HomeMy WebLinkAboutBuilding Permit #253-15 - 50 HAY MEADOW ROAD 9/15/2014 t Ai. OtN00 ". BUILDING PERMIT �? °oma r TOWN OF NORTH ANDOVER A APPLICATION FOR PLAN EXAMINATION �` ► Permit NO:� , Date Received CHus Date Issued: I ORTANT: Applicant must complete all items on this page LOCATION �3 D P aq a o d oLo led, N. Aq d a✓-"c m d9 D I RVS Print PROPERTY OWNER In 1[� Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yesnn Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential ❑ New Building eOne 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 g g le-figlde_ boys-e- 4- m0all new �4emdy�e .�►uS� l cStd, �fron�, ��r-�{ "I_S d����f NZCil7 rt�,co -fa Inf npu jq Sidej a l 4D A . :nkr Wil/ 14 h Identification Please Type or Print Clearly) L� OWNER: Name: Je�S i �-oL-- ior n Phone: �7 9 _73SDo'7s Address: 5D mtdou) 0 CONTRACTOR Name:n Phone: q7. 19 70 - Address: Supervisor's Construction License: q l q Exp. Date: Home Improvement License: Ll A3 8 Exp. Date: 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 Cost: $ 14 &DS;• Dy FEE: $ Check No.: Receipt No.: NOTE: Persons contracdn w' unre red ntractors do not have acc s t he guar n fund t 'Signature of Agent/Owner Signature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL CY Public Sewer ❑ Tanning/Massage/Body Art ❑ Sw"nlning 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 Signature_ 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 t Conservation Decision: Comments �..a Water & Sewer Connection/Signature& Date Driveway Permit tha' 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 Call Email Date Time Contact Name Doc.Building Permit Revised 2014 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/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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Li 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 o 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:Building Permit Revised 2014 Location ` �D ryI0'j No. �, Date S d r ► t y . - TOWN OF NORTH ANDOVER. = a Certificate of Occupancy Building/Frame Permit Fee „$ Foundation Permit Fee t'$ Other Permit Fee TOTAL 1 � P Check 28006 Building Inspector,.. r 1 NORTH WL ; . . � tE : �. .cve" '* No. h ver, Mass, 61 cocMunew�cw a. S U BOARD OF HEALTH Food/Kitchen PERMIT T L D Septic System THIS CERTIFIES THAT .......... S � BUILDING INSPECTORS� - ................................................. .. /e Foundation has permission to ereA'4V1.4e ........�............. buildings on ..... ...... Ir,w�lirlrr�r ,,, . Rough tobe occupied as ..... .... .......... .... .. ...... ......................... .. .....'....................... Chimney provided that the person accepting this permit sh In every respect conform to the terms of the application Final on file in 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 8• . PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCpq T RTS Rough Service ........ l.....e ................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street,Suite 100 •�t Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): RQ U _ Address: r a 44"Q_,(,l 11--YI City/State/Zip. 0U+_UU Quel l IMA OVq Phone #: Are you an employer? Check the appropriate box: Type of project(required): 1.2/1 am a employer with i 4. [] I am a general contractor and 1 employees (full and/or part-time).* have hired the sub-contractors 6. F]New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. [L] emodeling ship and have no employees These sub-contractors have g, M Demolition workingfor me in an capacity. employees and have workers' Y P tY• 9. r_1 Building addition [No workers' comp. insurance comp. insurance. required.] 5. We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I Ln Plumbing repairs or additions myself. ' right of exemption per MGL Y [No workerscomp. 12.❑Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t 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. �h ' t Insurance Company Name: A 1111 f�I U+Ucd 'Aw UMU U ( � Policy#or Self-ins. Lie. #: (?C 400 70d y 33aD14 Expiration Date: 9"'"I'" f✓� G�,1 VY1006.0 K er r 1M I��( lS Job Site Address: City/State/Zip: 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 d r thepainw and penalties ofperjury that the information provided above is true and correct. Si afar Date: Phone#: Official use only. Do not write in this area,to be completed 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#: 9/12/2014 Office of Consumer Affairs&Business Regulation-Mass.Gov The Official Website of the Office of Consumer Affairs&Business Regulation(OCABR) z Consumer Affairs and Business Regulation Home Consumer Rights and Resources Home Improvement Contracting HIC Registration Complaints Registration # 114238 Home Improvement Contractor Registration Home Page Registrant ROBERT BOHONDONEY CONST CO Name ROBERT BOHONDONEY Address 12 HALL ST City, State METHUEN, MA 01844 Zlp Expiration 08/16/2015 Date Complaints Details No complaints found for this registrant. You can also view arbitration and Guaranty Fund history. Back To Search ©2012 Commonw ealth of Massachusetts. Mass.Gov®is a registered service mark of the Commonw ealth of Massachusetts. http://ser\ices.oca.state.ma.us/McAicdetails.asp> rchLN=14200 1/1 (Mmiowfm) CERTIFICATE OF LIABILITY INSURANCE 7 9/12/14 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. 9 the certificate holder Is an ADDITIONAL INSURED,the policKies) 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 confbr rights to the certificate holder In lieu of such endorsemengs). PRODUCER CONTACT -NAME: _T_FAX Bates Insurance Agency Inc. PHONE 02 High Street, Suite BI LAR—NaEA1. (781) 396-4985 1 Wc,Not: (781) 395-9454 E' AOLEss: Andrea@BatesIns.com Medford, MA 02155 INSURERS)AFFORDING COVERAGE NAIC INSURER A:RCA-Essex Ins Co INSURED INSURERB:A.I.M. Mutual Ins. Co. Robert Bohondoney I NSURER C: Bohondoney Construction INSURERD: 12 Hall St INSURER E: Methuen, MA 01844 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICES 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 TIE POLICES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLLISIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD SUBR P CY LTR TYPE OF INSURANCE POLICY NUMBER (IPMO-MAX, (MMIDDIYYYY) LIMITS A GENERAL LIABILITY 2CH7726-14 2/3/14 2/3/15 EACH OCCURRENCE $ 1.000.000 DAMAGE TO RENTED X COMMERCIAL GENER4kLLLABUJTY ICW $ 100,000 —7 CLAIMSMADEFx_1OOCUR ME D EXP(Arry one person) $ 51000 PERSO NAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 11000,000 GEN'L AGGREGATE LINT APPLIES PER PRODUCrS-COMPIOP AGG $ 1,000,000 XCT LOC $ ___1 POLICY F-1 PRO- F COMBINED SINGLE LIMI I AUTOMOBILE LIABILITY (EaaccidBrit) $ ANYAUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIREDAUTOS NON-OWNED PROPERrY DAMAGE $ AUTOS tPer acciden U"BRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE -AGGREGATE $ DED RETENTION$ $ B WORKERS CON1PENSA'nON AWC40070243322014 8/9/14 8/9/15 1 WCFATWU OTH_ AND BAPLOYERS'LIABILITY YIN 10. 1. S I 1FR ANY PROPRIETOR/PARTNERIEXECUTNE NIA E.L.EACHACCIDENT $ 500,000 OFFICERIMEMBER EXCLUDED? (Mandabry In NMI E.L.DISEASE-EA EMPLOYEE $ 500,000 Ifyes describe under I DES6RIPTIO N OF opE RATIONS below EaL DIS EASE POLICY L IM IT s 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLFS (t;h ACORD 1011,Additional Rentaft Sctwdule,If mom space Is required) 50 Bay Meadow Road Nort�h Andover, MA 01845 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIO NS. 1600 Osgood Street AUTHORUXO RE PRESENTATIVE North Andover, MA 01845 1988-2010AC-ORD CORPORATION. All rights reserved. ACORD 25(20110105) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: Massachusetts -Department of Public Safety Board of Building Regulations and Standards 0)n�truction Superii.or License: CS-000979 ROBERT A BOHONDONEY 12 HALL ST ' METHUEN MA 81844 . Expiration Commissioner 04/21/2016