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HomeMy WebLinkAboutBuilding Permit #479-15 - 52 NORTH CROSS ROAD 11/18/2014`0 BUILDING PERMIT �? g6'6ry°� TOWN OF NORTH ANDOVER o APPLICATION FOR PLAN EXAMINA Permit NO: Date Received '�A°9 Date Issued: ORTANT: A LOCATION :S�a , C«sc ;ant must complete all items on this ,�C� Print ` PROPERTY OWNER vxoe_A� � �"��` mar t v` �/ Print MAP NO: 05 PARCEL: ZONING DISTRICT: Historic District yes (-no Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Resid tial Non- Residential ❑ New Building V6ne family ❑ Addition ❑ Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic El Well 0 Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer OWNER: Name: Address: , a LAC &A IJJ Aew je�,_k Identification Please Type or Print Clearly) J�,_e,L4nck�ll I, bee,_,d, tPhone: 331 Lf1{6 '3) f3 1,3 . C—r-o s -C �_, J CONTRACTOR Name: Phone: (7&- jl�-,902C- Address: 0 Address: 7 c)ivc_i,( -pae, vc- -p gAOT- AA a • (7),F Supervisor's Construction License: 4chav-1" 'A'ecr`r- Exp. Date: 60416i4� Home Improvement License: -4 1tP"G Exp. Date: ARCHITECT/ENGINEER Aloldnac) AGR PK, Phone: 91P -,P2W- DO Address: 1,,� P50Le��P+vr��ec,,� oi�e? Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL BASED ON $125.00 PER S.F. Total Project Cost: $ DZ kc -0 FEE: $ S %L Check No.: Receipt No.: NOT,: Persons contra ti g with unreMature ors do not have access Signature of Agent/Owner of contractor fund Permit No#: nn+n [eel IM& BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received 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 Pistrict, ❑ Waiter/Sewer - DESCRIPTION OF WUKK I U tit 1JtK1-UK1V1r-U-- Identification - Please Type or Print Clearly * OWNER: Name: Phone: Address: ARCHITECT/ENGINEER Phone: Address: Reg. No, FEE SCHEDULE. BOLDING PERMIT: M00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund ignature of Aggnt/Owner_ Signature of contractor 4 Plans Submitted ❑ Plans Waived El 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 Reviewed On-NSignature_ COMMENTS �1 CONSERVATION Reviewed on 1% COMMENTS 1 J6I'['f i 5 fV'J0NJ- '�, "'j 51114, 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 deaartment user 4� ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 r Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. 1' Roofing, Siding, Interior Rehabilitation Permits u Building Permit Application o Workers Comp Affidavit u Photo Copy Of H.I.C. And/Or C.S.L. Licenses Li Copy of Contract Li Floor Plan Or Proposed Interior Work u Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks u Building Permit Application u Certified Surveyed Plot Plan u Workers Comp Affidavit u Photo Copy of H.I.C. And C.S.L. Licenses Li Copy Of Contract a Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o 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) o Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit u Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o 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 ttxat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording na ust be submitted with the building application Doe: Building Permit Revised 2014 Location No. Date �t Check # 202 TOWN OF NORTH ANDOVER */ Certificate of Occupancy $ Building/Frame Permit Fee $;;12Zl Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Building Inspector !v1 Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supen-isor License: CS -004756 �..' .t I Is RICHARD J CHAgETTE" 301 OLD MARSH.HIL`L RD f3 DRACUT MA 0126 Shy X Expiration Commissioner 04/20/2016 r . _ _ V he �amma�nueczUl� u���JJacl uJet1,1 '", Office of Consumer Affairs & Business Regulation - OME IMPROVEMENT CONTRACTOR egistration: 118268 Type: xpiration: - =2/20/2015 Private Corporatic C & G ASSOCIATES IN RICHARD CHARETT� �3 , 7 CHUCK DRIVE UNIT C �. DRACUT, MA 01826 Undersecretary .DISPOSAL AFFIDAVIT As a result of the provisions of MGL c 40,S54, I acknowledge that as a condition of Building Permit Numbered alldebris resulting from the construction activity governed by this Building permit shall be disposed of in a property licensed solid waste disposal facility, as defined by MGL c 111, S 150A. I certify that I will notify the Building Official .by r h �0 �j (Two months maximum) of the location of the solid waste disposal facility where the debris resulting from the said construction activity shall be disposed of, and I shall submit the appropriate form for attachment to the building Permit. Date: AZV Signature of Applicant Name of Permit Applicant Firm Name (if any) ()-CRtcVI /Wass Name I Ile L'ommonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www. massgov/dia Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Address: I Chuc,)� -_Dj�?_i ✓c— a /W0C/ rs �Wqc`j-T Mw, & uPhone #: Are you an employer? Check the appropriate box: I am a employer with 5 4. I am a general contractor and I employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' __95P-1�o, Type of project (required): 6. [1 New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11 -El Plumbing repairs or additions 12.❑ Roof repairs 1310ther_ sTi3, lt, i comp. insurance required.] J L /1/c C j OQ. -C *Any applicant that checks box #I 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. tContractors 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. Insurance Company T.JvSvYi�F3h,c. Policy # or Self -ins. Lic. #:_ Expiration Date: __2 Job Site Address: -ZO /r%Or671, C.,ZpSs City/State/Zip11&9 h AS V�. '✓crt /%SSS 6/SkjS 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 cerci under the pains and penalties of perjury that the information provided above is true and correct / !�Y 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): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone el 'rA'w Vl � � F cal p 0 cl: Z u w O �u++ a0 Q w d N U H LLI x '^ Z0 (D m CA Z O. Q D Z Z_ LLI u LM Z o LU cr LL O J J m L m C O. w O u O \txo L U t N YN L twu -O p p is D to 7 C O p =3y, E cr- 0 In L0 0 V LL d' LL d' N LL K LL co !n N f _ O ' Q Q. L O QCD A, ' 0 0 V U N CL N V V d ID � t v0 0 { • •� _ O N Z 0. M y_ N J L In d Z L O A, U / W 0 Z y_ Z V • O N • J m 0 CD CM Cl) iRL Q .0 Cl) v Z O i C CL Z N V y y �/ •� W N D O 001 Cl) C Q AW cc �LLuv,m as a-1 (A = m o 0 v c� V N o N ,F. O CL ® � Q 0 v _ J ACCOR©P CERTIFICATE OF LIABILITY INSURANCE DATE(MM/ 11 /07!22014014 Y) 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 the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Charles J Coughlin Insurance 14 DinleyStreet P. O. Box 10 CONTACT Carolyn A Coughlin PHONE (978) 957-3588 FAX AIC No Ext : (AIC, No): ADDRESS: Carolyn@coughlinins.com Dracut, MA 01826 INSURERS AFFORDING COVERAGE NAIC # INSURER A: Main Street America Assurance Company 29939 04/19/2015 INSURED C & G Associates, Inc. INSURER B: Safety Indemnity Insurance Company 33618 Richard Charette INSURER C : NGM Insurance Company 14788 7ChuckDrNe U nit C Utica Mutual Insurance Company 25976 INSURER D : y INSURER E: Dracut, MA 01826 INSURER F $ COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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 LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MM/DDNYYY POLICY EXP MM/DD/YYYY LIMITS A GENERAL LIABILITY \ COMMERCIAL GENERAL LIABILITY CLAMS -MADE M OCCUR MPB48499 04/19/2014 04/19/2015 EACH OCCURRENCE $ 1,000,000 PREMDAMAGE TO RENTED 'SESEa occurrence $ 500 0W MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENL AGGREGATE LIMIT APPLIES PER: POLICY PRO LOC PRODUCTS - COMP/OP AGG $ 2,000,ODO $ B AUTOMOBILE LIABILITY ANY AUTO ALL OWNED / SCHEDULED AUTOS V AUTOS NON -OWNED HIRED AUTOS V AUTOS 6203740 07/24/2014 07/24/2015 COMBINED SINGLE LIMIT 1,000,000 Ea accident $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident C UMBRELLALIAB `� OCCUR EXCESS LIAB CLAMS-MADEGREGATE CUB48499 04/19/2014 04/19/2015 EACH OCCURRENCE $ 2,000,000 AG $ 2,000,000 DED / RETENTION $ 0 $ D WORKERS COM PEN SATION AND EMPLOYERS' LIABILITY N ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OFFICER/MEMBER EXCLUDED? N (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A 4447686 08/20/2014 08/20/2015 \/ TZ LMIT °ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE -POLICY LIMB 1.$ 1,000,000 A Fire Insurance/Equipment Floater MPB48499 04/19/2014 04/19/2015 Installation 50,000 Floater 151,088 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Carpentry C:tK11tIUAI t NULUtK L:ANL:tLLAI IUN Kenneth Martin 20 North Cross Road North Andover, MA 01845 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 @ 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD PA Ar NORr1W CROSS 21an red' : E.N. D,e D. p/. /70./00/-5 e //375 +� p % p e nol /n From lours da hon �o septic dank �A� "AS • BUILT " SUB • SURFACE DISPOSAL SYSTEM / q/ IN NO AN®OVE a A . F0 R ; Robe, --I Lo ore/e N Scale: 1 =40� Date: S'ep1 /3, /990 RICHARD F KAMINSKI AND ASSOCIATES , INC. ENGINEERS ARCHITECT SURVEYORS LAND PLANNERS NORTH ANDOVER , MASS ELEVATIONS description as - built I NV. PIPE OUT OF HSE. 169.5 INV. PIPE INTO TANK /6.5. of INV. PIPE OUT OF TANK /68.57 INV. PIPE INTO DIST. BOX /x8.53 INV. PIPE OUT OF DIST. BOX O// Ilo8.�6 INV.e/ ow OF PIPE :0 " #2 .03 /68.25 mv.. al end o pipe /6 7. 95 +� p % p e nol /n From lours da hon �o septic dank �A� "AS • BUILT " SUB • SURFACE DISPOSAL SYSTEM / q/ IN NO AN®OVE a A . F0 R ; Robe, --I Lo ore/e N Scale: 1 =40� Date: S'ep1 /3, /990 RICHARD F KAMINSKI AND ASSOCIATES , INC. ENGINEERS ARCHITECT SURVEYORS LAND PLANNERS NORTH ANDOVER , MASS