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Home My WebLink AboutBuilding Permit #647 - 6 KATHLEEN DRIVE 4/6/2007Permit NO: Date Issued: TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Oma\ Date Received - IMPORTANT: Applicant must complete all items on this page I LOCATION 6 1e�I-CtA le - G f l )�V- ,, _ I J - Print PROPERTY OWNER �vCt' ZyrtiP a Print MAP NO.: PARCEL: ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 0 Addition ❑ Alteration ,`One family ❑ Two or more family No. of units: ❑ Industrial Repair, replacement ❑ Demolition ❑ Assessory Bldg ❑ Commercial ❑ Moving relocation 0 Other ❑ Others: 0 Foundation only DESCRIPTION OF WORK TO BE PREFORMED 12P�t4cc o.tit 4Q" ,- . Identification Please Type or Print Clearly) OWNER: Name: LCVfr^e1J 2-cA4ok Phone: L/75"- 5'71Z - Address: -,0,_` 14<4h Or. CONTRACTOR N y-WJ246.T 7zs°Y- `f5` � /V �% M4 yiYt�a r Address: v c Supervisor's Construction License: & f7 1 Exp. Date: 1� Home Improvement License: Iz 17 ? Exp. Date ARCHITECT/ENGINEER Name: Phone: Address: Reg. No. //-2--07 FEE SCHEDULE. BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost :$ 65boy . -" FEE:$ �0 Check No.: JDl 7� »Receipt No.: Page I of 4 TYPE OF SEWERAGE DISPOSAL Tanning/Massage/Body Art ❑ i wmmn SiPools ❑ g Public Sewer ❑ Well ElTobacco Sales ElFood Packaging/Sales 11 El Permanent Permanent Dumpster on Site ❑ Private (septic tank, etc. Meter location to project NOTE: Persons contracting with unregistered contractors do not have access to the guara nd Signature of Agent/Owner Signature of contract Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS DATE REJECTED DATE APPROVED ❑ ❑ DATE REJECTED CONSERVATION ❑ ❑ COMMENTS HEALTH DATE APPROVED DATE REJECTED DATE APPROVED ❑ ❑_ COMMENT , 1 FIRE DEPARTMENT - Temp Dumpster on site yes no Fire Department signature/date COMMENTS 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 Building Setback (ft.) Front Yard Side Yard Rear Yard Required Provided Required Provides Required Provided Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: lr V 1 LN ana llA 1 A — (For department use Page 3 of 4 VICES Created JMC. Jan.2006 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 Addition Or Decks ❑ Building Permit Application ❑ 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) 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 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: INSPECTIONAL SERVICES DEPARTMENT:BPFORMOS Page 4 of 4 ta� O 4 I h A c v a R. w a a°' w a r u a a cn l < W O OJ O H � � ui z CL c o C H O C V Ci 'ado �r a c i Ce c CD c z Cl c yr 0 d d! E5 r. m C � O0 C., c E C4) r OCD y � 3 m� _m 4= c c q W oo+ h W m m 0 CD LZ cz m �. 4%�a* Ca 0 W .1Z H CD cto c c = O US IV ZJ W 0 ��' Cm � H •� C=cC Z .� O wo L) d D � CCO2 0 ~ = w .0oM= O F- t Sawm s 0 Z O U cm CDO .� y O W � y O O 'E m m CD CD CD 3� CD L o a Sca N! -0 cv �o ts CIO z0 CL m �..� h O C C c y LLI 0 I�Iw YI U) 19 W W 19 W U) The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/organizationadividual): Address: 7 S Fyn 1. City/State/Zip:t11-dt/eI t, Dt?32 Phone #: q78=� 65—?L 55 Are you an employer? Check the appropriate box: 1.X I am a employer with Z. S 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheets t ship and have no employees working for mein any capacity. [No workers' comp. insurance required.] 3. ❑ I am.a homeowner doing all work myself. [No workers' comp. insurance required.] t These sub -contractors have workers' comp. insurance. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. E] Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information t Homeowners who submit this affidavit indicating they art doing all work and then hire outside contractors must submit anew affidavit indicating such 1contractors 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 insurance for my employees. Below is the policy and job site information. Insurance Company Name: tvf-q (AL UrAAGe— E '. Policy # or Self -ins. Lic. #: OT v GAIL S 7L/ 2 xPiration Date: 7D1O Job Site Address: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 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 c t under Ains�an—d-7 nalties of perjury that the information provided abo/e' is true and correct: 295' -72 5C _UVuc rr. • — — [1. fficial use only. Do not write in this area, to be completed by city or town official. ity or Town: Permit/License # suing Authority (circle one): Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Otherontact Person: Phone #• ACORDCERTIFICATE OF LIABILITY INSURANCE DATE 2OD61D/YYYY) o7rosnoMMMOI 4 PRODUCER Fred C. Church Fre 41 d C. Chu Street Connector Park Lowell, MA 01851 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. ALTER INSURERS AFFORDING COVERAGE NAIC 9 INSURED New England Window & Door Inc. 45 Fondi Road Haverhill, MA 01830 INSURERA: Hartford Insurance Company INSURER 8: Hanover Insurance Company INSURER c; Mass Bay Insurance INSURER D: INSURER E: [. v r cranvw 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DO1 POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS 1' GENERAL LIABILITY EACH OCCURRENCE il,�,� 1 f ^ TO RENTED = SOO,000 X COMMERCIAL GENERAL LIABILITY MED EXP Anone arson $10,000 CLAIMS MADE a OCCUR PERSONAL6ADVINJURY $ 1,000,000 B ZBN8161407 7/1/2006 7/1/2007 GENERALAGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AOG S 2,0()0.000 POLICY PRO LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000.00 (Ee accident) ANY AUTO BODILY INJURY $ X ALL OWNED AUTOS (Per person) C SCHEDULED AUTOS ADN8162169 7/1/2006 7/1/2007 X HIRED AUTOS BODILY INJURY $ X NON -OWNED AUTOS (Per accident) PROPERTYDAMAGE $ (Per accident) GARAGE LNOILITY AUTO ONLY- EA ACCIDENT $ OTHER THAN EA ACC S ANY AUTO AUTO ONLY: AGG $ EXCESSII/MBRELLALIABILITY EACH OCCURRENCE $.9,000,000 AGGREGATE S 9.000.000 a X OCCUR CLAIMS MADE $ B LTHN8167305 7/1/2006 7/1/2007 $ DEDUCTIBLE HxRETENTION $ S WC STATU- 0TH- WORKERS COMPIONENSATAND E.L. EACH ACCIDENT S 500,000.00 EMPLOYERS' UABIUTY A ANY PROPRIETORIPARTNERJEXECUTIVE ERPARTNE JE ECUTIVE 08WBNL5742 � 7/1/2006 7/1/2007 E.L.. DISEASE -EA EMPLOYE $ 500,000.00 E.L. DISEASE - POLICY LIMIT $ If yes, desarbe u^def500,000.00 SPECIAL PROVISIONS below OTHER Blanket Building & Contents B ZBN8161407 7/1/2006 7/1/2007 S5,540,000Deductible $1,000Blanket Business Property Income $4,500,000 DESCRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT! SPECIAL PROVISIONS CERTIFIGAIL MUL.UCK SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION New England Window & Door; Inc. DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAK 30 DAYS WRITTEN dba Pella Windows & Doors, Inc. NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO 00 SO SHALL 45 Fondi Road, Haverhill, MA 01830 IMPOSE NO OBLIGATION OR LIABILITY OF ANY BOND UPON THE INSURER ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE . ® ACORD CORPORATION 1988 ......... �� [�__.•__• [.Ilen[S ww f4SIBT wv. u[[uuw 1-+ � � •� ZjQ ,N '•'' • O O � 0 ' � "t3 a too o A" or cd Ah o 3 cd u m p 0 tA N U r'" U �" U N � •� OU N rte+ �� a 0 �� v �•+O pcn 4rCd N � o � •� � N O cd `+' a 1 o bA 2) U 0 W OU a p 0 U �O -Cd Q. O Cq to U cdCd r y 'd cn 0 O o 0 0. o ,0 i `4.4 Cd ~ N v p bA ~ 0 0� a� �. to a w 0 N Z��'a3� vi Locaiion 44 No. & Date AORTN TOWN OF NORTH ANDOVER AL I A Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ e-) j 45�� Check # - 20�i 02 Building Inspector