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HomeMy WebLinkAboutBuilding Permit #341-11 - 573 SALEM STREET 10/22/2010 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received �U Permit N0: Date Issued: 16 IMPORTANT:Applicant must complete all items on this page LOCATION > 7+i pvt S y Print PROPERTY OWNER :10 V A fZeo.s- (�O Y\- Print Print MAP NO:O_�PARCEL.0/6 ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PP OP D USE esidentia Non- Residential ❑ New Building family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial A Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other []�S_epte p Well ti(] FToo pl_am Sj❑ Wetland_s ❑ 'WatershedfDistnct: i DESCRIPTION OF WORK TO BE PERFORMED: a U�, ©d� �' af1JCw S 6JYw, Ir- g©dam tom* wOo�S Lt-0t?ruA#L<, Identification Please Type or Print Clearly) OWNER: Name: 6�, Phone: Address: S 7Y S ,\,e a, SA- CONTRACTOR Name: Cr UAA-cA-Cl :� h o Phone: C! Address: -:? P- 4 n Lc,h e ccs e r r Supervisor's Construction License: yb,5-1 S Exp. Date: Home Improvement License: 1 01�i Exp. Date: 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. j Total Project Cost: $ 71 AU FEE: $ Y-6 . 00 Check No.: Receipt No.: b`�, �I NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature�"of�Agent/®wnerr �_ --_ - _,_, G . ,� Signatureaof�confrac_or= � 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 a�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 Li 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 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: Doc.Building Permit Revised 2008mi Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art E] 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 ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Siqnature COMMENTS f Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments 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 2008 €. Location -J 2 .f No. Date ti NORTH TOWN OF NORTH ANDOVER o c F w 9 . + Certificate of Occupancy $ r'# s'"'°'�t�' Building/Frame/Frame Permit Fee $ s,kMusE 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 23592 Building Inspector UU/'L-L/Z01U Y1:34 kA—k U7853'L'GG17 mbi, inn 1,_]4. 002 ACC>RV® FI)AIE(MWDDNYYY) CERTIFICATE OF LIABILITY INSURANCE /23/2010 PRODUCER (978)532,5445 FAX: (978)532-2217 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION B.F. McCarthy Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 10 Centennial Drive ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. West Entrance Peab®_dy MA 01960 INSURERS AFFORDING COVERAGE MAIC 9 INSURED INSURER A:Merchants Ins Group JNR Gutters, Inc. INSURERB:National. UnioII Fire Ins Co os 19445 38-40 Lancaster Street INSURERC:ChartiS Insurance Company INSURER D; Faverhi.1,1 MA 01830 1 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTIMTHSTAN DING ANY REQUIREMENT,TERM OR,CCLNDITION 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 OD' - POLICY EFFECTIVE I POLICY EXPIRATION LIE INSR __ r- POLICY NUMBER LIMITS GENERALLIABILITY EACH OCCURRENCE S_ COMMERCIAL GENERAL LIABILITYASA F o dtrance S CLAIMS MADE OCCUR MED EXP(Anon ore S --•^ Y �Tt I PERSONAL 4 AOV INJURY S GENERAL AGGREGATE GEN'L AGGREGATE LIMIT APPLIES PER; PRODUCTS-COMPIOP AGG 5 POLICY 7 PRO- LOC ------ ---•-- AUTOMOBILE LIABILITY --- COMBINED SINGLE LIMIT S 1,000,000 ANY AUTO (Ea acc dcnl) A ALLOWNEDAUTOS 7015134 6/21/2010 6/21/2011 BODILY INJURY (For 5 X SCHEDULED AUTOS ( X HIRED AUTOS BODILY INJURY X NON-OWNED AUTOS (Per ec6denl) S -•- PROPERTY DAMAGE 8 (P(;r accldanl) GARAGE LIASILI TY AUTO ONLY-EA ACCIDENT 5 ANY AUTO OTHER THAN EA ACC 13 AUTO ONLY: AGG 5 EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE OCCUR 17 CLAIMS MADE AGGREGATE 5 S DEDUCTIBLE 3 RETENTION S S ViORKEpSF OMPENSATION C009752701 9/20/2009 9/20/2010 WCSTATUor •LIM X DTH• AND EMPLOYERS'LIABILITY ----AN I NY PROPRIEVOR/PARTNERI-eXeCUTIVE E.L.EACH ACCIDENT S 500,000 OFFICER/MEM ER EXCLUDED? C (Mandatory In NH) 0009774192 9/20/2010 9/20/2011 EL,DISEASE.EA EMPLOYEE 9 500,000 Irg,descrIbe under S?ECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT S 500,000 OTHER i DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Refer to policy for excluoioaary endoreements and special provisions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES a5 CANCELLED DtFORR THE EXPIRATION SAMPLE CERTIFICATE FOR DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN INSURANCE PtMPOSES ONLY NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO$0 SHALL SAMPLE COPY IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES, AUTHORIZED REPRESENTATIVE Timothy Tramonte/DC4 `1yyy - r 1 ACORD 25(2009/01) ©1988-2009 ACORD CORPORATION. All rights reserved. INS026(26nal) The ACORD name and logo are registered marks of ACORD � Niy , TONNM of ORTAndover ... . .... .. ...... _ dover, Mass., O ' ZZ ` l Q L- LAKE COCHICHEWICK V '7,950RATEo BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT 6�� '� .................................................................................................. ....... Foundation has permission to erect.................:...................... buildings on ...... .... ... ...............r................. Rough to be occupied asT Chimney ............. ....:.. ......... ...................................................... ....... ................................................................... provided that the person accepting this permit shall in every resp conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough L Final awlPER 111 EXPIRE THS ELECTRICAL INSPECTOR UNLESS CONS CTION ARTS ou ........................... .......................... . ..................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner _ Street No. SEE REVERSE SIDE Smoke Det. J! .U� ra F HIC 4 108503 All Types of Home Improvement 38-40 Lancaster Street ; Haverhill, MA 01830 Haverhill.MA: (978)37274088 Boston,MA: (617)423-3559 '$ 5 Andover,MA: (978)475-3723 Nashua,NH: (603)595-2272 Woburn,MA: (781)937-4212 Portsmouth,NH: (603)433-1811 - Natick,MA: (508 653-2200 Manchester,NH: ) (603)666-5502 www.jnrgrltters.coni Fax: (978)372-0360 Toll Free Nationwide- (800)966-9238 ri i, PROPOSAL SUBMITTED TO )(Aul PHONE r � Y � ?1: DATE ,A A it STREET ( ft { JOB NAME 1pN t CITY,STATE and ZIP CODE JOB LOCATION i l ARCHITECT JOB PHONE .1 j C PrVVVSB hereby to furnish material and labor- complete in accordance with specifications below, for the sum of: 1i `• dollars($ j! Payment to be made as follows: y t i i :I I ! Authorized Note:this proposal may be Signature i•' withdrawn by us if not accepted_within-,,-.. ``' days. ` We hereby submit specifications and estimates for: f >"7 'i r• 'z 1'j+. `T '7i tSAID ! tTh q.IVii i T :Slu'.3;iF +-4 �('' 1.. .` '.'�.`.; �T,-t'•'.; `�t"a" �� I1' t't1' I l..-tl 1,_'11 l.. 1 l +i �r`11.i t'fi- A('i' i ',_ -i^; ,; ; t.;i ^y ri Ei 1'-t'!� j� 1(t>'t)v,(, ;i�° ykgt,ep lt;� t-:• pp a° r: 04 I 1 ) 4 _ g46337. I� (. pR 1P it F'.. N1'}4 _y' [ .:3 -g 1"al ry p('; 1. 1 s tt,�13-5. :[[1,'f i°.iii . 1.1(-,i a�ppt d�.Ilg -I"F 1'I i(i I ifli_{�1r'1.8®(�i�p�1.f��'1,1p,� 1'1 ,7 P.Ctii}t;y f_'f',�..(P. yt(["yjjEa4)i'}�t'C�`y�K`5.,AjE'�g`' 4 47,E P y7y��r W,[,Yi.,t(Ft Sg' Yy' ,t.'t i n 'jf:t. erY A 3 4! 9 1� "�Sn .4841111 VC f 4'AV D E SIG 1..1R.SL NTi�E. i(*V ST01V'iV..R W11,1. 11AN;,.k. 1�iDl�� q.'ll�t.a'l�.t', M. i ''` i.[, 1;5. t.,- 'i;lTf...l rf' ! lllafi ;`o i`' fi I#�'1 {�' .f it,7,,ti t`> ii' ! �r t I y'` ` . ltt ! !'I,, t()t•i r,T1— ..k IP V1 1, Pa 6`- IN a , ESN t ,1 P 'F i; � ,H �.. :� l 1 ."1�1:.`�.ti('f 1 �,• P �'t'..;. . . v • ,�, s�r�;,_._ The Commonwealth of Massachusetts Department of Industrial.Accidents Office of Investigations 600 Washington Street Boston,IMA 02111 www.mass-gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/>Electriciansfplumabers Applicant Information Please Print Legibly Name(Business/Organization/Individual): �—n — R (�u �W� Vic Address: 3 ' k o Lin C_a5 k- r c �� City/State/Zip: �4tre�H •ill'114 C 3 o Phone#: q7 Z y Are you an employer?Check the appropriate box: Type of project(required): 1.W I am a employer with—o 4. ❑ I am a general contractor and I 6. ❑New construction ee employees(full and/or part-time).* have herd the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet.z 7 Remodeling . ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp,insurance 5. ❑ We are a corporation and its ' required.] , officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c.152,§1(4),and we have no 1,2 oof repairs insurance required.] employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box 41 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 their workers'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. \ Insurance Company Name: C kaA t S d_ ✓L � � 2 o Z olt Policy#or Self-ins.Lic.#: VX oG� Job Site Address: S 4.(e vvL Sk-��� City/State/Zip: (lJ. ✓4 ave 1__�/Vl 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under te pains and'penaldes ofperjury that the information provided above is true and'corr correct Si !E y_h—. 2 d) 0 Phone#• '1 3O z � 0-6 4 u Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town CIerk 4.EIectrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: � .ice -�� � �✓1� � r Office of Consumer Affairs&Business Regulation License or registration valid for individul use only i OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: x = Office of Consumer Affairs and Business Regulation Registration::08503 Type:, 10 Park Plaza-Suite 5170 w Expirat ori,f-"8119120;12 Supplement Card Boston,MA 02116 / J N R GUTTERji StINC KEVIN FRANCIS` k 38-40 LANCASTER.$T: Haverhill, MA 01830 I-.;`- Undersecretary I Not valid without signature Massachusetts-Department of Public Safeh .IVBoard of B,uilditig Regulations and Standards Construction Supervisor License License: 'CS 80515 Restricted to: 00 KEVIN M FRANCIS 35 WANNALANCET RD HAVERHILL, MA 01830 : ; c-- J"�- Expiration: 7/21/2011 ('onunissiu Hier Tr##: 18422 —_ ACOR[7rCERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 7/20/2010 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'CERTIRdATE OF INSURANCE DOES NOT CONSTITOTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT.'Af'the certificate holder is an ADDITIONAL INSURED, the olicy(ies)/fnust be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an en rseme'nt. A statement on this certificate does not confer rights to the certificate holderin.Iieu•of such endorsement(s). PRODUCER .47&-374-2500 866-494-4513 N°meACT Daniel J. Seaman Daniel J. Seaman AI°No Ezt:978-374-2500 a/c No):866-494-4513 229 Primrose Sf`reet E-MAIL dan seamaninsurance.corn ADDRESS: PRODUCER CUSTOMER ID#: Haverhill MA 01830 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A:Atlantic Casualty JNR Gutters Inc INSURER B: 38-40 Lancaster Street INSURER C Haverhill, MA 01830, 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 ADDL SUBR POLICY EFF POLICY EXP LTR INSIR WVDPOLICY NUMBER MM/DD/YYYY MM/DDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1000000 A COMMERCIAL GENERAL LIABILITY PREMISES a1 E IN occur ence $ CLAIMS-MADE F OCCUR MED EXP(Any one person) $ L18507 07/20/2010 07/20/2011 PERSONAL&ADV INJURY $ GENERAL AGGREGATE $2000000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICYPRO- T LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY(Per person) $ BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Per accident) $ NON-OWNED AUTOS $ $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB,`� HCLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION:'$, ; $ WORKERS COMPENSATION - WC STATU- 0TH- AND EMPLOYERS'LIABILITY Y/N T RY LI ITS E ANY PROPRIETOR%PARTNER/EXECUTIVE❑ E.L.EACH ACCIDENT $ OFFICER/MEMBER'EXCLUDED? N/A (Mandatory in NH)' E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF:OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Gutter, Roofing'and Siding Operations. Policy Paid and Effective through 7/20/2011 CERTIFICATE HOLDER CANCELLATION BEARER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. JAUTRIZED REPRESENTATI ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD