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HomeMy WebLinkAboutBuilding Permit #87-12 - 58 MAIN STREET 7/29/2011TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: l r Date Issued: IMPORTANT: A� R �-J Ani Date Received must complete all items on this int f Print MAP NO�PARCEL ZONING DISTRICT: J 7 - Historic District yes no Machine Shop Village yes no 100 year-old structure yes no 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 loFodp W and 1Wafersliec District �_� _ r - DESCV4PTION OF W�QBK TO BE P Please Tppe or Print Clearly) OWNER: Name: Address: CONTRACTOR Name: �� \ V Phone: Address: Supervisor's Construction License: C5 Exp. Date: Home Improvement License: l ��� l Exp. Date: 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: $ / fP, FEE: $ � Check No.: Receipt No.:� NOTE: Persons contracting with unregistered contractors do not hatejaccess_4he guaranty fund Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ElSwunm' 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 COMMENTS CONSERVATION COMMENTS e E HEALTH WIck COMMENTS - DATE REJECTED 0 DATE APPROVED X Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Con nection/Synature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site Located at 124 MainStreet Fire Department signature/date COMMENTS yes no 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 MGL Chapter 166 section 21A —F and G min.$100-$1000 fine NOTES and UA I A — (I -or cepartment use ❑ Notified for pickup - Date Doc:.Building Permit Revised 2011 June/mi No 0 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 Perri 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 Permii 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 .Permi 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 Location M.4 //-7 No. Date TOWN OF NORTH ANDOVER 0 Certificate Occupancy $ of Building/Frame Permit Fee CHU $ Foundation Permit.Fee $ Other Permit Fee $ TOTAL $ Check # 7 2 4 4 Building Inspector CA m X m /mom/ YI m CA mm v■ CA d C � B7 Cl) Z co C. r � � o C). CO) O c v CD CDCL O Q lic d cD CD C CD �■ CD CL v y co CD v CO2 O 'O Z O O O � • CD O C CD I 9101 7:% �E 1.5 ice C 0 O Z O_ CD 0 _ m c cc CD co 0 N O. H y m 1 c�=0 S w�7 G H S aH 5 m »®C.) m CO) ti � CLC.) ^ orf '�9 p � Uzi n `�G' N 't7 O G O. ... m nod C/) c� C7 y ?� m o = CO) -�OOy O �� o =rm CD �. 0 = O 'V , Z�n H � O C9 O m =r _ 7d nye o 7d � CLte...; o=r ==r: CD N ' 71 O 0 CL cl) M y - CL 0 �m CD W C42 �a O m O = .d■► H 0 r- - CD 'O O CD o CD �. =m .Z rA CD / • o: _ CD dm: n� 0 0; =C45 o c o 0 0 cn cn w�7 G G �d p orf p c� 7C1 p ^ orf '�9 p � Uzi n `�G' yd O 't7 O G O. l� V C/) c� C7 y al O O � W � 7d 7d • Z 0 0 0 c PROPOSAL McGILLEY Roofing & Construction 6 Eastside Ave. Saugus, Mass 01906 Phone(E81)52 90- 086 Fax (781) 665-7300 This proposal is submitted to: Joe Cronin 58-60 Main St. N. Andover, Ma. We hereby submit specifications and estimates for: DescdD ion of Job Date of Plans Proposal/Estimate No. 07/20/11 0240-11 Job Rubber Roof City State Zip N. Andover Ma. Phone Fax 978 853-3676 • Re move existing roofing from entire upper roof and back lower roof(not responsible for siding around back roof) • Remove 3 existing skylights (fill in with plywood) • Entire roof to be insulated with''/: inch sheets of insulation (secured with screws & plates) • Rubber membrane (.060) to be glued & fully adhered to insulation, • All seams to be sealed with lap sealant • All roof penetrations will be wrapped and sealed • Rubber membrane to be terminated around perimeter with a 3 inch edge metal(white) • Install new seamless aluminum white gutters and downspouts to back section of main roof • Install white metal coverage to all crown moldings around building(not in areas where gutters go) • Install white vinyl Soffits to overhangs and place Soffits vertically on freeze board around entire building) • Clean up and remove all debris on a daily basis Note: building to be tarp and covered while stripping roof (0bber 4Rgofi Note: Any rotted roof sheathing will be discussed for an additional fee (worst case scenario would be to have to, plywood entire upper roof $4800.00 and back roof worst case scenario would be $600.00to plywood) NOTE: To replace pieces of roof sheathing it will cost app. $3.00 a foot (W rough spruce) NOTE- to rPnlarP anv rotted crnwn moldinv will enst ann_ S15.00.9 fnnt We hereby propose to furnish material and labor, complete in accordance with above specifications, for the sum of.- with f with payment to be made as follows: All material is guaranteed to be as specified. All work is to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from specifications involving extra costs will be executed upon written orders, and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado and other necessary insurance. Our workers are fully covered by Worker's Compensation Insurance. Authorized Signature CAr c;jVmy Cl. gifcj,11e,,, � Note: This proposal may be withdrawn by us if not accepted within a"s�iztyL6JO day period DATE 07/20111 Acceptance of Proposal — The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. Date of Acceptance: Signature X Signature X 19 Mbh cW�aM R� a,��mdmn � I 4N W N O W 44-_ Cl) O <_ E D � Z D D�cn 0 N 00 0 r W m N c- �? 0 mo m c r 1 J � O f N � � �z r r' � G � � to G G r; G 'I '4 EI' CERTIFICATE OF LIABILITY INSURANCE DATE (MM/Y) RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 06/21/2011 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(les) 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). PRODUCERONTACT Genesis Insurance Group 599 North Ave. Door 6 Wakefield, MA 01880 NAME: Michael Sokolowski PHONE 781-350-4410 FAX No Ext1!Not: -MIL mike@geninsure.com ADDRESS: �g POLICY EXP YYY MWDD/Y PRODUCER MC 1004201223305 CUS ERID1t INSURERS AFFORDING COVERAGE NAIC p INSURER A : Arbella Protection INSURED Thomas McGilley dba McGilley Roofing and Construction 6 Eastside Avenue INSURER B Atlantic Charter INSURER C : Saugus, MA 01906 INSURER D: INSURER E : INSURER F: -- --- "—'-'--' RGYI,IVPI IYIIIYiIStK: 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. INSRADDL LTR TYPE OF INSURANCE SUBR wvnPOLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP YYY MWDD/Y LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED CLAIMS -MADE F OCCUR P IS a occurrence)$ MED EXP (Any one person) $ PERSONAL $ ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRO PRODUCTS-COMP/OPAGG $ $ POLICY LOC A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO 28495400004 04/06/2011 04/06/2012 (Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ SCHEDULED AUTOS PROPERTYDAMAGE (Per accident) $ CSL HIRED AUTOS NON -OWNED AUTOS - $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DEDUCTIBLE RETENTION B WORKERSCOMPENSATION AND EMPLOYERS* LIABILITY W CV00880100 04/19/2011 04/19/2012 $ OCC STATU- H - R ANY PROPRIETOR/PARTNER/EXECUTIVEY/N OFFICER/MEMBER EXCLUDED? ❑ N / A E.L. EACH ACCIDENT $ 500,000 (Mandatory In NH) Ifyes, describe under E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE - POLICY LIMIT 1 $ 500,000 DESCRIPTION OF OPERATIONS below — I — J DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) !`C OTICIn ATC VAS nre� _ I IVIV 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 ©1988-2009 ACORD CORPORATION. All riahts reserved_ AGORD 25 (2009109) The ACORD name and logo are registered marks of ACORD The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 S www.mass govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers iplicant Information Name (Business/OrganizatiorAndividual).. Address: City/State/Zip- Nk r you an employer? Check the appropriate box: 1 • I am a employer 3 with 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ I am a sole proprietor or have hired the sub -contractors listed partner- on the attached sheget t ship and have no employees These sub -contractors have working for mein any capacity. [No workers' comp, insurance workers' comp, insurance. 5. ❑ We are a corporation and its required.] 1. ❑ I am a homeowner doing all officers have exercised their work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp, insurance rewired . Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. El Demolition 9. ❑ Building addition 10-ElElectricalrepairs or additions 11 -0 Plumbing repairs or additions 12. Roof repairs q ] 13. Other I *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are 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 and their workers' comp. policy information. I am an employer that is providing workers' compensation insu information. A c i ' i rance for my employees. Below is tlae policy anti job site Insurance Company Name:_%�(i� Policy # or Self -ins. Lie. Expiration Date: 1 �. Job Site Address:_ (VNC��-f City/State/Zip:! 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 cral penalties of a iinin fine up to $1,500.00 and/or One 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 herehy cce y under the pgins I \ d pe � l ie , fperjury that the information provider above i4true and correct. 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 6. Other Contact Person: 4. Electrical Inspector 5. Plumbing Inspector Phone #: Information and Instructions 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, orad or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more Of the foregoing engaged in a joint enterprise, and including the legal representatives of a 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 of another 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 deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing 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 carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be 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 if you 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 Iicense 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 of the 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 permit/license number which will be used as a reference number. In 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 of the 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 permit not related for any business or commercial venture (i.e. a dog license or permit to bum 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 Con--n•oajwealtla ol'SVassachusetts Department of Industrial Accidents ®dice of Investigations. 600 Washington Street Boston; AMA 02111 Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax # 617,727-7749 www.mass.g.ov/dia