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HomeMy WebLinkAboutBuilding Permit #509-15 - 59 MEADOW LANE 12/1/2014Permit No#: Date Issued: I LOCATION BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION I IMPORTANT: Date Received icant must complete all items on this 0F NORTH q 11 %-FD ,61 .VO 6 O 6 o nD Ob 'M �4 Q�q^rED I.PP�'�y/ PROPERTY OWNER ` Print 100 Year Structure yes rv� MAPPARCEL: ZONING DISTRICT: Historic District yes r Machine Shop Village yes ! TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ ration No. of units: ❑ Commercial epair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic 0 Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer DES RIPTI N OF WORK TO BE PERFORMED: r Identification - Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name- &14 one. Address: Supervisor's Construc o License: -44Exp. Date: �'- Home Improvement License: Date:..;Z— VN 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. Total Project Cost: $ 00, 4D FEE: $ I �� Check No.: 1 q 1, Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner gnature 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 PLANNING & DEVELOPMENT Reviewed On COMMENTS Signature CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS J 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: FIRE DEPARTMENT - Temp Dumpster on site yes Located at 124 Main Street Fire Department signature/date COMMENTS Locatea 3154 usgooa street -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 — (1 -or department use ❑ Notified for pickup Call Emai 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) ❑ 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 Clerics 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 2014 Location � p ""' �'' No. rD�' ( `4 Check #' 1'_ v Date TOWN OF NORTH A14DOVER Certificate of Occupancy Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL ' �o Building Inspector in Eq—* MEW 5M 1� /I i 0 i W I ~d 0 h +r y " 3 a, M O' J �• L m a o.�0 0o E 0 O `m o z CL .� — yc o Q CL (1) 0 .� c a) O c d : Q. d co �+ O O m 'C O O LL '�LU .— Cc y CL O v v w Q V c. o N a� el UL) .0 O cc F- t *Z CLOU E Q C C O cc r Cc O V yr = .Q o L p V CL a) c O O Z J V W C a O W N V S Vaf Z N Z W LL. Q z J {A oC Q Z O Z Z U W W O -� u C7 w m E m J W LL ) O CL U Y O m ai Z + al o C L to — L °�° O U — L M ++ ar Y o o a a) O o ns o o ns ai m O c L v o LL (/I LL = U LL CC LL p[ N j.L LL i 0 i W I ~d 0 h +r y " 3 a, M O' J �• L m a o.�0 0o E 0 O `m o z CL .� — yc o Q CL (1) 0 .� c a) O c d : Q. d co �+ O O m 'C O O LL '�LU .— Cc y CL O v v w Q V c. o N a� el UL) .0 O cc F- t *Z CLOU E Q C C O cc r Cc O V yr c cc .Q o L V CL a) c (1) Q i 0 i W I ~d 0 h +r y " 3 a, M O' J �• L m a o.�0 0o E 0 O `m o z CL .� — yc o Q CL (1) 0 .� c a) O c d : Q. d co �+ O O m 'C O O LL '�LU .— Cc y CL O v v w Q V c. o N a� el UL) .0 O cc F- t *Z CLOU G O w a.Z z 0 m T Cl) COy 0 i/) Z ~ co LLI CL Cl) x0 � U N W CL Z El w E Q r 0 0 o c cc o L V G O w a.Z z 0 m T Cl) COy 0 i/) Z ~ co LLI CL Cl) x0 � U N W CL Z El w NAME OF OWNER HIC # 174377 c S-71` 87 Belmont Street • North Andover, MA 01845 UDINE 0: or—_ W -AA 11 7-70-0=�� We will remove all roof shingles off total roof area, up to two layers. Replace any boards or sheathing at additional cost. A new 8" white aluminum drip edge applied on all edges. Approx. 6ft of ice and water membrane applied on eaves, 3ft in valleys, strips around skylights, along chimney flashing and sidewall junctions. Existing step flashings to remain. A new base sheet applied. A 39W architectural roof shingle installed. Install new vent pipe boot fleshings. Waterproof existing chimney flashing and remove debris. We Propose herby to furnish material and labor - complete in accordance with above specifications, for the sum of: dollars ($ ) Payment to be made as follows fn?' ' C 46-7 ec Authorized Signature i� NOTE: This proposal may be withdrawn by us if not accepted with in days Acceptance Of ITOPOSId - The above prices, specifications and conditions are satisfactory and are herby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. Date of Acceptance: 111,51 -IX Signature Signature ® CERTIFICATE OF LIABILITY INSURANCE ACC)a 06/07 D /DD/YYYY) TYPE OF INSURANCE 05107!2494 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 00474-001 CONTACT NAME: Doherty Insurance Agency Inc PO BOX 1985 Andover, MA 01810 pjCNN . Ext : (978)476-0260 (FAX. No.: EMAIL ADDRESS: INSURER(Sl AFFORDING COVERAGE NAIC # INSURER A: A.I.M. Mutual Insurance Company 26158 DAMAGETO RENTED $ PREMISES Ea occurrence INSURED Damphousse Roofing LLP INSURER B: INSURER C: INSURER D: 87 Belmont Street North Andover, MA 01846 INSURER E: LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS 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 LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF MMIDDNYY POLICY EXP MMIDD/YYYY LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS -MADE [:] OCCUR EACH OCCURRENCE $ DAMAGETO RENTED $ PREMISES Ea occurrence ___ ___ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ EML AGGREGATE LIMIT APPLIES PER: OLICY PEo OC PRODUCTS- COMP/OPAGG $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMSMADE EACH OCCURRENCE $ AGGREGATE $ $ $ A yypRKDEERD pM ERETENTION AND EMPLOYERS' LIABI�ITY AN ppR�J�PPRRT�%E�'TpR11PARTNER/IXECUTIVE Y / N oF�ICER/h1EMBER IX � (Mandatory in NH) If yes describe under DESCRIPTION OF OPERATIONS below N1. gWC1300-7028774-2014A 4/17/2014 4117/2015 X TORY LIMITS ER E.L. EACH ACCIDENT $ 500,000.00 EL DISEASE - EA EMPLOYEE $ 500,000.00 E.L. DISEASE - POLICY LIMIT $ 500,000.00 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) No partners are covered by the workers compensation policy. IC 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 &'ea ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD .- (:lianfil- 1 AA1 S n A a&nu^r 2e ^- ACCORD. CERTIFICATE OF LIABILITY INSURANCE�;"� ANY REOUIREMENT. 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 14""" PRo01 M THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Doherty Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P.O. Box 1985 21 Elm Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. ITS Andover, MA 01810 INSURERS AFFORDING COVERAGE NAIC # INSURED Damphousse Roofing LLP 87 Belmont St North Andover, MA 01845 INSURER A Atain Specialty Insurance Compa INSURER e: INSURER C: INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REOUIREMENT. 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TNTSAH CrRg TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTME POLICY EDATE XPIRATKIN ITS A GENERALLIAINUTY CIP16938701 04112M4 04/12116 EACH OCCURRENCE $1,000,000 )( COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED :R spa aeftnefteal S100000 CLAIMS MADE Q OCCUR MED EXP (Arty one swnw) S5,000 PERSONAL 8 ADV INJURY S1 000 000 X GENERAL AGGREGATE s2.000.000 GEICL AGGREGATE UMIT APPLIES PER: PRODUCTS - COMP/OP AGG $2,000,000 X POLICY PRO LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea acadeng 5 BODILY INJURY ALL OWNED AUTOS SCHEDULED AUTOS (Per person) S BODILY eUURY $ HIRED AUTOS NON4OWNED AUTOS (Per acaderu) PROPERTY DAMAGE $ (Per aoc ddnl) GARAGE LIABILITY AUTO ONLY -EA ACCIDENT $ OTHER THAN EA ACC S ANY AUTO AUTO ONLY: AGG S EXCESSR)MBRELLA LIABRJTY EACH OCCURRENCE $ AGGREGATE S OCCUR M CLAIMS MADE S S DEDUCTIBLE S RETENTION S WORKERS COMPENSATION AND WCSTATU- I OTH- EMPLOYERS' LIABILITY ANY PROPRIETOMPARTNER/EXECUTWE E.L. EACH ACCIDENT S E.L DISEASE- EA EMPLOYEE S OFFICEWMEMBER EXCLUDED? II yes Aesenbe under SPECIAL PROYISK)NS bear E.L DISEASE •POLICY LIMIT S OTHER DESCRIPTION OF OPERATIONS I LOCATIONS/ VEH)CLES 1 EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Covering operations usual to Damphousae Roofing LLP... LD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THEREOF. THE ISSUING INSURER WILL ENDEAVOR TO MAIL In DAYS WRITTEN a TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. BUT FAILURE TO DO SO SHALL ill NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR AUTHORIZED ACORD 26 (2001108)1 of 2 #S304661M30465 / `� OfX ) 0 ACORD CORPORATION 1988 C�%/e �ca�rrnrorrroeal(1r c�PiT�issrrc/rrsetl' Office of Consumet' Affairs& Business Regulation IMPROVEMENT CONTRACTOR gistration: 174377 Type: expiration: 2/4/2015 LLP DAMPHOUSSE ROOFING LLP SHAUN TWOMEY 87 BELMONT ST N. ANDOVER, MA 01845 Undersecretary 4P Din%trurtion Superli%tir CS -067560 SHAUN M TWOMEY 61 PATROIT ST : N ANDOVER MA 0184 10/25/2015 • C•Un�T: iiCTiun Siijir:j t i�ni" �` �ti CS -055108 DOUGLAS J LEGARE 79 GARY AVE HAVERHI LL Mrd 01830 J�� ���� i •: 09102/2016 The Commonwealth of Massachusetts Department of IndustriqlAccidents Office of Investigations kvi 600 Washington Street Boston, MA 02111 www.mass gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers City/State/Zip: Phone #:: 7V Are y/u an employer? Check the appropriate box: ❑ Type of project (required): f 1. VI am a employer with 4. I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. ? 7• F1 Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in 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.E1 Electrical repairs or additions 3. ❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ PI bin repairs or additions myself. [No workers.' comp. c. 152, §1(4), and we have no 12. oofrepairs insurance required.] t employees. [No workers' 1311Other comp. insurance required.] 'Any applicant that checks box R must also fill outthe section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they ale 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 employee that is providing woekees' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Li''c"". 0: , A_/Z f -74 W-7,/�N0J Expiration Date: Job Site Address :�T/ 11 City/State/Zip: Kiration //��'. Attach a copy of the workers' compensation policy declaration page (showing the poliy number and ex date). Failure to secure coverage as requiredunder Section 25A ofMGL 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert uyder the pains anffp*alties ofperjury that the information provided above is true 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): 1. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone #: