement License: 1 K$?y Co Exp. Date: t© l 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: $ Zz unto. FEE: $ e;�� ��— Check No.: Z 15.3 Receipt No.: 90v-e /3 NOTE: Persons contracting with unregistered contractors do not have access to the uaranty fund Signature of Agent/(Jwner Signature of contrac i 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 Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature&Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS 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 Doc:.Building 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 NOTE: 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 ❑ 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: Doc.Building Permit Revised 2008 f f Location No. Date �^ NORTH TOWN OF NORTH ANDOVER F ' 9 # • • i ; , Certificate of Occupancy $ -, sACMUs Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # j53 Building Inspector Licensed&Insured Member of Boston Better Business Bureau �1 Page No of Pages COHEN BROOKLINE C11 MALDEN (617) 734-9100 FULLY LICENSED ROOFING SPECIALISTS FULLYINSURED (781) 322.0822 405 WALTHAM ST#356,LEXINGTON, MA 02421 PROPOSAL SUBMITTED TO PHONE DATE r.M -1 `174 r.sc�c c,n 11 v y v 9 STREET JOB NAME 5 viFlix,,,iz ?,(D CITY,STATE AND ZIP CODE JOB LOCATION nil'6IlS ARCHITECT DATE OF PLANS JOB PHONE We hereby submit specifications and estimates. Strip roof down to the boards, replace normal amount of boards. Maximum amount of boards to be replaced 75 feet at no charge. Gtx Put three feet of Winter Guard onall bottom edges of roof, and existing valleys. Refer to Exhibit A. Cover entire roof with roofing paper. Install 8" aluminum drip edge on all edges of roof(color counter flash chimney, new vent pipe flashing(s). Install a GAELu< 30 year roof. All roofs hand nailed. We DO NOT use nail guns. -TInt3t11LW� All debris will be removed by Cohen Construction 12 year guarantee on Workmanship License O year guarantee on Materials #148746 - C�E��ic Ruc,r res cK��iCa C,)I�rr1 YZ PI Yl,(,60 T1�1SIAA P,\(,)(-f � 'i tr..�Z r7�:-I-Z 4xt-tAt,GT y./�°v�inf/a . Ir"SiAt 1 101- PR(P4 iZ A-1ri,^.T Gk <i,f IF,T V�,.,T< 111E propose hereby to furnish material and labor—complete in accordance with above specifications, for the sum of: 7WQk)S>nrvrN A`40 C' �� dollars ($ 2 r.. . aymeni to m e as ows: rf 7(c G r,„ p')T- �-1 A T A-Iv O P-A t�c f o-,, r f 16,5_-T t c,Q All material is guaranteed to be as specified.All work to be completed in a workmanlike man- ner according to standard practices.Any alteration or deviation from above specifications Authorized involving extra costs will be executed only upon written orders,and will become an extra Signature /15�. ! charge over and above the estimate.All agreements contingent upon strikes,accidents or // delays beyond our control.Owner to carry fire,tornado and other necessary insurance.Our Note This proposal may be workers are fully covered by Workman's Compensation insurance. withdrawn by us if not accepted within n 3 V days. � cceptttnre of Proposal - The above prices,specifications and conditions are satisfactory and are hereby accepted.You are authorized to do the work Signature as specified.Payment will be made as outlined above, g r - i Date of Acceptance: Signature The Commonwealth of Massachusetts >=- Department of Industrial Accidents 57 Office of Investigations 600 Washington Street Boston, MA-02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): (�rJ fl� Cp�S'rRU G? (U l�) Address: '-i-z L 61[ZCLE- SHL Mt 03071 City/State/Zip: , hone#: 6I7 3 3 L� 3 9*6 Ayou an employer? Check the appropriate box: Type of project(required): 1. 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.❑�I am a sole proprietor or partner- listed on the attached sheet. 7• ❑ 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 10.❑ Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ lambing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12. 00f repairs insurance required.] t employees. [No workers' 13J] Other comp. insurance required.] *Any applicant that checks box 4::nu=a:so fill out the section below showing their workers'compensa *ion policy information fi Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. xContractors 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 isproviding workers'compensation insurance for my employees Below is thepolicy andjob site information. t 1 Insurance Company Name: I pt ,56kr4y �i.(�i1RAJ.It /4c-� G7 Policy#or Self-ins. Lic.#: Expiration Date: d 1c)Zg I ZU l U Job Site Address: 57 W41-KEK City/State/Zip: AkJYXVtKi M� p1 � 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 certify er the pains an penalties of perjury that the information provided above is true and correct Si ature- Date: tlhoa Phone#: 6/ Official use only. Do not write in this area,to be completed by city or town official j 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-contractors)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 bum 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 021.11 Tel. # 617-7274900 ext 406 or 1-8,77-MASSAFE Fax# 617-727-7749 Revised 5-26-OS wvvw.masS.gov/dia c e40RTH Town of 3 o No. 71 00� dover, Mass., T 0 LAKE COCHICHE WICK DRATED PPa�.�S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT..... r .. 1.............X�y ................................................................ ................. Foundation has permission to erect........................................ lulldi on .............. g • �. ...... . . ... .................. Rough to be occupied as............ f chimney .................................................. provided that the person accept g this permit shall in every respect c rm to the terms of the application on file in Final 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 CONSTRU STARTS Rough ......................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT zq': Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. 07/17/2009 13:29 19786859460 HASBANY INSURANCY PAGE 01 ATTN. IT NIS ACORoCERTIFICATE OF LIABILITY INSURANCE DATE(MMf1111IM Y) `� 107/17/2009 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Hasbany Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 236 Pleasant St HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Methuan, NA 01844 ' Phone #: 978-685-3188 Fax 0: 978-68S-9460 INSURERS AFFORDING COVERAGE NAIC Y Craig Cohen 'MRUW*D& Penn America Insurance, Compa wwnfno: AIG-Granito State Insurance 405 Waltham St. — — INSURER C: Mm tkuea, Mh. 01844 INcnRER D: INSUflER E: COVERAGES THE PDLICIES OF INSURANCE LISTED BFI,OW 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 19 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONq OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE 9FEN REDUCED BY PAID CLAIMS. —. ... ... .— Lm IBRD TYPR OF INSURANCE POLICY NUMBER 'Y E n� CX°K+Ano — DAYS(M DATE LIMITS A OENERALLIABILITY 987668 106/28/2009 06/28/2010 EACNOCCURRENCF $1,000,000_ ..X COMMERCIAL GENERAL LIABILITY PREMISES NEI OaaYAXnrot 5 100,000 1 CLAIM9 MADE -- I OCCUR MED EXP IAAy 6,*P"AN 410,000 -- ..-- - PERBONALA ADV INJURV_ $1,000,000 GENFRAI,AOOnEGATE 12,000,000 OGNL AOaREoATE LIMIT ArrLIES PER: PRODUCTS•COM;.,AOD $2,600',-000 XrOL.1' JECT LOC AUTOMOBILI'LIAMLm COMtUNED SINGLE LIMIT .. ANY AUTO (FA AnpWnq S ALL OWNED MlT(A lDNEDULEDA105 RODILYBLIURY B (Pa aarea) MIRED AI)TOS •• .- 90DILY INJURY NON.OwNED AUT08 (Pm�aotdonq $ PROIERTvDAMAOF ! (IM uddenq DARAOE LIABILITY AUTO ONLY•EA ACCNT S ANY AUTO ...--•. IDE• •. ••• OTHER THAN F1 AM, p MITOONLt .. .. . AGO B E110E!lIUMMELLA LMBILITT EACH OCCVRRENCE ! prrj,rR �CLAIMS MAGE I _ AfiORE!iAYE •� .• • JJ i RETENTION 3 $ 8 WORKERSCOMPEPAArONAND WCMA97-318-09 1 06/28/2009 06/28/2010g EMPLOYI!W LUIBILLTY f TORY I IMITS ER ANY PnOrnIETORIPARTNERJTX[CVnVE F)..FACFI ACCIDENT $1,00_0,000 _ OFFICFWMF.MRER EXCLUOED7 - ,• B yN,fiw,b Unum C.L.DISEASE•EA EMPLOYEE R 1,000,000 SPFCNL rROWSIONB we.x -- OTHER F.L.DISEASE•POLICY LIMIT ! 1,000,0 0 0 OCACIU VTION OF OPP,RATIONS I LOCATWNA I VEHICLES I EYCLU$IONS ADOED BY ENDORSEMENT/SPECIAL PRDVI,gQN$ Opps:General Contractor CERTIFICATE HOLDER CANCELLATION building Inspector $MOULD ANY OF THE ABOW MECRIBED POLICIES OF 1,ANCELLED RI!FORE THE FWRATIDN Town of No. Andover DATE fHEREOF, TTIE ISBUING INSURER VALL ENDEAVOR TO NAIL 10 DATE wRITTEN NOTICE To THE CPATIHCATE HOLDER NAMED TO TIME LEFT, BUT FAILURE To DO SO :MALL IMPOSE NO OBLMATION OR LIABILITY of ANY XIND UPON THR INSURER, R5 AGENT_$ OR REPRESF,NTAT AUTNDRIZ EPREM! 1-603-898-9581 Eric ACORD 25(2ooTJ0$) / 0ACOAD CORPORATION T9B8 �f� 19onvnulation Co Office of nsumer Affairs AC&Business Reg lugHOME IMPROVEMENT CONTRTOR Registrat►on 148746 Tr# 289727 1012012011 Expiration 7 Individual A CRAIG COHEN<l 1r CRAIG- COHENL 8 JANA ROAD \„ 4 Undersecretary SALEM,NH a � � ✓fie '�omiriio�uue�1�l tand�l'�a.C��ce6e,�r� .�-.j Soard of Btitidrng Regulations ani Sds� 1 Con,`strtr�tiarrSupervisor License s L�te`nse CS 96405 sTT�i 96ts' xxpirat 6114!2010 46 1 Restnotioft 0©, �. 1 ,� CRAIG CQHEK , k ROAD I S LEM NH 03079 r r Gam �s�oner, r 41 I F Jy. f .b