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Building Permit #688-14 - 50 BLUE RIDGE ROAD 4/8/2014
BUILDING PERMIT ••:'� ��,\ TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received rap Date Issued: 6 �,Ss�CM 5 ORTANT: Applicant must complete all items on this page 1, *1 Lt .: °-, TYPE OF IMPROVEMENT PROPOSED USE Phone: 6-4 ty q?3 ' (03 Residential Non- Residential ❑ New Building ..One family ❑ Addition ❑ Two or more family ❑ Industrial %.Alteration No. of units: ❑ Commercial Repair, replacement ❑ Assessory Bldg ❑ Others: D Demolition ❑ Other in5ft)ltilotwFPY , -� L----T+e woad �- f ch) mncy _ •J ( t Identification Please Type or Print Clearly) OWNER: Name: Bru Ce d+ Phone: 6-4 ty q?3 ' (03 1:10 Address: fj (U e Q C(Aq e N. Q� � N5 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cos $ FEE: $ 5-V Check No.: W41 Receipt No.: NOTE: Persons contra ting with unregistered contractors do not have access t th aran of r" �, tur�rof Agenfr �.- MAC TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION -.. Print. PROPERTY OWNER Print 900 Year Old Structure yes no MAP NO: 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 11 Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: Phone: CONTRACTOR Name: Phone: Address: _ Supervisor's Construction License: .Exp. Date:._ 1Home Improvement License: Exp. Date: _ I ARCHITECT/ENGINEER Phone: Address: FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ EE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature:of Agent/Owner Plans Submitted Ll i Plans Waived ❑ Signature of contractor i4i4 a Certified Plot Plan ❑ Stamped Plans ❑ M Location ?A — j No. & Date Check # I TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Building Inspector Plans Submitted ❑ Plans Waived ❑.. Certified Plot P-san ❑- Stamped Plans ❑ TYPE OF::SEWERAGEDiSROSAL Public Sewer ❑ Tanning/MassageBodyArt ❑ ... ,Swimming Pools ❑ Well ❑ _Tobacco.Sales ❑ -Food Packaging/Sales ❑ Private --(septic tank, etc:_❑ Permanent I3urnpster on:Site - THE -FOLLOWING SECTIONS FOR'OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE. REJECTED DATE:APPROVED PLANNING & DEVELOPMENT` ❑ F1 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: Comm Conservation Decision: Comments Water & Sealer Con nectionisignature & Date Driveway Permit DPW Tows! Engineer: Signature: FIRE DEPARTME - Temp Dump;st8r on site yes_:. `Located7bi: 124 Mair, Street, Fire Departure►it-sighaitu`r_e/date`1` COMMENTS Located 384 Osgood Street no Dimension INumber 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 DANGERZONE LITERATURE: Yes No MGL -Chapter -166 section 21A -F and G min.$100-$1000..fin.e NOTES and DATA — (For department use i ® Notified for pickup - Date Doe.Building Permit Revised 2010 ww�w - Certified Plot Plan ❑ Stamped Plans ❑ Building Department The foli"owing.is'a=list of,tho required,forms to be filled ouffor. the appropriate. permit to be obtained. Roofir?cg, Siding, Interior Rehabilitation Permits aRuilding Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/O'r 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 o Building Permit Application a Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses a 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 a 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 cas<s if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apnaal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.tted with the building application Doc: Doc.Building Permit Revised 2012 Q 2 LL O m N Y -Y�O O LL N i N O. N 0 N1 CL z Z p J m C O -p 7 LL spp O w T O C U r6 C LL 0 U Wa H z ? m D C t j d' r0 C LL O V oW. Z u pC v W W t j O OC O u N _ c0 C LL O0 W H z Q t 7 O K _ m C LL Z w a p w LL v �. 7 Co z ) O N VI a a)N Y O N 0 cn J L m N C C O y C1 O _ O O O = mm"a �. E "" C d O Z Q C0 O s N 3 CD •> O o E- Q�aD CD 0 •y cm V O = r- 4) �a = d H O to (u �� w = moo LL. 'y d _ .O - s O F' :3�.:_. w E N Q._ O>N d O 2 -0 ILO LO C 0 cn r C �z cfl z co M Lu N L.L. cn CL z w0 F- V C G W a. z o LU CO Z . 