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HomeMy WebLinkAboutBuilding Permit #873-11 - 55 FOXWOOD DRIVE 6/20/2011TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: M -// Date Received Date Issued 6/ ,70 1t IMPORTANT: Applicant must complete all items on this page LOCATION �� j(Woo> !,� ✓C Print PROPERTY OWNER MQaZ—A Print MAP NO: S PARCELZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building El Addition ❑ Alteration S-0)ie family 11 Two or more family No. of units: ❑Industrial ❑ Commercial ❑ Repair, replacement ❑ Demolition . a ® Septic DEW llr ❑ Assessory Bldg ❑ Other ®Floodpla Wetland®kyVatershed {.. ❑ Others: Di'AMstrct' 1 Y�'. .� 3 M1t .tib X� , A � _.tea`, DES`CRIPTION OF WORK TO BE FEKFU e p) Ce. �e i,l (�' W , %1� D2W/S h/rL�S e �/ I I ,J5 -mit N e 1�4 s-��c —h2 �` - E-ic-rE,2 -,A a �J�� �, �� c°� ► ��. Identification Please Type or Print Clearly) i OWNER: Name:'I�A w ,- Phone: c7 Address: 5 5 i-)�,W�� ��. V� n(� fF.� T►n� �-- 01 �l4 S CONTRACTOR Name: eo o Phone: Address: v� i2 r c c.✓'�et Lq �� fB�-�`F1� Supervisor's Construction License: L' 5 5�? ivy Exp. Date: Home Improvement License: Exp. Date: A lac ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cost: $ ��00 FEE: $ 9C — Check No.: -2Y a5' Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access t4hkkuarantyfund Location 57�— No. Date 61,;2 0 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ MU Foundation Permit Fee $ Other Permit Fee $ TOTAL' $ Check # 24265 /Buijding inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ To 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 El— COMMENTS COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes © Planning Board Decision: Comments Conservation Decision: Comm Wager & 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 Fixe 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 2008 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 rod g products i 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 a ❑ 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 o 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, Xn all cases if a variance or special permit was required the Town clerks office must stamp the decision from the Board of Appeals Mat 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: Doc.Building permit Revised 2008mi Cd �o O :u c :W 0 0 c H O C CL C J: 0 C Ea � J m c E cy Ev- ia = CD C> m .G. t C 4.4 y O C O �T� E O e0 F+ -i U Q1 L 0 'C C O ,I o. -V L m CD 0 O cm � \ c O Q m Q, :CCJ3 :CAZ. o c CL c Q m : !!.,D m C •O = as :of9 N ~ r0.. V) C o CD CO r r.+ w •y 0 0 Z W E tot = w .y O C3 ® ca CD g . COD CL O 'C 0 (a m 1— Z .0.. ��m � O • L O O v Z CL O CO) D C CD cm I C C CO2'O Q9 M O O 'E CO CO CL CD CD o 0 _O O d CL CMQ C Cc CL 0 C C � � C.) CO) O C C C C. 0 O u. v U) ro.U p w O cG C U cz G w p w G w a' w p w a cn tj. C7 rz iI, w CLW w acd Go 5 m o i v) Q cn �o O :u c :W 0 0 c H O C CL C J: 0 C Ea � J m c E cy Ev- ia = CD C> m .G. t C 4.4 y O C O �T� E O e0 F+ -i U Q1 L 0 'C C O ,I o. -V L m CD 0 O cm � \ c O Q m Q, :CCJ3 :CAZ. o c CL c Q m : !!.,D m C •O = as :of9 N ~ r0.. V) C o CD CO r r.+ w •y 0 0 Z W E tot = w .y O C3 ® ca CD g . COD CL O 'C 0 (a m 1— Z .0.. ��m � O • L O O v Z CL O CO) D C CD cm I C C CO2'O Q9 M O O 'E CO CO CL CD CD o 0 _O O d CL CMQ C Cc CL 0 C C � � C.) CO) O C C C C. 0 UN -20-2011 09:38 AM ACADEMY INSURANCE 9785216873 AUUKU. l;t:K 11HUA I t Ur LIAMLI I V MUKAMA 06110I201 I THIS CERTIFICATE 16 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIOHTS UPON THE CERTIFICATE HOLDER. THIS PCDTICPATC n A00 ►VAT A=lV11RT1%1Fr Y IID R,Cp AT11/CI v AtlaA,rA CV7C11r1 nD A, TC0'rMC PAIrCDAnv ACCADMCIA eV RIC M, IAIC0 RC1 Nu THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERM), AUTHORIZED REPRESENTAI)VE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANTt If fhe oarNod• holder loan ADDITIONAL INSURED, oho polay(lara) must he srdareed. M SUBROGATION IS WAIVED, suNsmt to ft tetme end oondlllons of the polloy, oartdn pollelos InaY reWire end erdoroslTent. A stetatnerrt on tH s 000108% does not oontsf r1gMs to ft eerlitioete holder In lieu of such endereemsmIvi. PRODUCER ACADEMY INS AGCY 67 R[VER 91'RUT HAVBRHILL, MA 01832 WIN.. INSURED EAGLE BUILDERS CORP CONTACT NAME: PHONE FAX (AIC, No, Est): FAX (AIC, No): E-MAIL ADDRESS: PRODUCER CUSTOMER ID 0: INSURERS) AFFORDING COVERAGE INSURER A. ACT AMIMC'AN IN61XMCE COMPANY INSURER B: INIJUMI:N 0: INSURER 0: 23ROPXENTREE LANE INSURER E: BYFIELD, MA 01922 INSURER F: COVERAGES CCRIMATE NUMBER: REVISION NUMBER: n US 15 TO CERTIFY THAT TRIG POLICIES or INSURANCD LISTED BELOW HAVE DECN =UGD TO THR IN41UN 0 NAMED ABOVE FOR THE POLICY PERIOD INDICAT0. NOTWITHSTANDING ANY RECUIREMENT, THAM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH REBPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PtIRTAIN, TNN INSURANC I AFFORDED BY THE POLICIES DEBCRIN BD HEREIN IB IIUBJICT TO ALL THE TERMS, INCLUSION@ AND OCNIMTION9 0P OUCH POLICIES, LIMIPS SHOWN MAV HAV% BEEN REDUCED BY PAID CLAIMS, INOR TYPE OF INSURANCE LTR GENERAL LIABILITY COMMERCIAL ORNERAL LIABILITY CLAIMS MADE OCCUR CEN'L AGGREGATE LIMIT APPLIES PER: POLICY PROJECT LOC AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULEAUTOS HIRED AUTOS NUN -OWNED AUTO'S ADDLOUSR POLICY EFF DATE POLICY EKP DATE POLICYNUMSER (MROD0IYYYY) (MMIDGYYYY) Nan WVD LIMITS EACH OCCURRENCE 5 DAMAGE TO RENTED 6 PREMISS (E0 fmcurrenr:e) MED EXP (Any one pllrson) S PERSONAL Am ADV INJURY GENERAL AGGREGATE $ PRODUCTS -COMPIOPAGO COMBINED WNGLE S LIMIT (En Aoolderlt) BODILY INJURY S (Per person) BODILY INJURY 8 (Per siceftt) PROPLRTY DAMAGE 3 (Par uoldent) UMBRELLA LIA9 OCCUR EACH OCCURRENCE 8 EXCESS LIAR CLAIMS -MADE AGGREGATE 8 DEDUCTIBLE R RETENTION S $ WC STATUTORY LIMITS OTiIER WORNF..R'S OOMPCN$ATION ANO EMPLOYER'S LIABILITY YM UB-448OP458-11 02/21/2011 02121/2012 E. L. EACH ACCIDENT 3 ANY PROPS ITC"ARTNERIEXECUTIVE N E.L. DISEASE - EA EMPLOYEE 8 OFR(:FR/MFMAFR FXCI I IDM? (Msndetery In NH) E.L. DISEASE - POLICY LIMIT S It y4e, d000dhe under INSCRIPTION OF OPERATIONS MIOW DESCRIPTION OF OPERATIONS!LOCATIONS,MEHICLESIRESTMCTIONBfSPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIRCATH ISSUED TO THE CERTIFICATE HOLDER AFPECTINO WOR14MB COW COVEAAOE, CERTIFICATE HOLDER NORTII ANDOVER BUILDING INSPECTOR 1600 OSGOOD ST NO ANDOVER, MA 01845 ACORD 25 19009/09) P.01 NAIC tr 100.000 100,000 500,000 CANCELLATION 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 1808.2009 ACORD CORPORATION. All rlphts reserves!. U p.j C,3 O Cd r d � Z - O N (YO W Z OU R O �N � W� o LLJ'^ N La w ❑ M W WW Q WJC�J JZ(DW c J LLI0 m O Q L O L U� rn CO u ❑ C-4 Mnn�-� T LL (O R �+-a C N C I I L O O O •ca fl r� Ej LLJZ r O M n a I M M• �••i a) W d L r,,.4 a U p.j C,3 O Cd r Z - O N (YO W Z OU O �N x W� LLJ'^ v J Z M W WW Q WJC�J JZ(DW J LLI0 m AYN The Commonwealth of Massachusetts Department oflndustrial.Accidents A; .�. 1 Office of Investigations , MY'e t �il ` • 600 Washington Street ��•" Boston, MA 02111 www mass.gov1dia VP'o?rkers' Compensation insurance Affidavit: Buiddelrs/Contractors/FIectlricians/Piumbers Applicant Information Please PrinfLegibly Name (Business/Organization/Individual): E -46 -LC 'S'), ID, F•(z_s Address:_ C ; e e,�,� es, City/State/Zip: j��'G Y\A A Phone /#: A,rre,you aln employer? Check the appropriate 1. UJ 1 am a employer with �_ box: 4. ❑ 1 am a general contractor and I Type ofproject (required): employees (full and/or part-time).* have hired the sub -contractors 6. ❑ New construction 2. ❑ I am. a sole proprietor or partner- listed on the attached sheet. # 7• ❑ Remodeling ship and have no employees These sub -contractors have 8. n Demolition working for mein any capacity. [No workers' comp. insurance workers' comp, insurance. 5. ❑ We are a corporation and its 9. ❑ Building addition required.] officers have exercised their 10.❑ Electrical repairs or additions 3. ❑ I ain a homeowner doing all work right of exemption per MGL - I I.0 Plumbing repairs or additions myself. [No workers' comp, c. 1,52, § 1(4), and we have no 12.[] Roof repairs " insurance, required.] i employees. [No workers' 13.[] Other .comp. insurance required.] -nuy appucanr mar cnecxs oox ff i must also 1111. out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they aie 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 acid their Workers' comp. policy information. 1 am an employer that is providing workeis' compensation insurance far my employees. Below is the policy and job site information. Insurance Company Name: h& Awl f A, 't A J wn_ Policy # or Self -ins. Lie. #: ` ?� v P�5 Expiration Date: c�l Job Site Address: � � 'S� X W o ©� (' City/State&ip:_N p. AA -v AA- Q 1 I Jr - Attach a copy ofthe workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL cA52 can lead to the imposition of criminal penalties of 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 maybe forwarded to the Office of Investigations of the DI -flor insurance coverage verification. I do hereby certify pains andpenalties ofpeijury thatthe informationprovided above is true and correct.' Y- 376_-- 5 2 -� Official use only: Do not write in.this area, to be completed by city or town official. City or Town: Permit/License Ik 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 #: bforma%®n and Instrueti®ns Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more ofthe foregoing engaged in a joint enterprise, and including the legal representatives 6f deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant: of the dwelling house ofanother who employs persons to do maintenance, construction or repair work on such dwelling house or -on the grounds or building appurtenant thereto shall not because of such employment be,deeined to be an employer." MGL chapter 152, §25C(6) also states that "every state or local Iicensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to cavy workers' compensation insurance. [fan LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you Have any,questions regarding the law or ifyou are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom ofthe affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the pennit/lieense number which will be used as a reference number. Irl addition, an applicant that must submit multiple�permit/license applications in. any given year, need only submit one affidavit indicating current Policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy ofthe affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or pen -nit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The COMM-awealth of Massachusetts Dr,partment of Industrial Accidents Of -Bee of Investigations 600 Washington Street $oaon, MA 02111 Tel. # 617-7274900 ext 406 or 1-877 MA.SSAF.F Revised 5-26-05 Fax # 617427-7749. www.mass.gov/dia EAGLE BUILDERS CORPORATION 23R Greentree Lane Byfield, MA 01922 (978) 463-3110 NAME: Randy& Denise Murdza 55 Foxwood Drive North Andover, MA 01845 r DATE: 6/7/11 Window installations: Remove existing wood windows (18) Install new Andersen 400 series tilt -wash window units w/ Smart sun low -e glass, grilles between the glass, factory painted interior, white screens.& white hardware on casement units. re -flash, fix all rotted areas, install new house wrap, trim with plastic trim boards, reside affected areas, install new 2'/2" matching interior trim. Price includes all materials & labor. Building permit is included in price (limited to pricing of contract). One 10 yard dumpster is included in price. Note: No exterior painting is included in this price. No interior painting is included in this price. PAYMENT SCHEDULE Total contract price is $24,600 1/3 due upon signing of contract ($8,200) 1/3 due at approx. halfway (kitchen gutted, electric& plumbing rough complete) ($8,200) 1/3 due upon completion ($8,200) I By signing this contract: Eagle Builders Corporation & Randy Murdza agree as above. Randy urdza le' Eag u' ders Corporation Da Glen Lewis