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HomeMy WebLinkAboutBuilding Permit #635-14 - 61 RUSSETT LANE 3/18/2014f BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: l% �I Date Received Date Issued: IMPORTANT: Applicant must complete all items on this paee LOCATION Ca / 90 S 5 ell L 4ht T y Tint PROPERTY O ER S Gy [- ja Print MAP NO: PARCEL. ZONING DISTRICT: Historic District yes Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building QOne family Addition Two or more family Industrial teratio❑ No. of units: Commercial Repa' , replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer /-rte Identification Please Type or Print Clearly) OWNER: Name: S7eilll �Phone: Address: CONTRACTOR Name: b / Phone: i7 '4-'3'- i12 Address: L,/ ,J��'� Ji��►t �U�G � �ylt�,�J�/�'1.���a Supervisor's Construction License: Home Improvement License: Exp. Date: - � Exp Date: r�� Y ,� oI 5- 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: $ /, yO4 FEE: $ lis Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund (Signature of Agent/Owner Signature of contractor a - -Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ 'TYPED F::SEWERAGEDISl?_OSAL7-7 Public Sewer ❑ Tanning/MassageBodyArt ❑ .. .Swimming Pools ❑ Well ❑ Tobacco.Sales 0 ToodPackaging/Sales ❑ Private>(septic tank, etc.. ❑ - .:. Permanent Dnnpster on Site L1 :THE. FOLLOWING SECTIONS FOROFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED: DATE:APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS .CONSERVATION COMMENTS HEALTH COMMENTS Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes . Planning Board Decision: Conservation Decision: Com :Com Water & Sewer Connection/Snature Date Driveway Permit DPW Tow;! Engineer: Signature: _ Located 384 Osgood Street FIRE-DEPARTIlf ENT : -. Temp Dumpster on siteyes no 1­6cat4at'124; Mair Street.- Fire"Departme►i Dir 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 'ZilectricalInspector _ Yes No DANGER.ZONE LITERATURE:. -Yes No MGL -.Chapter-• 166. Section 21A -F and G min. $10041000.fine NOTES and DATA — (For department use ® Notified for pickup - Date Doc.Building Permit Revised 2010 Building Department ---'The fol;owing is'a list. ofahe required forms to be filled out -for the. appropriate:permit to .be obtained. Roofivg, 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 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 apo. al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submAted with the building application Doe: Doc.Building Permit Revised 2012 Location DateM .- A4 k 2 Al No. 6 Check # -0�0 27354 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee st&� Foundation Permit Fee Other Permit Fee TOTAL $ Building Inspector CO) 0 z CD O _• r CL - to a � O o v Q c CDD O CD Q O CO CD U) m O N O cn F _ r_ 0 CD 3 CO)� CD iv z CD in - 91 O z Z cn m O z m cnO n m '0 m cn Z A7 O Z 2 cn 0 h rr 0 N O co O cm CD co 0 0 CA 2. cn CD 0 0 MO � � —I O c O x < a Ma M -0 N c �, m 0 m n ,cy Q- c7 m 0 =r =r -0 (n CL 0 h =R=r m CD oca0' to 0 -i CD <D Z 0 O H CLO Sl rt 0 0 �CD CD CD o .0 0cn �C o � cr "' ;.. =r Err rt D CD y O. 0 CLQ- o - CD C 0 � 0 � 0O � U) r . m 0 0 0 �j. 0 0 to 3 `•„ rt C CD CDch I, .'' 0 N C3, 0 r nCD L CD- @� 0 2)0 CL C3 0 � V) ; O i° Ln rr Z O O7 (D =' m oy o D —1 m z T:0 S. 0 S G1 ZD H •� n O T Lnm fD Uq S m m '° � H m T a :;o OL S M C m z N m T n :3 m 'G A OC =- T Q lu 3 C g z & m 0 V7 �. n T Q T o0 v O T m D = 0 y 0 =Bo ONO . \2i 2J rL 0 o Mir 000 Be�E m r 3 m (n CL rr 0 M W X 72. CL En CL RaB [E R LICENSED & FULLY INSURED March 6, 2014 Steve Duffy 61Russett Lane N.Andover, Massachusetts 1) Tarp house and bushes to protect from falling debris. (Magnetic sweep performed daily) 2) Remove and dispose of existing layers of roof shingles. Attic area to be covered by owner. 3) Inspect re -nail and replace any rotted roof boards. Board replacement over 50 Feet will be an additional $4.00 per foot. 4) Apply "Grace Ice & Watershield" barrier to the first six feet of roof deck, valleys and all roof penetrations. Twelve inch strip will be wrapped over facia board prior to installation of drip edge. 5) Remaining roof deck will be covered with Grace Tri Flex underlayment paper. 6) All roof edges will receive an eight -inch aluminum drip edge flashing. 7) Re -shingle roof using a selected Certainteed Landmark architectural shingle with a Manufactures Limited Lifetime Warranty. 240 pounds per sq. (Five year workmanship warranty) 8) All vent pipes and chimney will receive new flashing. 