0 m 'O 00 o CL cL cm Q J •O O CD z CLN AcC7RQ' CERTIFICATE OF LIABILITY INSURANCE 1/DATE(MMIDDIYYYY) `--�'3/2014 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 tjilikirris and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the ONEWcate holder in lieu of such endorsement(s). PRODUCER FIAT/Cross Insurance 1100 Elm Street Judith George CIC,CPIA,CPIW ,). (603) 669-3218 FAX Net: (603) 645-4331 iaeorae@crossaciencv.com INSURERS AFFORDING COVERAGE NAIC # Manchester NH 03101 INSURERA:Continental Western Ins CO INSURED Fences Unlimited, Inc. INSURER B :Union Insurance Company Mis-Bec of NH, Inc. dba The Stove Shoppe INSURERCAcadia Ins Co. The Commons INSURER D :Granite State WC Manufacturer's 25 Indian Rock Road, Route 111 INSURER E: Windham NH 03087 INSURER F: CnVFROGFS CFRTIFICATF NI1URPR•14-15 All linps- MW WC OCvlcrnrr du teeQCo. 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 L TYPE OF INSURANCE ADDL SUB POLICY NUMBER POLICY EFF M /DD/ Y POLICY EXP MM/DD/YYY LIMITS - A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR CPA0311123 /1/2014 1/1/2015 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $ 250,000 M E D EX P (A ny one person) $ 5,000 PERSONAL BADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICYFX PRO X LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ B AUTOMOBILE LIABILITY ANY AUTO ALL OWNED F—y1 SCHEDULED AUTOS AUTOS HIRED AUTOS X NON -OWNED AUTOS CAA0311124 /1/2014 1/l/2015 EO aBINEDtSINGLE LIMIT 11000,000 BODILY INJURY (Per person) $ BODILYINJURYPeraccident $ ( ) PROPERTY DAMAGE $ (Pere Auto Expansion Endorsement $ C X UMBRELLA LIAB EXCESS LIAR XCLAIMS-MADE OCCUR CUA0311125 1/1/2014 1/1/2015 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 DED I X I RETENTION$ 5,OOC $ D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXc"IIVE `YIN OFFICER/MEMBER EXCLUDED? N❑ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A WC012014000032 (3a.) NH 1 officers included 1/1/2014 1/1/2015 X WC STATU- OTH- E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Refer to policy for exclusionary endorsements and special provisions. %,rM I IrDA I r nUL.UtK GANGtLLATIUN For Informational Purposes Only 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 J George CIC,CPIA,CPIj'sM ACORD 25 (2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 r201005L01 Tho ArORn namp anfl Inno arc+ rpnictprpr9 markt of ArORn o s'v c N. F V 0 p sCD o 'D W 8 �� N 3 � _ 3 n z 0 0 O omA Ozo na . 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I7$$E'fR;�:■!'a§!;a■��!lEler>r■I-00G)> �B§!!4§§!|\\)//\ 22!!!x_,« !(!E} =a2))!`:E�#lJEJ®/)itflt)»!a®-G«a0.55m50. 0 |!;%)« ;77f1f\!,: §#2:,3o �&7if;y �:!|:\�al2i,:°°l,; |=!;\!|�: ;. . . 3m0—m::7e-�B0ca , . o»_ o,::0:�|■::�\9: )f:#}�(+:1E4�:::1, 02 @:�:■: n;'::,: (...! a : ::l,: l`::£l::E: : )::0. -g:,::�(: :::::::::��•::::::::::°:®:::::::0 .a�a....... ! la::`:: - :;E ::::: ® :2&:m 00 \\::::;:::\\/: \\:\:: mcaud app. S A L E S THE STOVE SHOPPE 25 INDIAN ROCK ROAD, ROUTE 11 WINDHAM, NH 03087 Phone #: (603)537-0555 Fax #: (603)537-0556 BILL TO 131487 Bruce Feldt 50 Blue Ridge Rd North Andover, MA 01845 USA t CCC"I�?j- O R D E R PHONE #: (214)923-0263 CELL #: ALT. #:(972)768-5954 P.O.#: TERMS: Cash SALES TYPE: Work Order TAG #: DATE: 3/23/2014 ORDER #: 10483 CUSTOMER #: 131487 CP: Stephen T LOCATION: 1 STATUS: Pending TECH: John G SHEP TO Bruce Feldt 50 Blue Ridge Rd North Andover, MA 01845 USA PAGE: 1 YEAR MFR I MODEL NUMBER DESCRIPTION VIN/SERIAL # MILEAGE/METER 1: INSTALL 33ELITE MFR PRODUCT NUMBER TRV 99800603 TRV 95600752 TRV 96100212 **** LAB25 ZFX 20ILKTX06251 OLY ELLF-6/30 ROC 6DP LAB LABOR COST 6 RUT 76C LAB note LAB NOTE 1 LAB NOTE 2 PER Permit **** MISC Tech: John G DESCRIPTION 33 Elite Fish Wd Plus Incl 1 door & 2 90 Universal Face -Rectangular Panel - One Piece Rectangular Face 30-1/ Install Wood Insert w/ Full Liner Liner Kit, SS - 6" x 25' No T w/ A Type Liner, Elbow 30deg Fixed - 6" Damper Plate 6" Labor Cost for Install Silicon CLEAR High Heat10.3oz Cartridge ********NOTE********** These parts represent a typical install However other parts may be require. Permit & Processing Fee CHIMNEY CLEANING DURING INSTALL Thank you for your business! I l ORD SOLD 1 1 1 1 1 1 1 1 1 1 1 1 1 1 B/O PRICE NET 1 $2,828.00 $2,545.20 1 $262.00 $262.00 1 $161.00 $161.00 0 $0.00 $0.00 0 $724.73 $724.73 1 $61.72 $61.72 0 $44.95 $44.95 0 $660.00 $660.00 0 $14.95 $14.95 0 $0.00 $0.00 0 $0.00 $0.00 0 $0.00 $0.00 1 $125.00 $125.00 0 $99.00 $99.00 Parts Job 1: Subtotal Job 1: TOTAL $2,545.20 $262.00 $161.00 $0.00 $724.73 $61.72 $44.95 $660.00 $14.95 $0.00 $0.00 $0.00 $125.00 $99.00 $4,698.55 $4,698.55 TOTAL PARTS: $4,698.55 TOTAL LABOR: $0.00 SUBTOTAL: $4,698.55 TAX: 00 ORDER TOTAL: $4,698.55 3/23/2014 PMT MASTERCARD: 06724S $500.00 BALANCE REMAINING: $4,198.55 Pmt MasterCard AUTH #: 06724S $500.00 XXXX-XXXX-XXXX-4481 Credit The Commonwealth of Massachusetts , - Department of Industrial Acci6uts Office of Invesfigations 600 Washington Street Boston, MA 02111 www.mass gov/dna Workers' Compensation Insurance Affidavit: Sunders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Businos/Organizaiionitndiividual): Address: f 11� (KOD City/State/Zip: (4i� •�c� lti // iT U30Q- one #• 0 Are you an employer? Check the appropriate box: Type of project (required): _II 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. t 7. ❑ Remodeling ship and'Itave no employees These sub -contractors have 8. E] Demolition working for mein any capacity. workers' comp. insurance. 9. E] Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10. r_1 Electrical repairs or additions required.] officers have exercised their 3111 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbingrepairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roofrepairs insurancere ed. employees. [No workers' x-1.41 W� . �i�' ] 13.� Other comp. insurance required.] u xAny applicant that checks box#I must also fill out the section below showing their Workers' compensation policy information. TQtrk t -Homeowners who submit this affidavit indicating they tie doing all work and then hire outside contractors must submit a new affidavit indicating such tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. f am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Z, I I _ I I i Insurance Company FAM z Policy # or Self -ins. Lie'. #: Lt% G n no00�� �— Expiration Date: Job Site Address: � «� City/State/Zip: Attach a copy of the workers' compensation Jiolley declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL o. 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 advis t a copy of this statement may be forwarded to the Office of Investigations of the Dl�or ihn wane covera ern ation. f do hereby Aat the information provided above isPrue and correct. Official use only. Do not write in this area, to be completer) by city or town official 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-contractor(s) name(s), address(es) and phone numbers) 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 maybe submitted to the Department of Industrial Accidents for coniirm�ation 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 burn 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 C0rnxa0RWe-ajthiOf.Massa..rhvsPt s Depaxttnent ofJndustdal Accidents office of Tuvestigatiom 6QG Wasbington Sfreet Boston., MA 421. It TO, # 617-7-2.7,4900 eyt 406 or. 1-877,MASSAFE Revised 5-26-05 Fax # 617-727-7749 wwwaaagovaa fie wpa)nrnarurseah� (11P %IKsac/-1jelz4 1 Office of Consumer Affairs & Business Regulation VEME IMPROVEMENT CONTRACTOR Type. gistration: 154473 xpiration: 3/14/2015 Private Corporati( MIS -BEC OF N.H. INC. KEN SZYMANSKY 25 INDIAN ROCK RD. SUITE 19 WINDHAM, NH 03087 Undersecretary Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supemisor License: CS -096606 �r.rI'S KEN T SZYMANS 41/'� 27 TICKLEFi1�Vj SALEM NH 03079 1 Expiration Commissioner 02/25/2016