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Home My WebLink AboutBuilding Permit #162-13 - 53 WHITE BIRCH LANE 8/28/2012 BUILDING PERMIT °tt NORkORTh TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION * yy ry T Permit N0: Z • 3 Date Received AA7ED Date Issued: L� � .� 9SSqS�� IMPORTANT:Applicant must complete all items on this page LOCATION W W (Te fA LAPS � Print. PROPERTY OWNER S �45A� � N� Ir- Pnnt MAP NO:/J PARCEL: ZONING DISTRICT: Historic District yesAno Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE oa Resi(Jential Non- Residential ❑ New Building N6ne family ❑Addition ❑Two or more family ❑ Industrial Iteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: 12 oQ 5-: 1 Ir-i e7i Identification tPlease Type or Print Clearly) OWNER: Name: Phone. Z �• Address:93 w\A1'j�C. 5h' C—" GA*,V, CONTRACTOR Nam e�� 5 hu—* Phone- 1 Address: 4A. SA) X -t�.3 /t�,� 0L00 Supervisor's Construction License: q Exp. Date: D 6 • 2.► Home Improvement License: !2V&0A k Exp. Date: 62-- It • IS 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: $ -7g, 1i970 bFEE: $ Check No.: ��' S Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature oft/Owner Signature of contractor 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ i COMMENTS CONSERVATION Reviewed on Signature COMMENTS -HEALTH Reviewed on Signature COMMENTS w Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments d Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit 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 - Date Doc.Building Permit Revised 2009 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:Building Permit Revised 2008 Location 4N h C e f No� _ Date ot • - TOWN OF NORTH ANDOVER • Certificate of Occupancy $ o m - s1 Building/Frame Permit Fee Foundation Permit Fee $ • r' Other Permit Fee $� TOTAL $ Check# �� 25656 Building Inspector i tkORTH Town, oftAndover o - No. 161 14 - �o h ver, Mass, '�.� • ��i COC MIc Hl WICK y1• ��A�RgTED I.PP��S S lJ BOARD OF HEALTH PER IT T LD Food/Kitchen Septic System • THIS CERTIFIES THAT �1. (AS-06-o... + .C,. BUILDING INSPECTOR .......... ...... �.._....... • ca. �.�. Foundation has permission to erect .......................... buildings on ..... .......... l�.. ...... ..,... Rough to be occupied as .... ....... ... .qAr. .. ..�►. ................Nomw........................... Chimney provided that the person accepting this permit shall 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 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR • UNLESS CONSTRUCT ST Rough Service. .............. ..... ......... 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. SEEREVERSE SIDE Massachusetts- Department of Public Safety Board of Building Re-ulations and Standards Construction Supervisor License jLicense: CS 79181 1 �r WILLIAM C PENNY j 4 EMERSON PLACE#514 i BOSTON, MA 02114 —` Expiration: 11/6/2012 Commissioner Tri#: 7791 TIM Office of Consumer Affairs&B siness Regutallon HOME IMPROVEMENT CONTRACTOR Type: Registration: :4128016 private Corporation Expiration: -21�112p13 . � = NS,INC AN VER RENO. J'. a: = WILLIAM PENNY',`¢=_. 110 WINN ST WOBURN,MA01801'' i ` Undersecretary �r \ 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 Legibly Name(Business/ ): �+J p 9fr,'�CJ A't l OtQ1 Cep(J() c*3 LAC . Address:IkL-> W t t- 10 City/State/Zip: AAA. Q(501 Phone#: IN C13-7 52)0&_ Are ou an employer?Check the appropriate box: Type of project(required): 1.; I am a employer with_6 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑ w construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. YRemodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp. insurance.$ 9. ❑ Building addition 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 11.❑Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no 13.❑ Other employees. [No workers' 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. lContractors 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 Name:_ Policy#or Self-ins.Lic.#: (�!4e, 15o0$,,46 o t 2.01 C> Expiration Date: (� 2.� , ► �_ Job Site Address: 93 W" % (Y ?i%JUi A Lr 4Lr City/State/Zip-0. AW 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 thviolator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for ins ce coverage verification. I do hereby cern under the and penalties of perjury that the information provided above is true and correct Signa re: - '^ Date: Phone#: a$05"$O5" 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#: OP ID: MS � CERTIFICATE OF LIABILITY INSURANCE DATE(MYYY) 03/006/16112 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 781-729-9200 CONTACT SCOW&Company,Inc. PHONE FAX 19 Mount Vernon Street 781-729-9500 (A No Ext): A/C,No): P.O.Box 1000 E-MAIL Winchester,MA 01890-8300 ADDRESS: Michael P SCOW PRODUCER-CUSTOMER RODUCER ANDOV-1 CUSTOMER ID#: INSURER(S)AFFORDING COVERAGE NAIC# INSURED Andover Renovation INSURER A:Endurance American 41718 Solutions,Inc. INSURERB:Associated Employers 110 Winn Street,Ste.207 Woburn,MA 01801 INSURER C INSURER D: INSURER E: 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 TYPE OF INSURANCE DDL UBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DD/YYYY MM/DDIYYYY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO A X COMMERCIAL GENERAL LIABILITY NN186805 02106112 02106113 PREMISES Ea occurrence) $ 50,000 CLAIMS-MADE �OCCUR MED EXP(Any one person) $ 1,00 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Per accident) $ NON-OWNED AUTOS $ $ UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER B ANY PROPRIETOR/PARTNER/EXECUTIVE Y I N CC 5008746012010 11123111 11123112 E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBEREXCLUDED? ❑ NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION PROOF02 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN For Insurance Information ACCORDANCE WITH THE POLICY PROVISIONS. Purposes Only For verification please call AUTHORIZED REPRESENTATIVE 781-729-9200 ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD