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HomeMy WebLinkAboutBuilding Permit #817 - 60 MIDDLESEX STREET 6/3/2011TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO• Date Received Date issued: I- I BHORTANT: Applicant must complete all items on this pane LOCATION 6o °f J--- Print PROPERTY OWNER A(&I � -- Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes Cno Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ddition ❑ Two or more family ❑ Industrial Iteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other O�Sepf�c ®iWell OWKJ � ©IWetlaiids �' IL.®Watershed+District } k4ev a` .*., ri,;'"`. Q n'r"r'ki'- :��, ;sir`S.Sy •� �" ;: 7'� --�'' ���'�.*�. ����'�� 4 et ,kyr R, ;,}. �_E���•�� rw�a �_.�;���: �y�.�.. 1)F.,,RCRIPTION OF WORK TO BE PERFORMED: OWNER: Name: J+ -t cd_ Type or Print Clearly) Address: G� ��L/-c>eic ow ®9•? CONTRACTOR Name: !) * \r-ci4k-t_q4% A� - Phone: Address: Supervisor's Construction License: LI) 6 �r Exp. Date: Home Improvement License: ! ,fX_ Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No FEE SCHEDULE: BULDING PERMIT: $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Q� 01— Total 1Total Project Cost:$ / l c 1 �� FEE: $ Check No.: �,, o Z Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund =`Si nature of co" z �er,`� nfractor> :til 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/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) ❑ 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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals A the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording ist be submitted with the building application Doc: Doc.Building Permit Revised 2008mi Plans Submitted ❑ - Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Well ❑ Private (septic tank, etc. ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS 4 Reviewed on Si-gnature Reviewed on Siqnature Y 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: Located 384 Osgood 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 Doc:.Building Permit Revised 2008 Location ,& Af,�4� r No. Date 4 - NORTH TOWN OF NORTH ANDOVER � s .. 9 Certificate of Occupancy $ �ssACMUst<�' Building/Frame Permit Fee $ /. Foundation Permit. Fee $ �- Other Permit Fee $ F TOTAL $ Check # 0 �� 2424 Building Inspector The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 www.rnass.gov/dia Workers' Compensation Insurance davit: Builders/Contractors/Electricians/Plum-bens Appitcant iniormaitonme se rrmt jue jiug Name (Business/Organization/Individual): �`V�/f C,3.A_P4-mu1 oti Address:/)."Lc01-,� l� t2, � 37�A City/State/Zip: �,1-� �a Phone 7Y e you an employer. Check the appropriate box: Type of project (required): 1. I 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. ❑ Remodeling ship and have no employees 'These sub -contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' insurance # 9 ❑ Building addition [No workers' comp. insurance comp. 5. ❑ We are a corporation and its 10. El Electrical repairs or additions required-] 3. ❑ I am a homeowner doing all work officers have exercised their 11. ❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. Roof repairs insurance required.] t C. 152, § 1(4), and we have no 13. Other employees. [No workers' comm -insurance reauircd.l ... *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 are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that isproviding workers' compensation insurance for my employees. Below is thepolicy andjob site information. Insurance Company Name: Policy # or Self -ins. Lic. #:� ,��yy Uly Expiration Dater%�/',L Job Site Address: �y �� -cam '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 certify under thepains and enalties of penury that the information provided above is true and correct. Phone #: 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): L'Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: _ The Commonwealth of Massachusetts Board of Building Regulations and Standards Massachusetts State Building Code, 780 CMR, 7t' edition Building Permit Application FOR MUNICIPALITY USE d January Revised 2008 This Section For Official Use Only Building. Permit Number: Date Applied: Signafure-`. " .. Building Inspector Date SECTION 1: SITE INFORMATION Residential ❑ Commercial ❑ Other Description: LIP opperty Address: / 1.2 Assessors Map & Parcel Numbers Map Number Parcel Number 1.1a Is this an accepted street? yes no 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area (sq ft) Frontage (ft) 1.5 Building Setbacks (ft) Front Yard Side Yards Rear Yard Required .'Provided Required Provided Required Provided I - 1.6 Water Supply: (M.G.L c. 40, §54)1.7 Public ❑ Private ❑ Commercial- Service Size Flood Zone Infotnaation: Zone: Outside Flood Zone? Check if yes❑ 1.g Sewage Disposal System: Municipal ❑ On site disposal system ❑ SECTION 2: P.-ROPEkTY.OWNERS1[IP1 2:1" -awn rl of Decor Nt) Address for Service: . - 17 h.cv-- ?7� --,�0 y Signature Telephone =. "SECTION 3: DESCRIPTION OF PROPOSED WOi8I0 (shack all that aPP1Y) New Construction ❑ Existing Building ❑ Owner -Occupied ❑ 1 Repairs(s) ❑ Alteration(s Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑Specify: Brief Description of Proposed Work2: ! PVo F, :. SECTION 4: ESTIMATED CONS'T'RUCTION -COSTS . Item Estimated Costs: (Labor and Materials OfTacial iJse ®nly 1. Building$ I.* Building Permit Fee: $.. 2. Indicate how fee is determined:, 0 Standard City/Town Application Fee ❑ Tofa1 Project Costa (Item 6) x multiplier.: x' 3: Other.Feesc:. S- List: 2. Electrical $ 3. Plumbing $ 4. Mechanical (HVAC) $ 5. Mechanical ire Suppression) $ 6. 'Total Project Cost: ,,.. $ j�� �� Total All Fees: $ Check No..: Check Amount.: Cash Amount: We Prowt hereby to furnish material and labor — complete in accordance with specifications below, for the sum of: ell, ,11 dollars ($ Payment to .�a. made as follows: Visa, Mastercard, Discover gladly accepted. Financing also available NOTICE: All home improvement contractors and subcontractors engaged in home improve- ment Authorized contracting, unless specifically exempt from registration by provisions of Signature Chapter 142A of the General Laws, must be registered with the Commonwealth of 9� Massachusetts. Inquiries about registration and status should be made to the Note: This proposal may be Director, Home Improvement Contract Registration, One Ashburton Place, Room withdrawn by to if not accepted within 1301, Boston, MA 02108. We hereby submit specifications and estimates for: ROOF WORK STRIP ROOF OF LAYERS OF ASPHALT SHINGLES, COVER DECK WITH UNDERLAYMENT PAPER, COVER EXTERIOR WALLS AND FOLIAGE WITH TARPS TO HELP PREVENT -DAMAGE. tNSTALL ICE & WATER SHIELD AT LEADING EDGE, VALLEYS AND ALL,ROOF PENETRATIONS.. OVER ALL PERIMETERS WITH 8 INCH ALUMINUM DRIP EDGE. , Ric NSTALL RIDGE VENT.FFIT VENTING WITH RIDGE VENT FOR PROPER ATTIC VENTILATION. OVER SOIL PIPES WITH NEW RUBBER FLASHING BOOTS. OUNTER FLASH CHIMNEYS) WITH ALUMINUM FLASHING AS NEEDED. ELEAD CHIMNEY. CUT ALL EXISTING TAR AND LEAD FROM CHIMNEY (S), CUT NEW REGLET, CEMENT NEW LEAD IN PLACE WITH MORTAR. IF NEEDED FOR A WATER-rtHT JOB, ADD i TO ABOVE PRICE. INEY FROM ROOF DECK UP V�(IREPTH NEW .OR USED BRICK.. ADD ~ _ 70 ABOVE PRICE.> COVER:ROOFSURFACE WITH4. REPLACE DEFECTIVE ROOF DECKING WITH--'ATAN ADDITIONAL OST OF Z Z L ALL SHINGLES WHEN APPLICABLE (SEPI-, FG. INSTRUCTIONS). LITES PROVIDED BY CUSTOMER, FRAME ROOF DECK AS NEEDED, PROPERLY FLASH UNITS WITH FLASHING KIT(S) PROVIDED, CUSTOMER TO DO INTERIOR.FINISH WORK. ADD TO ABOVE PRICE. 01 V9-EXiS11NG :GUTTERS.. Q INSTALL NEW -,-SEAMLESS .032 ALUMINUM 1GUTTER.USING THS 1 IVE LOGKING.BAR<HANGER SYSTEM. �i 1=ACSIA BOARDS AS NEEDED WITH PRE -PRIMED FACSIA BOARDS, ADD r TO ABOVE PRICE. b �.�if�FST�kL-L IOW ALUMINUM DOWNSPOUTS. POP RIVET ALL CONNECTIONS: 4 -�IF MORE-LAYERS,ARE-FOUND.THAN INDICATED=ABOVE =AN ADDITIONAL5CHARGE�, )F� : SWILL BE ADDED. CLEAN ALL DEBRIS FROM OUTSIDE WORK AREA. OBTAIN ALL PERMITS AND CARRY ALIf NECESSARY INSURANCES AS REQUIRED BY LAW. WE CANNOT ACCEPT RESPONSIBILITY FOR DEBRIS FALLING INTO ATTIC AREAS. CUSTOMER SHOULD COVER VALUABLES. GREAT CARE WILL BE USED TO PROTECT THE STRUCTURE DURING STRIPPING, HOWEVER, SOME MARRING COULD OCCUR. SPECIAL INSTRUCTIONS: JUN 01,2021 02:14P Lindmark Insurance 181-246-5553 page 1 9 7f -79.19 ACORD_ CERTIFICATE OF LIABILITY INSURANCE 06/01/20],1 6/01/2011 PRODUCER (101) 245-0100 LINDbG= INSURANCE AGENCY 607 NORTH AVENUE DOOR 12 LAKESIDE OFFICE PARK WAKEFIELD MA Die80— _ __. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE .._ .....-- :..... INwr*i4 A• PENN -AMERICAN INS. CO. INS1At1Ne SAFETY INSURANCE wsT.me AIN NAIL III INSURED DAVES CONSTRUCTION 119 DRUMMILL RL) #372 CRELMFORD MA 01824- OERRALLIABILm 000447 -- INSURM D. INSURER C. I-ACHOCC THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WTH RESPECT Tn WMICH THIS CERTIFICATE MAY Of 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. TSR ADdI POLICY EFMCYWE POLICY EXPIRATION iR sR OF INSURANCE POLCYNUgRFR OATE(MMIDDIYYI DATE MMIDM—q LIMITS A OERRALLIABILm 000447 06/11/2010 06/11/2012 I-ACHOCC 1,000,000 X i.'UMMERI:IN t;FAIrNN LIABILITY DAMAGE. TO RFN ILI) PREMI$E6 9 aaurence 4 100,000 ANY AUTn Xi(:1 nAM�I MADE L- J OCCUR / / / / / / MED EXP (An, am pemm% 5 5,000 PERSONAL L MDV na)URY — S 1,000,000 $ 2,000,000 N.r;REGAIL- EXCESSMMRRELLA LIABILITY '3EN1 W.CREGATE LIMIT APPLIES PEN• % / / / PRb01Ir.TS - MWjoP AUL; S 2,000,000 1'OIICr E 1k LOC EACH ayCURRENCE S. OCCUR U CLAIMS MADE 8 Af5GREtiATC # AUTOMOIKE LIABILITY 2433640 12/16/2010 12/16/2011 D6DUCTII31 I- • ..... CQMBINM'SINGLFIAMAI b 1,000,000 s ANYAum (Eaamiderd) C W0ROYRRCOMAPEN A ON AND 6015510012010 05/01 2011 AA I OWNED AUTOS S / / / / BODILY ANIURY IWRRUINITS FIR S:HFhUI m AUTOS n�� a�%m) S 500,000 1-RAIEMBER ExcLUOED't 1 HAWH)AUTOS / / / / 90DILY1NJUWY Inbt.ASC EL CA EMM UYt $ 500,000 NONUWNEDAU103 (Feramxunn s 1,000,000 OTHER CL EM!+A'+- POLICY LIMIT : 200,000 JULIE ALLARD 25 XIDDLESEX STREET ACORD 25 (2001101) INS026 miou) a, SHOULD ANY OF THE ABOVE OESCRIBED POLICIES BE CANCELLED BEFORE THE E7(PIRATION GATE THEREOF. THE ISSUING WSURER Wp L ENDEAVOR TO MML 030 DAYS WRITTEN NOTICE TO THE CERTIFICATE MOLDER NAMED 10 THE LEFT, BUT FAILURE TO BO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY HIND UPON THE 1119URER IT8441TSORREPRE AUTHORR E ATNF n Q1 01845- CA m ACORD CORPORATION 198E ELR:rWnNlcLAsoDwRAIs, INc. (Mools:�.osls Page 1 02 11 ,E (I'm Aswidenl( S 500,000 OARAGELIABA.ITY AU)pgNLY•EAAi_u.70ENT S ANY AUTn / / / / _ ' w .tA 01 HtH THAN ACC S AUTOC+M Y AGS) S EXCESSMMRRELLA LIABILITY % / / / EACH ayCURRENCE S. OCCUR U CLAIMS MADE Af5GREtiATC # D6DUCTII31 I- • ..... s RETENTION 5 C W0ROYRRCOMAPEN A ON AND 6015510012010 05/01 2011 05/01/2012 S IWRRUINITS FIR ANY PROPRIF1GNmARTMRIEKEcUvrvE fA1ACCIDENT S 100,000 F1• Cl 1-RAIEMBER ExcLUOED't Of M. Af0SG1pC uminr If M. Inbt.ASC EL CA EMM UYt $ 500,000 RPEGIAL PROVISK)NSbekm OTHER CL EM!+A'+- POLICY LIMIT : 200,000 DESCRIPTION of OPERATIONSPLOCATION9ND11CLESMXCLU910NS ADDEOSr ENDORSpAEH175PECIAL PROVISIONS JULIE ALLARD 25 XIDDLESEX STREET ACORD 25 (2001101) INS026 miou) a, SHOULD ANY OF THE ABOVE OESCRIBED POLICIES BE CANCELLED BEFORE THE E7(PIRATION GATE THEREOF. THE ISSUING WSURER Wp L ENDEAVOR TO MML 030 DAYS WRITTEN NOTICE TO THE CERTIFICATE MOLDER NAMED 10 THE LEFT, BUT FAILURE TO BO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY HIND UPON THE 1119URER IT8441TSORREPRE AUTHORR E ATNF n Q1 01845- CA m ACORD CORPORATION 198E ELR:rWnNlcLAsoDwRAIs, INc. (Mools:�.osls Page 1 02 `LEAN nn� rvuivu ► MAIN INUICATED ABOVE, AN ADDITIONAL CHARGE OF ALL DEBRIS FROM OUTSIDE WORK AREA. OBT AIN ALL PERMITS AND CARRY AL NECESSARY INSURA� AS REQUIRED BY LAW. WE CANNOT ACCEPT RESPONSIBILITY FOR D -- WILLADC SHOULD COVER VALUABLES. GREAT CARE WILL BE USED TO P HOWEVER, SOME MARRING COULD OCCUR. EBRIS FALLING INTO ATTIC AREAS. GUSTO PROTECT THE STRUCTURE DURING STRIPF SPECIAL INSTRUCTIONS: WARRANTY = All work warranted to be free of installation. defects forti be free of defects for ^'* — _years, limited to installed item and its repair only years, see mfg. warranty for exact warranty'pertormance. Customer has legal t under federal law to cancel this contract without enol y Material warranted by mfg. telegram sent to Dave's Construction Roofing S penalty or obligation within three business days from acceptance date by mail or g _PeGlatists,_119-Drum. Hill Rd. #37�,��helrrtsford, MA 01824. Once all items in this contract are completed as agreed, customer has 3 days to fulfill payment , M See reverse side for cancellation procedures. Construction with interest of 112% per month on the unpaid balance. All parties agree that all di by the Better Business Bureau or the Secretary or the Executive Office of Consumer Affairs and BusiinAm or '^ pay all attorney and legal fees incurred by Dave': side, Arbitration of Disputes. sputes will be settled through binding arbitration a� 9 i m m m //mom� V/ ,,mww Y/ m —v y d C � d H n 'fl O MZ CO) CL �. r c ? c 5 CA0 0 0 CD CD o cr J ..E CD 0 CD WW a. �. CDrA CD CL CA Cc CD S- CO) O .O CD O CD O 44 CD f. 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