HomeMy WebLinkAboutBuilding Permit #769 - 50 WILLOW RIDGE ROAD 6/24/2008Permit NO:
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION S13U L k l 4k? <-'- c� �R-
PROPERTY OWNER PA'0Cv k N _ Print
0�t LQC ib*'NO\
/ Print
MAP NO:! 9% 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
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
DESCR TION OF WORK TO BE PREFORMED:
Type or Print Clearly)
OWNER: Name:
Address: Jd O t t�45W W\�
CONTRACTOR Name:
.60-
9
03
91 t -W04 - NO
Address;
Supervisor's Construction License: Exp. Date;
Home Improvement License: I lc,
ARCHITECT/ENGINEE
Address:
Phone:
Reg. No
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASEED' ON $125.00 PER S.F.
Total Project Cost: $ -cc FEE: $ (�
Check No.: 67 o Receipt No.: 2 y
NOTE: Persons contracting with unregistered contractors do not have access to -Me guaranty fund
Signature of Agent/Owner Signature of contractor_ f�
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
COMMENTS
CONSERVATION
4 COMMENTS
HEALTH
COMMENTS
DATE REJECTED DATE APPROVED
Reviewed on Signature
Reviewed on . Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
FERE DEPARTMENT Temp Dumpster on site
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Located 384 Osgood Street
yes no
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
NOTES and DATA — For department use)
❑ Notified for pickup - Date
Doc.Building Permit Revised 2008
No
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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2008
Location ,
No. Date 2 611""? -
TOWN OF NORTH ANDOVER
S
Certificate of Occupancy $
\sA .ISt<Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # 4
A
2 L 7 Building Inspector
r
Board of Building Regula ions and Standards
One Ashburton Place - Room 1301
Boston, Massachusetts 02108
Home Improvement Cvontractor Registration
-` Registration: 137193
Type: Supplement Card
Expiration: 10/15/2008
'r
BAY STATE ROOFER INC.
ROBERT O'KEEFE �` f
240 PARK ST. " e'
,�, �.... Update Address and return card. Mark
N. READING, MA 01864 reason for
Address E] Renewal Employment LostCard
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(MMIDD
ACORD. CERTIFICATE OF LIABILITY INSURANCE OP ID S3 DAT 4/22 08
BAYSTI4 04 22/08
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
MacIntyre Fay & Thayer Ins Agy HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
77 Accord Park Drive Unit B-1 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Norwell MA 02061
Phone: 781-261-2000 Fax:781-261-2099 INSURERS AFFORDING COVERAGE NAIC#_
INSURED INSURER A' National Union Fire Insu_rance_-
INSURER 8: J'
Bay State Roofers Inc. 'INSURER C:
PO Box 189
( INSURER D:
North Reading MA 01864 ---- —�' ---`
INSURER E:
COVERAGES
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
ont rQ A!]rSGPreTa t IWTR cwnVM MAY NAVE- BEEN REDUCED BY PAID CLAIMS.
LTR
NSR
TYPE OF INSURANCE
POLICY NUMBER
DATEYMM DDYY i
DATE MIDDmO�
LIMITS
GENERAL LIABILITY
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$
-UAMAGE70 RENI-EU--
PREMISES {Ea oec irence)
—._..
$
MED EXP (Any one person)
$
CLAIMS MADE OCCUR
PERSONAL & ADV INJURY
$
(
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GENERAL AGGREGATE I$
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS COMPIOP AGG `
$ _-
POLICY PRO LOC
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AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT
(Ea accident)
$
ANY AUTO
ALL OWNED AUTOS
BODILY INJURY
(Per person)
$
SCHEDULED AUTOS
I
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HIRED AUTOS
`
(
BODILY INJURY
(Per accident)
$
(
f
NON -OWNED AUTOS
--
-
PROPERTY DAMAGE
(Per accident)
$
---
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT
$
OTHER THAN EA ACC
AUTO ONLY: AGG
$-
ANY AUTO
----
-
$
I EXCESSfUMBRELLA LIABILITY
EACH OCCURRENCE
$ —
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AGGREGATE
$
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OCCUR C
4 J CLAIMS MADE
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$
--
DEDUCTIBLE
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----
RETENTION $
A
WORKERS COMPENSATION AND
• EMPLOYERS'LiABILITY531-5167
ANY PROPRIETORIPARTNERIEXECUTIVE
i OFFICER/MEMBEREXCLUDED?
04/03/08
04/03/09
TORY LIMITS ER_
-
E.L. EACH ACCIDENT
$ 500000
-
'
E.L. DISEASE -EA EMPLOYEE
$ SOOOOO
E.L. DISEASE - POLICY LIMIT $ 500000
j if yes, describe under
i SPECIAL PROVISIONS below
`
1 OTHER
I
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES/ EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
Evidence of WC insurance for Insured while acting in the scope of their
normal operations.
CERTIFICATE HOLDER
EVOFINS
Evidence of Insurance
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATI01
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 030 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
OACORD CORPORATION 198
ACORD 25 (2001108)
Glientiv tsui*4
ACORD,. CERTIFICATE OF LIABILITY INSURANCE
DATE Dmrv)
I 04121108
PRODUCER
CAD -Commercial Insurance
HUB INTL New England, LLC
PO Box 9146
Norwell, MA 02061-9146
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE NAIC #
INSURED
Bay State Roofers, Inc.
P.O. Box 189
North Reading, MA 01864
INSURER A: Nautilus Ins. Co.
INSURER B: Safety Insurance Company
INSURER C:
INSURER D:
INSURER E:
COVERAGES
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR
A
NSR
TYPE OF INSURANCE
GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
CLAIMS MADE a OCCUR
POLICY NUMBER
NC584521
POLICY EFFECTIVE
DATE MMIDDIYY
10/24/07
POLICY EXPIRATION
DATE MMIDDNY
10/24/08
LIMITS
EACH OCCURRENCE $1,000,000
DAMAGE TO RENTED $50 000
PREMISES (Ea occurrencel
MED EXP (Any one person) $
PERSONAL & ADV INJURY $1,000,000
GENERAL AGGREGATE $2 000 000
PRODUCTS - COMP/OP AGG s2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY PRO JECT E LOC
B
AUTOMOBILE LIABILITY
2433055
10/24/07
10/24/08
COMBINED SINGLE LIMIT $1,000,000
(Ea accident)
ANY AUTO
ALL OWNED AUTOS
BODILY INJURY $
(Per person)
SCHEDULED AUTOS
HIRED AUTOS
BODILY INJURY $
(Per accident)
NON -OWNED AUTOS
'
PROPERTY DAMAGE $
(Per accident)
AUTO ONLY - EA ACCIDENT $
GARAGE LIABILITY
ANY AUTO
OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESSIUMBRELLA LIABILITY
EACH OCCURRENCE $
OCCUR FICLAIMS MADE
AGGREGATE $
DEDUCTIBLE
RETENTION $
WIRY C STATU- OTH-
TLIMITS IR
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
E.L. EACH ACCIDENT $
E.L. DISEASE - EA EMPLOYEE $
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
E.L. DISEASE - POLICY LIMIT $
If yes, describe under
SPECIAL PROVISIONS below
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
As respects operations normal to insured
.04
Bay State Roofers, Inc.
P.O. Box 189
North Reading, MA 01864
ACORD 25 (2001108) 1 of 2 #514UUZ3IM14uu1y
WOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
)ATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL I0DAYS WRITTEN
JOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
MPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
c ro n ACORD CORPORATION 1988