HomeMy WebLinkAboutBuilding Permit #941 - 601 CHICKERING ROAD 6/28/2012BUILDING PERMIT I D
TOWN OF NORTH ANDOVER
0
APPLICATION FOR PLAN EXAMINATION
Permit 1404ij(
Date Received -1, c"
17 91 -
ly . S Ac�
Date Issued: ]4L
IMPORTANT: Applicant must complete all items on this page
'LOCATION 16ief C 1��
Print
'PROPERTY OWNER --vp 0,1� 6��-
Print
'MAP NO: 'PARCEL:02,q
ZONING DISTRICT Historic Dis-ffict. yes. (no
Machine Shop Village -yes. 00
TYPE OF IMPROVEMENT
PROPOSEDUSE
Residential
Non- Residential
New Building
One family
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
Repair, replacement
Assessory Bldg
Others:
Demolition
Other
8eptic Well
Floodplain W-e-flands"
Watershed District-
Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
#J V_ �Q AT
Identification Please Type or Print Clearly)
OWNER: Name: 5-(o ip-r C4� &-f at:5-ag 8Ka-e Phone:
V KX?
Address: H9 5P �-�L_bten k*
CONTRACTOR Name: -,'Phone:
Address: 1- 0 4 rz,� S_z z 0 A-
SulJorvisors Construction License-,. 'Exp. Date:
Home. Improvement License-; E Pate:
x
ARCHITECT/ENGI NEER7*b 40 /U ((S Phone:—Z -/ ;7
.2�Z ?
Address: 0 (:6j97 66 7, 5,e9t L72gaK Reg. No.
FEE SCHEDULE. BULDING PERMIT. MOO PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ 2. T&O FEE: $
Check No.: Receipt No.: os -
NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund
i nature of contractor
7 J I I � I _. - .1 . __
we -5
Location (4�� I vv I �,/
No.—I Date 41 --Ji
/ r-- V v
Check# e3
25467
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $r , I ----
Foundation Permit Fee $
Other Permit Fee e -
TOTAL
S-��
C--- �� � �
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
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE REJECTED
DATE APPROVED
Reviewed on Signature
Reviewed on Simature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comm
Comments
Water & Sewer Connection/signature & Date. Driveway Permit
DPW Town Engineer: Signature:
Locatea 384 USgooa btreet
.FIRE. DEPARTMENT �Te.'.m'pp*u-mp4te(-on.-sitb'.ye�s no
Located -at?124'Main'Street-
Fire Departinent,.-Mgnature/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
MGL Chapter 166 Section 21 A —F and G min.$100-$1000 fine
NU I tb anci UA I A — w or ciepartment use
Q Notified for pickup - Date
Doe.Building Permit Revised 2008
No
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
o Building Permit Application
Ei Workers Comp Affidavit
u Photo Copy Of H.I.C. And/Or C.S.L. Licenses
u Copy of Contract
Li Floor Plan Or Proposed Interior Work
a Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
Li 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
Li Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
u Mass check Energy Compliance Report (if Applicable)
u 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 d.umpster 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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2008
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License: os 64217
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06/21/2012 01:38 FAX 978 720 6970 SALEM FIVE IM001/001
Sale ive
June 21, 2012
Daniel Babine, Jr,
Commodore Builders
90 Bridge Street
Newton, Maswhusetts 02458
Dear Dan-,
This is to conffirn our intent to enter into an AIA A Contract Agreement with
Commodore Builders for the (construction or renovation) of our 601 Chickering Road,
North Andover, MA for a total lump sum value of $19,900.00 per the final estinuft
packaged dated
nds L=.itz of',Awant shall be considered effective as of the deft of this letter.
T%Nok you for your continuing cooperation.
Very truly yours
JO ph J. Lo
2 10 Bssex Stram, Salem,, IMA 0 1 't -
Telephone 800.522.BANK and978.745.Ar)T?!1
77ze Commonwealth of Massachusetts
Department of Industrial Accidents
Offi c e of In v es tiga tio n s
600 Washington Street
Boston, MA 02111
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le2ibly
Name (Business/Organizadon/Individual):
Address:— Oc�) F) d4 D � &_ �5-t P
City/State/Zip: P--', t14 e:��
0/111 -
Phone #: & /' -7 6; � �,4 3 J-C�,o
Are you an employer? Check the appropriate box:
4�amarmployeT,�&ith &5�r)
4. E] I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2.0 1 am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub -contractors have
working for me in any capacity.
employees and have workers'
[No workers' comp. insurance
comp. insurance.t
required.]
5. F_� We are a corporation and its
F�officers
I am a homeowner doing all work
have exercised their
myself. [No workers' comp.
right of exemption per MGL
insurance required.] t
c. 152, § 1(4), and we have no
employees. [No workers'
como. insurance recruired.1
Type of project (required):
6. F-1 New construction
7. Poemodelin g
8. []Demolition
9. F� Building addition
10.7 Electrical repairs or additions
11. F� Plumbing repairs or additions
12.7 Roof repairs
13.7 Other
*Any alypli cant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contmctoTs must submita new affidavit indicating such.
'Contractors 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-contmctors have employees, they must provide their workers' comp. policy number.
I am an employer that isproviding workers' compensation insurancefor my employees. Below is thepolh7, andjob site
information.
Insurance Company Name: CIL ez:_ k��
Expiration Date: 1Z /
Policy # or Self -ins. Lic. #: -717 9 L, Z17
7
Job Site Address: 4�0
M
Attach a copy of the workers' compensation policy
d) - City/State/Zip: 4k -)000&,V, HP,
I
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
Z�
Investigations of the DIA for insurance coverage verification.
Ido hereby certift unjer#w- 'fls-
gw a
)4yen ormation provided above is true and correct.
wities ofperjury that the infi
use onlj�'Do not write in this area, to
City or Town:
or town official
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone 4:
7 a
ACC)RO CERTIFICATE OF LIABILITY INSUIRANCE
lllb_�
DATE (MM/DDIYYYY)
1 1/912012
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
CONTACT
NAME:
PHONEO, FAX
WC. N Ext), (AIC. Nol�
LISI Ins Sery of MA, Inc
P 0 Box 920444
Needham MA 02492
E-MAIL
ADDRESS,
INSURER(S) AFFORDING COVERAGE NAIC #
1/1/2013
INSURER A:Travelers Indemnity Company 25658
DAMAGE To 'ENT"
PREMISES (Ea oc�,nrence) $300,000
INSURED COMMOBUI
INSURER B
INSURER C
Commodore Builders Corp.
80 Bridge Street
Newton MA 02458
INSURERD:
$
A
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 451981056 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
ADDLSUBR
INSR
WVD
POLICY NUMBER
POLICY EFF
(MM/DDfYYYY)
POLICY EXP
(MM/DDIYYYY)
LIMITS
A
GENERAL LIABILITY
0,
C MMERCIAL GENERAL LIABILITY
CLAIMS -MADE FTIOCCUR
C0633M4748IND12
1/1/2012
1/1/2013
EACH OCCURRENCE $1,000,000
DAMAGE To 'ENT"
PREMISES (Ea oc�,nrence) $300,000
MED EXP (Any one person) $5,000
PERSONAL & ADV INJURY $1,000,000
GENERAL AGGREGATE $2,000,000
GEN1 AGGREGATE LIMIT APPLIES PER:
-] PRO- F-] LOC
POLICY � JECT
PRODUCTS - COMP/OP AGG $2,000,000
$
A
AUTOMOBILE
X
LIABILITY
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
X NON -OWNED
HIRED AUTOS AUTOS
q
8102132X250TIL12
1/1/2012
1/1/2013
M11INED SINGLE LIMIT
O(E',' accident) $1,000,000
BODILY INJURY (Per person) $
BODILY INJURY (Per accident) $
PROPE,,RT DAMAGE
(per.. , d an t) $
$
A
X
UMBRELLA LIAB
EXCESS LIAB
OCCUR
CLAIMS -MADE
CUP2132X262IND12
1/1/2012
1/1/2013
EACH OCCURRENCE $5,000,000
AGGREGATE $5,000,000
1
1 DED IX I RETENTION $10,000
$
A
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y/N
ANY PROPRIETOR/PARTNER/EXECUTIVEF—]
OFFICERWEMBER EXCLUDED?
(Mandatory in NH)
ffesS6 describe under
D RIPTION OF OPERATIONS below
N/A
DTNUB633M717312
1/1/2012
1/1/2013
TATU- TH_
X T'OORY' I DER
LIMITS I
E.L. EACH ACCIDENT $1,000,000
EEL DISEASE - EA EMPLOYEE $1,000,000
E.L. DISEASE - POLICY LIMIT $1,000,000
DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
The following are listed as additional insureds as respects General Liability where required by written contract:
Proof Of Worker's Compensation for Permit Applications
Commodore Builders
80 Bridge Street
Newton MA 02458
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
@ 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
�) 1P
0 1 FFICE OF BUILDING INSPECTOR RECIWED
40 . ft TOWN OF NORTH ANDOVER JUN 2 6 2012.
CONSTRUCTION CONTROL
C COMMODOR6
BUILDERS
PROJECT NUMBER:
PROJECTTITLE:
PROJECT LOCATION: ("VaWi A)C-AD
to. nat
NAME OF BUILDING:
NATURE OF PROJECT: I hL<g&jfflj1(N- OF- laim/4 1 P ATM Lag, mr JIWIReffllmS
IN ACCORDANCE WITH ARTICLE 116 OF THE MASSACHUSETTS STATE -BUILDING CODE,
I, 560-1r E. -1—exj)(Ue - —REGISTRATION NO.—% 6 S
BEING A REGI,5TERED PROFESSIONAL ENGINEER)ARCHITECH HEREBY CERTIFY THAT I
HAVE PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS;
COMPUTATIONS AND SPECIFICATIONS CONCERNING:
ENTIRE PROJECT 0
FIRE PROTECTION 0
ARCHITECTURAL VSTRUCTURAL 0 MECHANICAL 0
ELECTRICAL OTHER (SPECIFY)
FORTHE ABOVE NAMED PROJECT AND THAT, TO THE BEST OF MY KNOWLEGE, SUCH PLANS,
COMPUTATIONS AND SPECIFICATIONS MEET THE APPLICABLE PROVISION OF THE MASSACHUSETTS
STATE BUILDING CODE, ALL ACCEPTABLE ENGINEERING PRATICES.
AND APPLICABLE LAWS AND ORDINANCES FOR THE. PROPOSED USE AND OCCUPANCY.
I FURTHER CERTIFY THAT I SHALL PERFORM THE NECESSARYPROFESSIONAL SERVICES AND B
EPRESENT ON THE CONSTRUCTION SITE ON A REGULAR ANDIPERIODIC 13ASIS TO DETERMINE THAT
THE WORK IS PROCEEEDINO IN ACCORDANCE Wl'TH THE DOCUMENTS APPROVED FOR THE BUILDING
PERMIT AND SHALL BE RESPONSIBLE FOR THE FOLLOWING AS SPECIFIED IN SECTION 116.0
1. ReView, for conformance to the design concept, shop drawings, samples and other submittals
which are submitted by the contractor in accordance with the requirements of the construction
documents.
2. Review and approval of the quality control procedures for all code -required controlled materials.
3. Be present at intervals appropriate to the stage of construction to become, generally familiar
with6the progress and quality of the work and to determine, in general, If the work is being
performed In a manner consistent with the construction documents.
PURSUANT TO SECTION 116.2.2 1 SHALL SUBMIT WEEKLY, A PROGRESS- RE�ORT
TOGETHER WITH PERTINENT COMMENTS TO THE NORTH ANDOVER BUILDING INSPECTOR.
UPON COMPLETION OF THE WORK, I SHALL'SU
QMIT A FINAL REPORT AS TO THE
SATISFACTORY COMPLETION AND READINESS OF THE PROJECT FOR OCC
-�fPANCY.
I 1c, TUPF,
UPF7
L
S CRIBED N ORN TO) MORE ME THISL-aj DAY OF
S
N ARY UBLIC
Notary Public
N RY UBLIC MY COMMISSIff--:1RE*"y s -Alves
. Commonwealth of Massachusetts
Myo
My Commission U�ires�orn hg. 25,2017