9) House will be vented along the ridge with Air Vent II. 10) Robert L. Green, Inc. will fumish all materials, disposal, insurance & permits for the entire roof project. Main roof section & front lower section............................................$7,200.00 Rear lower section.....................................................................$2,200. Robert Green Custom 14 Hadley Street Unit D Billerica, Ma. 01862 (781)-861-7900 (781)-275-2338 (978)-439-9200 FAX (978)-439-9205 The Commonwealth of Massachusetts Print Form;: Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organizatiordlndividuu�a/�l): /j (,,b��� f G &rnen --/,7 l , Address: �`' ' /Y "'.4A4 3J, X141 p City/State/Zip: 4,' Ile,- Lci ,104r• Phone #: 9 %a" 5 351 Are 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). * have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' comp. insurance.+ 9. ❑Building addition [No workers' comp. insurance required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. ' y �o workerscomp. right of exemption r MGL per 12.5d Roof repairs insurance required.] t c. 152, § 1(4), and we have no 13.❑ Other employees. [No workers' comp. insurance reouired.] *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. *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 -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. j Insurance Company Name: �rI f 1�7e4Tu Policy # or Self -ins. Lic. #: Z-16: �_r ,� L/ d/- G Expiration Date: 4Y.20/i1 Job Site Address: C/ X SJr,,-�z �.�-e_ City/State/Zip: ""i el - Attach 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 thein%rmation provided above is true and correct. Phone #: 2 %� ?Y 1 91200 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/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector G. 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 certificate(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 application for the pennit or license is being requested, not the Department 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 officially 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 burn 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 Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 7-2010 www.mass.gov/dna 9/9/2013 10:33 AM ,FROM: John A. Pierce Insur TO.: 17818612780 PAGE: 002 OF 003 ACORD CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDOIYYY'() 09/09/2013 PRODUCER 781. 729. 8770 FAX 781. 729. 0053 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION John A. Pierce Insurance Agency, Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS'CERTIFICATE DOES NOT AMEND, EXTEND OR 934 Main St. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Winchester, MA 01890-1994 INSURERS AFFORDING COVERAGE NAIC # INSURED Robert L Green Inc INSURERA First Mercury Insurance - 4 Fieldstone Terrace INSURERB:, Safety Indemnity 33618 Chelmsford, MA 01824 INSURERC:. Continental Indemnity Co 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 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 LTR INS D'L TYPE OF INSURANCE POLICY NUMBER POLICYEFFECTIVE DATE MIDD POLICY EXPIRATION DATE (MMIDOrrrM LIMITS Lexington, MA 02420 AUTHORIZED REPRESENTATIVE . GENERAL LIABILITY MACGL000000928002 04/13/2013 04/13/2014 EACH OCCURRENCE $ - 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 50,000 CLAIMS MADE M OCCUR MED F --P. (Any one person) $ Excluded PERSONAL & ADV INJURY $ 1,000,000 A GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS- COMP/OP AGG $ 2,000,000 X POLICY PEa LOC AUTOMOBILE LIABILITY ANY AUTO 3175382 01/08/2013 01/08/2014 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ f3X X X ALL OWNED AUTOS SCHEDULED ALTOS HIRED AUTOS NON -OWNED .AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ (Per accident) . GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ ' $ $ DEDUCTIBLE $ RETENTION $ C WORKERS COMPENSATION AND'EMPLOYERS' LIABIL17Y Y / N ANY OFFICRER/MEMrO R DCCLUDEEX CUTIVE ❑ (Mandatory In NH) 46-812524-01-05 04/08/2013 04/08/2014 X TORY LIMITS ER E.L EACH ACCIDENT $ 1,000,000 E.1— DISEASE - EA EMPLOY $ 1,000,000 If yes, describe under SPECIAL PROVISIONS below E.1— DISEASE - POLICY LIMIT $ 1,000,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS, CERTIFICATE HOLDER CANCELLATION ' -SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION_. DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 - DAYS WR=N NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO 00 SO SHALL. Lexington, Town of IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR 1625 Massachusetts Ave REPRESENTATIVES. . Lexington, MA 02420 AUTHORIZED REPRESENTATIVE . [Kevin Pierce AC -ORD 2� (2009/01) FAX; 781. 861. 2780 © 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD