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HomeMy WebLinkAboutBuilding Permit #893-14 - 58 MOLLY TOWNE ROAD 6/10/2014Permit No#: —/zr Date Issued: BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received 'IMPORTANT: Applicant must com LOCATION(} Imt,tc.,Tmw�.� PROPERTY OWNER No,[+k V% *-0101V12!Z Print MAP _PARCEL:4�� ZONING DISTRICT: TYPE OF IMPROVEMENT ❑ New Building ❑ Addition ❑ Alteration ❑ Repair, replacement ❑ Demolition ❑ Septic ❑ Well PROPOSE bone family ❑ Two or more family No. of units: ❑ Assessory Bldg 0 Other all items on this ❑ Floodplain ❑ Wetlands �-�Y (-DC- 100 Year Structure yes Historic District yes Machine Shop Village ves RIPTION OF WORK PE PERFORM Non- Residential ❑ Industrial ❑ Commercial ❑ Others: ❑ Watershed District Q �ntii ti &Please T e or Prin Clearly OWNER: Name: © Y� klp� PhonE Address: �oSPt%� �/'ir� A� dU ",Lz r Contractor Name: NOPk NVZ eQO'- I ( Address: Of/I►ORTN 0 11'LED o a. to V Supervisor's Construction CS �� 5V License: Exp. Date: Home Improvement License: _ i % Z y5 Exp. Date: .3 1 ARCHITECT/ENGINEER Jetf JyV©Phone: (�63 / 1 5 3 Address: Reg. No.g FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ oo © FEE: $ klo°0 V Check No.: M Receipt No.: O' NOTE: Persons contracting with unregistered con ctors do t have access to the guaranty fund Signature of Agent/Owner M T T ature of conot-rakOor--�� 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 PLANNING & DEVELOPMENT Reviewed On COMMENTS Signature_ CONSERVATION Reviewed on Siqnature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments 0 Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: FIRE DEPARTMENT - Temp Dumpster on site yes Located at 124 Main Street Fire Department signature/date COMMENTS LUI:cIICU JO'F %JZ) UUU QU ccs 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 No MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine NOTES and DATA — (For department use ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 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/Cross Section/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) o 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 Doe: Building Permit Revised 2014 Location No. Date Check # X J U TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee TOTAL $ Olcfi�g Inspector APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION ADDRESS/LOCATION OF PROPERTY: BUILDING PERMIT #_ 5(o5 43 Map Parcel 1 Lot Number oZ SUBDIVISION: S DATE REQUESTED FILED/READY FOR INSPECITION: I °D S f y CLOSING DATE ON PROPERTY: l� I 1511 FIVE (5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED ALL WORK AND SIGN -OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A REINSPECTION FEE OF TWENTY DOLLARS ($20.00) WILL BE CHARGED IF THE STRUCTURE DOES NOT MEET ALL APPLICABLE CODES. Permit Issued Issued to: Address: APPLICANT SIGNATIlU,,RE nv CONSERVATION PLANNING DPW -WATER METER SEWER CONNECTION ROUTING /,g lq /I U/ DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST SIGNATURE File: Application for OC form revised Jan 2007 1.9-/°// Enter construction cost for fee cal - North Andover Fee Cakulaflon Construction Cost $ 409000.00 m $ - $ 480.00 Plumbing Fee $ 60.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 60.00 Total fees collected $ 700.00 58 Molly Towne Road 893-14 on 6/10/2014 Finish Basement with A Bath &S = = O D a O m ' T G �p v O LL � a V) p a z Z c O 3 LLO 3 = U io c LL O ~ H z Z d 3 K m c LL O L0. n z J CQJ v LY 3 W 0) V) E LL oc u w {n Z a C7 to 3 0v M _ LL Z = Q CL w w a_ cu L co v V) +' N . V1 UJ Z a 2 Z O G to Z W _w a. W H W a_ o a Z Z m cn I.L V/ O U Z O U) J M I w I w ♦.+ = C O _ �O CD Qi Q O = U) V Q N w C N d E tm w Q ci i CL J i C� V, > _ y fit.. O > > 0,0 =mss o a' .�Qo c •> 3 lam- t: = o H _� •a n •� Q as t6 0 y O CY) _ I— v O = _ 0 2 m CL N CO w 2 m as W LL 0 a- O O to = O N •� t O W U O Q U)N > y. C o J O H .� - CLOU > 2 Z O G to Z W _w a. W H W a_ o a Z Z m cn I.L V/ O U Z O U) J M I w I w ♦.+ 59-T .... P"�M+e � 1RJR'�1Ri4 6rf �f I11�prCIG`... ���C (iC+UlUl07I/I/CfI�%�C/�'I �CIr3CCC�C(.iC�IJ Office of Consumer Affairs & Business Regulation a ME IMPROVEMENT CONTRACTOR egistration: 171245 Type: pi ration: 311/2016 Individual CARROLL V. JAMES CARROLL JAMES 21 JOHNSON CIRCLE NO. ANDOVER, MA 01845 Undersecretary Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supervisor 4 License: CS -063503 JAMES V CARRQU 21 JOHNSON CIRE11 North Andover WA 01845 Expiration Commissioner 07/19/2015 The Commonwealth of Hassachasetts Departmentof iidgstrlglAccie%nts Office oflnvestigaflons 600 Washington Sheet Boston, MA 02111 www.mass gov1d1a Workers' Compensation bmuxance A rdavit: BOdersiContractoxsfElecfriciansil litmberc� Dame (Business/Organization&dMdual): Address: 66 1,5pr ► 11ta - rn go CxylS ia�e/Zip:�UeL �� �_ Phone Are you an employer? Check the appropriate box: Type o£ o�ect (required): El1. I am a employer4. with �-- a g El I am general contractor and I � 6. ��ITIew c6nstrttciion employees (full and/or part-time).* 2,111 am a sole proprietor or partner have hiredthe sub -contractors listed on the attached sheet, T 7• ❑Remodeling ship and`have no. employees These sub -contractors have S. ❑ Demolition working forme in any capacity. workers' comp. insurance, g, gg addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.[j Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised.theix right of exemption per MGL 11.[] Plumbing repairs or additions myself [No workers' comp. c.152, §1(4), and we have no 12.QRoofrepairs �. ] insurancere ed employees. [No workexs' 13.❑ Other comp. insurance required.] 'Uny applicautthat checks box#I must also fiil out the section below showing their workers' compensation policy information. ►'Homeowners who submitthis affidavit indicatingthey 9doing allworlc and then hire outside contractors must submit anew affidavit indicating such. tContractors that cheAtbis box must affached an additional sheet showing the name ofthe sub. -contractors andtheir workers' comp, policy information. I am an employer that is providing workers' compensation insurance for my employees Bellow is the pokey and jab site information.. n I Insurance Company Policy # or Self ins. Lic. #: W CC Sib 1 IZ`7 3 <0 1 001 Li n i rob Site A ddxess: 5p, Cwedc.t n�C� fCity/StatelZip: ��� dV1Q �j �S-- Attach, a copy of the workers' compensation -policy declaration page (showing.the policy number and expiration. date). Failure to secure coverage as requiredunder Section 25A of MGL o. 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 ofup to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the AIA for 1surance coverage verification. Ido liereby ktil 4nilergepains andpenalties ofparlwy that the information provided abyve isf'rue and correct. official use: only. Do not write in Mis area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health. 2. Building Department 3. CiiyfTown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone #: Information and Instructions,' Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person tri the service of another under any contract of hire,. express orimpiied, oral orwxitten." An ervloyei is defined as "an individual, partnership, association., corporation ox other legal entity, or any two ox more Of the foregoing engaged in a joint enterprise, and including the legal representatives of a•deceased em to ex or the receiver or. trustee of an individual, partnership, association or other legal entity, employing employeesSowevex ilre owner of a dwelling house having not more than three apartments and who xes ides therein, or the occupant ofthe dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment ba doemedto be an employes." MGL chapter 152, §25C(6) also states that "every state or local iic$nsing agency shall withhold the issuance or renewal of a license or p ermit to op erate 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 ofpublic work until' ccepfable evidence of compliance with the insurance requirements of this chapter have beenpresented 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) andphonenumber(s) alongwiththeir certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability partnerships (LLP) with no employees other than the members orpartners, are notrequired to carry workers' compensation insurance. IfanLi C orLLP does have employees, a policy is required. Daadvised that thisaffixdavitmay besubmitted tothe, Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be xetumed 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 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 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 submitmultiple permit/11cense applications in any given year, need only submit one affidavit im(licatiug current policy information (ifnecessary) and under "rob Site Address" the applicant should wxite "all locations in (city or towu)" A copy of the affidavit that has been officially stamp ed or marked by the city or town may be provided to the applicant as proof that a valid affidavit -is' on fife fox future permits or licenses. Anew affidavit must b e, filled out each year. Where a home owner or citizen is obtaining a license ox permit not related to any business or commercial venture (i.e. a dog license orpermit to burn leaves etc.) said person is NOT xequired 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 andfaxnumber: the Ca oRwealth ofMassachwotE, Department 4£Zadu*ial Aceldouta • Q�co o�'Ti��e�ii�a�iau�• ' 60G WaW agton reet Boston, MA 02111 Tool # 617-7-21'&4900 ayd 406 Qr- 1-877,MASSAF Revised 5-26-05 `ay, 6 M27 7'49 ' w�t�.zxtass,go-��dia 06/09/2014 09:36 9786833147 PAGE 01/01 acts CERTIFICATE OF LIABILITY INSURANCE 6/9/2014 - THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES I;IOT 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($), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the cerdficate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed_ If SUBROGATION IS WAIVED, subject to the terms and condigons Of thO policy, certain policies may require an endorsement A statement on this cer0flcate does not confer right; to the certtfloats holier in Ilan of such endorsomenl(a . PRODUCER NAME! M P R013ERTS INS AGCY INC arc E ,. (978) 683-8073 Arc No078) 683-3147 1060 Osgood Street ADDREss:sMSSO robertsinsurancO - COM North Andover, MA 01845 Ri31 AFFOROINO COVLIRAOE NAIU NsuRER A : ATED EMPLOMRS INS CO INSURED NORTH ANDOVER REALTY CORP. INSURER B: 66 SPRING HILL ROAD INSURER C: _ N01kTH ANDOVER, NA 01845 -gikerR D INSURER E: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: I THIS ISIS TO CER'nFYTrHAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE: ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND C01401TIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. MR �R TYPE OF N8URANCE INep POLICY NUMBER MMlODlYYYY !DD LIMITS COMMORCIAL GFNiaAL LIABILITY EACH OCCURRENCE Is CLAIM&MADE OCCUR PREMI$Es L11, $ MED EXP Any are per..en) $ PERSONAL&ADV INJURY 5 O"N'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ PRO- F LOC POLICY PRODUCTS - COMP/OP AG© S JE.CT S OTHER: AUTOMOOILE LIABILITY Ea acodont S ANYAUTO BODILY INJURY (Per person) s ALL OWNED SCHEDULED BODILY INJURY (Par amitlent) $ AUTOS AUTOS HIRFO AUTOS NON -OWNED Pl 5 AUTOS $ UMBRELLA LIAR OCCUR EACH OCCURRENCE s EXCESS LIAR CLAIMS -MADE ; AGGREGATE S DED RETENTIONS $ WORKERS COMPENSATION STATUTE ER AND EMPLOYERS' LIABILITY03/13/14 03/13/15 ANY PROPRIETOR/PARTVE,RrEXECLUIVE Y{ —1 NIA WCC5010734012014 E.L. EACH ACCIDENT 8 500,000 A OFFICERNFwER EXCLJOEJ7 I`JI C.L. DISEASE • EA EMPLOYE S 500,000 (Mandatary In Ne) i}YYaA,,vauntsuntler E.L,DISEASE-POLICY LIMIT s 500,000 DESGRrPT1pN OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS f VEHICLES (ACORD 101, AddRional Remeft Schedule, may be attechad If more spam Is requ'red) FAX: 978--655-4760 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF NORTH ANDOVER THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH TME POLICY PROVISIONS. 1600 OSGOOD STREET NORTH ANDOVER, MA 01845 AUTHORIZED REPR $E ATIVE M � 1988.2014 ACCRD CORPORATION. All riahts reserved. ACS RD25(2014)01) The ACORD name and logo are registered marks of ACORO