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HomeMy WebLinkAboutBuilding Permit #22 - 51 MILLPOND 7/11/2007 4 �� BUILDING PERMIT NORTF� �StlO 6�tiO TOWN OF NORTH ANDOVER 0r4ao APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: 0 7y IMPORTANT: Applicant must complete all items on this page "l:sin I• '' - vINS "10 MA was 00 r051x lOR14111 �' v� I NUMN Hlol_ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family [I Addition [I Two or more family El Industrial ❑ Alteration No. of units: ❑ Commercial Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other rt i11 oo0111It ds Nr z " DESCRIPTION CtF WORK TO BE PREFORMED: 1 � entifi tion Please Type or Print Clearly) OWNER: Name: �,`i1 �_ ` �1� , 0s1ft t u Phone q7� 10 Address: l mill p I . kL'"�w� � � cr�[1 �LYI�� � � �I Y nE �•y,. y+� � t a 3 5 f 2 yg;a '�s 9 may, '��• F '�f (� s ��.� f �� � w�y.�'".�' c 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: $w /A FEE: $ Check No.: Receipt No.: ao S�r NOTE: Persons contracting i unre i red contractors do not have access to the gu nd Signature of Agent/Owne Signature of contractor 6 LIMA 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 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 Of APPlicable ) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products New Construction (Single and Two Family) ❑ Building Permit Application-- u Certified Proposed Plot Plan Li 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) I ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products 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 DEPARTMENTMFORM07 Revised 2.2007 f Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF -U FORM i DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ 4 COMMENTS I DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art - ❑ Swimming Pools ❑ Well ❑ Tobacco ales - S � ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ Zonong Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments 4 { Conservation Decision: Comments Water & Sewer Connection/Signature&Date Driveway Permit Located at 384 Osgood Street FIR�DI ►R, N1 �T} �f rnp ur�pster o yes SM ¢ ne N Locatedt �2�MatrStf8�et q� � ; a ; yam FDepairment signa�ur�Idat a � &; x re Sr - 2. fr v. �r ¢ �a F➢+� 3 f fi✓.s 7 F't & w6r xy sa C1711METS� '� «_ 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 I ❑ Notified for pickup - Date Location No. O�c�"'� Date MORTM TOWN OF NORTH ANDOVER + i : . Certificate of Occupancy $ , cMusEt� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # Building Inspector ACORD CERTIFICATE OF LIABILITY INSURANCE DATE rM 0 7/1 DATE 1/2007 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION NORTH ANDOVER INSURANCE AGENCY, INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 9 WAVERLY ROAD ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NORTH ANDOVER MA 01845-2415 INSURED INSURER A:CITIZENS INSURANCE CO Michael Rodden INSURER B:HANVOER INSURANCE 47 Prescott Street INSURER C:AMERICAN INTERNATIONAL GROUP INSURER D: North Andover MA 01845— 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. INSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR DATE MM/DDM' DATE MM/DDM' A GENERAL LIABILITY / / / / EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY FIRE DAMAGE(Any one fire) $ 300,000 CLAIMS MADE FRI OCCUR ZBN 8605683 02/01/2007 02/01/2008 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY JECOT LOC B AUTOMOBILE LIABILITY ADN 8336670 07/16/2006 07/16/2007 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS / / / / BODILY INJURY X SCHEDULED AUTOS (Per person) $ 100,000 HIRED AUTOS / / / / BODILY INJURY NON-OWNED AUTOS (Per accident) $ 300x000 PROPERTY DAMAGE (Per accident) $ 100,000 GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO / / / / OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS LIABILITY / / / / EACH OCCURRENCE $ OCCUR EICLAIMS MADE AGGREGATE $ S DEDUCTIBLE / / / / $ RETENTION $ $ WORKERS COMPENSATION AND X TORY LIMITS OT EMPLOYERS'LIABILITY ER E.L.EACH ACCIDENT $ 100,000 C WC1760133 01/01/2007 01/01/2008 E.L.DISEASE-EA EMPLOYEE $ 100,000 E.L.DISEASE-POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER ADDITIONAL INSURED;INSURER LETTER:_ CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT TOWN OF NORTH ANDOVER FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABIL TY OF PON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE I NORTH ANDOVER MA 01845- ACORD 25-S(7/97) C ACORD CORPORATION 1988 rGrM INS025S(ggio).oi ELECTRONIC LASER FORMS,INC.-(800)327-0545 Page 1 of 2 r `��F�� �� The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le 'bl Name(Business/Organization/individual): Address: City/State/Zip: 1 �yES- � 2f 7.2) .31.}, Wit__ Phone#:� Are you an employer?Check the appropriate box: L❑ I am a employer with 4. ❑ I am a general contractor and I Type of project(required): 2.❑ employees(full and/or part-time).* have hired the sub-contractors 6 ❑New construction I am a sole proprietor or partner- listed on the attached sheet.i �• ❑Remodeln Remodeling and no employees These sub-contractors have working for me in any capacity. workers'com .insurance. g• ❑Demolition [No workers'comp. P p insurance :5. ❑ We are a corporation and its 9' Building addition i required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c. 152,41(4),and we have no insurance required.]t employees.[No workers' 12•❑Roof repairs comp.insurance required.] 13•0 Other Homeowners who submit this 'Any applicant that checks box ection b affidavit indicatt must also fill out the selow stowing their workers'compensation policy information. t ing they are doing all work and then hire outside contractors must submit tContractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp. Ir information. a new affidavit indicating such. I am an employer that is providing workers'compensation insurance for my employees. Below is the polic information. - p y and job site Insurance Company Name: Policy#or Self-ins.Lie. #:_ Expiration Date: / ' CU Job Site Address: t Attach a copy of the workers'compensation policy declaration a e(showingCity/State/Zip Policy number an Failure to secure coverage as required under Section 25A of MGL . 52 can lead to the imposition of criminal penal ti datea fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties of a of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded oof a STOP th Offic o and d a fine Investigations of the DIA for insurance coverage verification. Ido hereby certify under the peri and p !ties of perjury that the information provided above is ue and Si na e• J correct Phon # �ag Date: !a d 77. OJJ?cial use only. Do not write in this area,to be completed by city or town gJj'lciaL City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4 6.Other .Electrical Inspector 5.Plumbing Inspector Contact Person: Phone#: I 1 1 + �.� t ._ C.., � l ,. E.�,s ti:,r Page No. of Pages _ 1..,.2 +1 P,e-scott Siraet ,!ORT'-i ,a;V)n%I i3 iOeASSACHUSETTS 01845 PROPOSAL SUBMITTED TO , PHONE ' DATE STREET JOB NAME CITY,STATE and ZIP CODE r JOB LOCATION C ARCHITECT - 1 DATE OF PLANS JOB PHONE P FrIlpillit hereby to furnish material and labor— complete in accordance with specifications below, for the sum of: t� ,r i r t', l ° i�-�- �' t 1 dollars ($ la, LC.-.C.. C-c, ). Payment to be made as follows: ` t All material is guaranteed to be as specified.All work to be completed in a workmanlike manner according to standard practices.Any alteration or deviation from specifications be- Authorized low involving extra costs will be executed only upon written orders,and will become an Signature extra charge over and above the estimate.All agreements contingent upon strikes,acci- dents or delays beyond our control. Owner to carry fire,tornado and other necessary insurance.Our workers are fully covered by Workmen's Compensation Insurance. withdrawn by us if not accepted within days. We hereby submit specifications and estimates for: C-Q cc A�,Z Araptunrr of 11roposal—The above prices,specifications C and conditions are satisfactory and are hereby accepted. You are authorized Signature '� J! "� ✓ i to do the work as specified. Payment will be made as outlined above. Date of Acceptance: Signature FORM 218-3 Available fromses Inc.,Groton,Mass.01471 txORTH TO" Of Andover 0 k.. 0 No. 2o2wo tL- 0 dower, Mass., 0 LAK 1. COC HIC HE WICK OCHICHEWICK RATE BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System 101- BUILDING INSPECTOR THISCERTIFIES THAT............i ......... . ............................................................................................... Foundation has permission to erect........................................ buildings on....P......rhov.... ..... .4. ............. Rough to be occupied as f In.to. Chimney ..................................................................................................... provided that the person accepting this permit shall in every respect conform 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 ON S Rough .............. TS -vice . ............................................................... Set .................. BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det.