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HomeMy WebLinkAboutBuilding Permit #625 - 60 AMBERVILLE ROAD 4/15/2010NORTF/ BUILDING RER""",.„ TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION ~ Permit NO: t(f�� 1 Date Issued: — IMPORTANT: A Date Received must complete all items on this LOCATION &67 Al e-nh e.2 V t ll e Z - Al- 2q-- J2d a/1'% Print PROPERTY OWNER h r r.-- % 4-t' /'� zC k j f b " 4 Print MAP 210 (. PARCEL: BONING DISTRICT: Historic District yes no Machine Shap Village yes no TYPE OF IMPROVEMENT PROPOSED USE Reside Non- Residential New Building Onefamily Additi n �gS2..�20�; Two 0 ore family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District atedSe e DESCRIPTION OF WORK TO BE PKE1-UKmtu: wo 111A11C Identification Please Type or Print Clearly) ! OWNER: Name:j„7 0, 4112:4 r14' Address: CONTRACTOR Name: Address:frc' Supervisor's Construction License; -z Exp. Date 11.111/ o) t Home Improvement 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, ®° FEE: $ <, Z Check No.:Receipt No.:� NOTE: Persons contracting with unregistered contractors do not have access to the guaranty, fund ignature of AgentlOwner;Z;p-._ Signature of contractor Location No.IliaDate .� j TOWN OF NORTH ANDOVER Certificate of Occupancy $ , �'�b'•° ''<�' Building/Frame /Frame Permit Fee ss,4cwusa 9 $— Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check #6 —' 22958 Building Inspector 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature 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 Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: t_ocatea :1254 vsgooa 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 2010 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 o 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 Li 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 Permit New Construction (Single and Two Family) Li 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 Doc: Building Permit Revised 2008 - x a LQ x 0 O w v Vl v cn z r -a O O w O aG T v .0 U ca G w O w C w w O u2 V) C w O cG G w" w � A. 5 mrj) O t Q E (n ' �� : • d � c :on ... k Q y y d'� lo o C y Q % O m sr G0��Q, % o N 0 o On <O -L ** • ` s c O N cm m Cc N W E� mo : CLIS N m c OQ O aC� O ;��Z C C O � O a = O CCDL. D0 N o •� y m S W_ C �+=+�Z V W LL O O C +s H .y co •ateco O•C N •CL H e cm COL O LU WO m OS z a ���ay= t- = swm 0 �O a r� N O w U C W m r L O CD C C N m S O Z O O' O CD -- a C�- O E i co Z fl. O h 0 CO O� I G� y CO m m CD H= CD V M o no. a- cma E o c ca .Q O o C CD �..� No � C C a O — 0 LU LU Y) W W W N c c • m C C V O O � C N O C � O V V •m CL �O td m C M.0 — r +. � � O h ' �� : • d � c :on ... k Q y y d'� lo o C y Q % O m sr G0��Q, % o N 0 o On <O -L ** • ` s c O N cm m Cc N W E� mo : CLIS N m c OQ O aC� O ;��Z C C O � O a = O CCDL. D0 N o •� y m S W_ C �+=+�Z V W LL O O C +s H .y co •ateco O•C N •CL H e cm COL O LU WO m OS z a ���ay= t- = swm 0 �O a r� N O w U C W m r L O CD C C N m S O Z O O' O CD -- a C�- O E i co Z fl. O h 0 CO O� I G� y CO m m CD H= CD V M o no. a- cma E o c ca .Q O o C CD �..� No � C C a O — 0 LU LU Y) W W W N kA 0. a G V3 � n i G c kA 0. tlrn 0114ieTtrtu undsAaInnd �ri(r HOME IMPROVEMENT CONTRACTOR 'A J Ragistrouon: 152820 Exp+ritron: iona010 Tro 27M4 Type: InclfwJual BLAINE SCRIB1:ER BLAINL SCRICiNCR 335 SUTTON ST�.,�,.,r�.��.-. NORTH ANDOVER ?AA 01845 %dr^inisIrahlr I,frtnw or rel;ioralion %slid for individul use ant% Wort tiir eviration daitr. If fmind t•rturn in: Ilunrd t►f tluilding Regulatit+tri and Stantinrds Onr .%sllburton flare Ittn 1.101 1111sinn. W).112ION f of valid w1111out 5121inturc � s•stttnutt► . Deprluunt r:i Publit S-'!�Az ��� �lltxrd rtf �Iuil+ilin;; Its^u1.Ili+�� .;GaT3 �r�sntf.trd, Contsttuctlor Supervisor License L`t>u•'_a: C8 63513 a,t✓ tom: 00 BLAINE A SCRIBNER 385 SUTTON ST N ANDOVER, MA 01845 cit -..cn i?J18mI1 Tf- IIsw P 0 Ow 973 M aa. Mx 01049 P1t-"r 070) 265 SIPS April 5, 2010 Contract to do work at 60 Amberville Rd. North Andover, Ma. Bailey Custom Homes L.L.C. will provide the following: Install walls in the basement in areas shown on plan. Including blue board with skim coat plaster, insulation on exterior walls not already insulated and all electrical outlets required by code. A double door to be installed into furnace area and a single door to be installed into front storage area at the bottom of the stairs to the left Doors and ceiling tiles per builders specs. Install a suspended ceiling using white tracks and 2 x 2 tiles with 3 drop in tights located where existing lights are. Lower 2 fire sprinkler heads below new ceiling and relocate washer overflow drain to the outside. Re -switch lights as discussed. Pricefor above...............................................................................55,900.00 Not included: Painting, trim around existing door and windows, cost of building permit. Payment to made as follows: $500.00 deposit. $3500.00 upon completion of plastered walls and doors installed. Balance upon completion of ceiling. Each item listed below will be paid for upon completion. Additional items If desired charged as follows: Plywood risers Installed on existing stairs..........................................$175.00 and Labor to install rubber floor supplied by homeowner .....................$1.00 persq.ft. Labor to Install swings, locks, bumpers etc............................$40.00 per hour plus the cost of materials not supplied by homeowner. Extend walls for future bath as discussed........................................5250.00 Screw existing balusters to deck .....................................................$100.00 �=3C, rrr UAAOC"Y� -0o Homeowner Date Contractor Date a R LN v DATE(MMID[YYYYY) f+ o® CERTIFICATE OF LIABILITY INSURANCE 4/13/10 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION M.P. Roberts Insurance Agency enc' I ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE �HOLDER. THIS CERTIFICATE DOES NOT AMEND, EX -END OR 1060 Osgood Street ( ALTER THE COVERAGE AFFORDED BY THE POLI`:iEs BELOw. North Andover, MA 01845 ! I INSURERS AFFORDING COVERAGE INSURED BAILEY CUSTOM HOMES, LLC. A/0 BLAINE SCRIBNER 385 SUTTON STREET NORTH ANDOVER, MA 01845 !NSURERA: Travelers _ INSURER B: LLOYD'S LONDON INSURERC: _. _ INSURER D. _----__---- _ INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVEFORTHE 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. ____— ADD'l� POUCY EFFECTIVE POUCY EXPIRATION LIMITS NSRO TYPE FIN URANCE POLICY NUMBER p MMIDD/YY DATE M IDDIYYYY� GENERAL LIABILITY EACH OCCURRENCE $ 1 , 000 1 000 DAMAGE TO RENTED X CONHMERCIALGENERAL LIABILITY LGL0917762 10/1/09 10/1/10 PREMISES Eaoccurrencel 100,000 rB CLAIMS MADE � OCCUR MED EXP (Anyone person)_ $ 0 000 PERSONA_L8_A_DVINJURY _--r$-1 DOO DOO - AGGREGATE _$_ 21000 000 GEN'LAGGREGATE LIMIT APPLIES PER _GENERAL_ PRODUCTS - COMPIOPAGG $ 2000,000 --- —7 JECT POLICY PRO LOC ! AUTOMOBILE LIABIUTY COMBINED SINGLE LIMIT (E a accide M ) $ ANY A UTO ALLOWNEDAUTOS BODILY INJURY (Per person) $ — SCHEDULED AUTOS --- - HIRED AUTOS BODILY INJURY (Per accident) $ - -" - NONCWNED AUTOS ----------------- --- PROPERTY DAMAGE Per accident) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANYAUTO OTHER THAN EAACC AUTOONLY: AGG $ $ EXCESS IUM13RELLALIABIUTY EACH OCCURRENCE_. _— $_-______ AGGREGATE $ OCCUR CLAIMS MADE -- DEDUCTIBLE ---_ RETENTION $ WORKERS COMPENSATION WC STATU- OTH- I TORY LIMaSd--J-F-- $ E.L. EACH ACCIDENT $ 500,000 . A AND EMPLOYERS' LIABILITY ANY PROPMETORIPARTNERIEXECUTIVE Y/N OFFIGERMENIBEREXCLUDED? (ManrlaODry in NH) It yes, describe under SPECIPi PROV!SIONSbelow 0740N77 7/14/09 7/14/10 E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE -POLICY LIMB $ 500,000 - OTHE R i DESCRIPTION OF OPERATIONS/ LOCATIONS I V EM CLES I EX CLUSION S ADDED BY E NDORS EMENT I SPECIAL PROVIS IONS MULUCR TONTN OF NORTH ANDOVER 384 OSGOOD STREET NORTH ANDOVER, MA 01845 SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WPoiTTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. ,.. AUTHORIZED REPRESENTATIVE A n 1QRR_7nnQ ACORD CORPORATION. All rights reserved. AGVI(U [0 tcuuyiu T) The ACORD name and logo are registered ma rks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations kvi 600 Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): �qs Address: City/State/Zip: - , ,A -,q , Phone #: Are you an employer? Check the appropriate bob: 1. ❑ I am a employer with 4. I am a general contractor and I employees (full and/or part-time).* 2. ❑ I have hired the sub -contractors am a sole proprietor or partner- listed on the attached sheet. t ship and have no employees These sub -contractors have working for me in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We area corporation and its required.] 3. ❑ I am a homeowner doing all work officers have exercised their 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 required.] Type of project (required): 6. ❑ New construction 7. Remodeling 8. Demolition 9. Building addition 10.❑ Electrical repairs or additions 111 - Plumbing repairs or additions 12.❑ Roof repairs 13.OrOther , -22f__��, _. __ :-a caJ w' Out "Ie Secuan oe:ow a000 A._g �woP!C;c' C�mnoncasinn ..ni .... ' Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must ,submi 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 insurance for my employees Below is the policy and job site information. Insurance Company Name:_ �2✓�.iP l r - Policy # or Self -ins. Lic. #:_ d L1 -r 77 Expiration Date:_? Job Site Address: City/State/Zip: ,CJ -,r " ,� ©��YS 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 the pains and penalties of perjury 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. City/Towu Clerk 4. Electrical Inspector S. PIumbing 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 in the service of another under any contract of hire, express or implied, oral 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-contractor(s) name(s), address(es) and phone number(s) along with their cerdficate(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 applicationfor the permastor license is being requested, not the Deparbnerst 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 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 officiilly 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 to 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 Commonwealth of Massachusetts Department of Industrial Accidents Office of Invesfibations 600 Washing -ton Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-72.7-7749 www.mass..gov/dia