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HomeMy WebLinkAboutBuilding Permit #762 - 615 MASSACHUSETTS AVENUE 5/27/2010TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One famil Addition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Se,ticUVell loo,d;pla�n W.e#lands Wrshed Dist aterict ,F R W�#er/S.e�nrer } utbUKII 1UN ui- woRK To BE PREFORMED: (JA-, 000V 000V C) YL W kzeskj&iGlr- 30 6 -3C4 -CQ t4e IC4 Identification Please Type or Print Clearly) OWNER: Name:_ Z) S.f-Q,wAy Phone: Address: CORN'ACTName' sir\ f*r 4-;e,.„ Phone Address ` r Sup"Visor'sConncense Exp Date i7:-�c,;t1 R` s x F ome wrovementticense t tl $ S`y Exp Dade ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE; BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ (A S'00• FEE: $ Check No.: ( 4-o K— Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Ag ed Signature of contractor^ ---- -, 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/Stales.' :', - - 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 COMMENTS HEALTH COMMENTS Reviewed on Signature Reviewed on Signature i 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: 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 ❑ 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 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 Location No.Date ,.ORTp TOWN OF NORTH ANDOVER OL 9 Certificate of Occupancy $ Building/Frame Permit Fee $ —fL— Foundation Permit Fee $ Other Permit Fee $ TOTAL $ f Check # ! `�)' og r 232.2 �41uilding Inspector 04%01/2010 15:36 FAX 9785322217 BKM,Inc 0 002 ___V , A� 4/1/ CERTIFICATE OF LIABILITY INSURANCE M/DD/YYYY) 4/1/2010 PRODUCER (978)532-5445 FAX: (978)532-2217. THIS CERTIFICATE 1S ISSUED AS A MATTER OF INFORMATION B.R. McCarthy Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 10 Centennial Drive HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR West Entrance ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Peabody MA 01960 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A:ProBuilders Specialty JNR Gutters, Inc. INSURERB:Safety Indemnity 33618 38-40 Lancaster Street INSURERC:PMC Insurance Group INSURER D: Travelers Ins. Co. Haverhi 1 MA 01830 INSURER E_ - COVERAGES COVERAGES i nt rULIL.Itb Ur INSUKANGt LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTAN DING 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 = TYP9 OF INSURANCE POLICY NUMBER POLCYEFFECTIVE DTCYAONE Y, LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 11000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED A FZOCCUR PREMISES Ea occurrenceI $ 50,000 MED EXP (Any one person) $ 51000 CLAIMS MADE NBS022881 6/21/2009 6/21/2010 PERSONAL & ADV INJURY $ 11000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: —1 PRODUCTS -COMPIOP AGG $ 11000,000 X POLICY PRO- LOC JECT AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT (Eeaccident) $ 11000,000 B ALL OWNED AUTOS 3945441 6/21/2009 6/21/2010 X SCHEDULED AUTOS BODILY INJURY (Per person) $ X HIRED AUTOS X BODILY INJURY $ NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGELIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN 'ACC $ AUTO ONLY: AGG $ EXCESS / UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR F—I CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE I RETENTION $ $ C WORKERS COMPENSATION AND WC STATU- OTH- EMPLOYERS' LIABILITY Y / N Y XFR E.L.EACH ACCIDENT $ 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE © OFFICEFJMEMBER EXCLUDED? (Mandatory In NH) Il yes, describe under 9CO09752701 9/20/2009 9/20/2010 E-LDISEASE. EAEMPLOYE $ 500,000 E.L DISEASE -POLICY LIMIT $ 500 0 00 SPECIAL PROVISIONS below D OTHERCOntractora Equip. 607305N967 6/21/2009 06/21/2010 975,000 Leaeed or ' Rented Items .29110 T)Pdj,nPib1P DESCRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Refer to policy for exclusionary endorsements and special provisions. IG SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION SAMPLE CERTIFICATE FOR DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN INSURANCE PURPOSES ONLY SAMPLE COPY 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 John McCarthy/RB1 ACORD (2009/01) ©1988-2009 ACORD CORPORATION. All rights reserved. INSo25 (zot00 isot) The ACORD name and logo are registered marks of ACORD 04/01/2010 15:36 FAX 9785322217 BKM,Inc 8003 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER This Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACffRn 94I9nnaimi INS025 (2ooso>) O z x _ o w° Cf)U a cn O H w c� Or. w° EDow a�' U w o w � co w a a W Cno a°' "—co cn w a p U o tz cz w z w a a o �i cn v 0 cn o m c o � :.0 L O y v C �p O C.) C.) CL. C M O ,CD O CD O � CO2 :Ea CF • L O Lts ts �. a y �.�cm E ``m a L O �y N y �3_ La m y CCI C y W OC Ey m mo dis i m y m ; c =JC*7 O O> CDoa :• _ y a C t Co CD o 'C Q.Z y O Q. - O Z l0 w CD r C CLO C F-- O: H m C �C _ m :moo H H 0 y o o� m VD ev = m LLI MD ,y CL= OC Z cc O — m•y _0 C.3 'm V ® C7 V� = =— O _ .G O ti 0 !— 0 L- .0 .6" O _.. m O w w P-4 :T C/) z O U C/) " 2 O Ia� o, o .0 C o-0 CIO CD m m 0 = a_� CD �3 .o O C O cc 0 a CL cma 0 c ccc C.) •C Z 0 0 CL C.3 ca c C cc CL ' c .y uj CA LLIU) C9 W 19 LLIW N ' The Commonwealth of Massachusetts Department o f Industrial _,accidents Ofjice of £nvestia adons 600 Washington Street Boston, MA 02111 www-Mass-g0v1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers 'Plicant Information Name (Business/Organization/Indimi dual): Zr` h' jr� Address: O LeiV,1C c,5" v. Gu4tX0 7x! S�_ City/State/Zip: 2 3'� 2 �Vl C� is Phone #: cj j, A Are you an employer? Check the appropriate boa: I . [LT I am a employer with �- 4. ❑ 1 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 sheet I SA -UP and have no employees working for me in any capacity. fNo workers' comp. insurance require&] 3. ❑ 1 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' Pomp. Durance re d Type of project (required): . 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. [� Building addition 10.[] Electrical repairs or additions Plumbing repairs or additions 12.[] Roof repairs q ] 13.❑ Other 'A–"y a p'lic-,-t t mus? `so jM ou; .hs che^� box �? the sect, -ow shotivi :�- `^a ^COM— ho Homeowners wsubmit this affidavit indicating the;, are doing al: work and A as �s . ..., r E then hire outside con=cto, rjinst submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their worker;' comp. poiicy information, i nfoormation. an employer Hurt is providing workers' compensation insurance for my employees. Below is the policy and job site Insurance Company Name: P tkk Policy # or Self -ins. Lic. #: WC Opcj 7 5r2 7 o l Q Expiration Date: ! — Z G Zo 10 Job Site Address: 10 f11e Cit Attach a copy of the workers' compensation policy declaration page (showing y//policyi n. b ) Y A�90 e ( e umber and expiration date). 1 Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of fine up to $1,500.00 and/or one-year imprisonment, as well as civil of up to $250.00 a day against the violator. Be advised that a cc penalties criminal penalties of a in the form of a STOP WORK ORDER and a fine Investigations of the DIA for insurance coverage verification. Py of statement may be forwarded to the Office of 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct L'-'— _–_ t� 7F 37i= 4vag- Official use only. Do not write in this area, to be completed bJ' city or town officiaL City or Town. Issuing, Authority (circle one): Permit/License # L Board of Health 2. Building Department 3. City/Town Clerk 6. Other Contact Person.: . Z.-7 -_ 2 a 10 4. Electrical Inspector 5. Plumbinb inspector Phone #: Information an- d 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 ox- other legal entity, employing employees. However the owner of a dwelling house having not more than three apartmL ents and who resides therein, or the occupant of the dwelling house of another who employs persons to do mainte:x=ce, 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 c--anstruct buildings in the commonwealth for any applicant who has not produced acceptable evidence of co.>mpliance 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 contra cting authority." Applicants Please fiIl 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' comp enation 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 store to sign and date the affidavit, The affidavit should be returned to the city or town that. the apulication for the per ait.or license L4 being requested, nut the Depart—.ont of Industrial Accidents. Should you have any questions zegazdittg the law or if you are reg'' rued to obtain a workers' compensation policy, please call the Department at the numbe:T fisted 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 peiaiit/liccme 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 andfag. number... The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Inrestigations 640 Washington Street Boston, MA 0.211.1 Tel. # 617-72.7-4900 ext 406 or, 1 -977 -KA SSAFE Revised 5-26-05 Fw. # 617-72.7-7749 v�untJ.mass._�ov/din. iliassachusetts - Depil tment ofPublic Safetl. Board.of iiuildinga Regulation Construction Supervisor L censetndards License: Cs 80515 Restricted to: 00 j KEVIN M FRANCIS I 35 WANNALANCET RD HAVERHILL, MA 01830 Expiration: 7/21/2011 Commissioner Tr#: 18422 " � ' ✓%, ,�aa�xiriaoouuea�fJi a�✓l.cixuael�G Board of Building Regulations and Standards HOME IMPROVEMENT cONTRAC'T0 i" Registration ..108503 i Expiration:=g/1 9/2010 r r . Type: Supplement Card ' J'N R GUTTER .lNC KEVIN FRANCIS' '3640 LANCASTER' -ST Haver ill; MA 01830 Administrator V4 ----------- 7 JeN.l� HTC # 108503 All Types of Home Improvement 38-40 Lancaster Street Haverhill, MA 01.830 a Haverhill. MA: (978) 372-4088 Boston, MA: (617) 423-3559 Andover, MA: (978) 475-3723 Nashua, NH: (603) 595-2272 Woburn, MA: (781) 937-4212 Portsmouth, NH: (603) 433-1811 Natick, MA: (508) 653-2200 Manchester, N14: (603) 666-5502 wwwJ111-gutters.corn Fax: (978) 372-0360 Toll Free Nationwide: (800) 966-9238 PROPOSAL SUBMITTED TO PHONE DATE i. STREETJOB NAME 615 N-4assachusetts A_-vf, Rod CITY, STATE and ZIP CODE JOB LOCATION No ,-kndovcr INIA 0 1845 ARCHITECT JOB PHONE A W-PrapaSe hereby to furnish material a d1a or - complete in accordance with specifications below, for the sum of: 6 be �nac!Tas follows: Payment dollars($ it Authorized Note: thisproposal may be Signature withdrawn by us if not accepted within days. We hereby submit specifications and estimates for: I -N -P, W11.1 JHF �tiH)N� FR(.)N1 S,,".11) R1U;TLr)1N(,-,' AND 171SPOST I OF IT',! A LFG� A,1, 17AS1110N. 101'ILVIT-4,"l-, AIN Aj,ljljj�qjNj DRIP ET)i3F PFR1N4,r_,1'PR 01' THP 1"HVI"i A, 151.13 IVITI BF APPLIED TO RO('.-)F DECK, THE SHINGLES rHAT 1AILL BE USEDWILL II BE A 30 ITAR CERTAINILED ARCHITECITITAL DESIC.NER STATE (CUSTONMER WILL HAW TYIE ('11(I1"' 01" 'Illy SHINGIT COLOR) ANY ROOF R),'1.RDS N)"TDIP4,11 R1"J'LACINk.3 NVILIL, BF AN' F'1-%-rRAi .11AR ft, THE- R.)B SITH r-kREA WYLI, 13F (`L;F,AT11F.F) F. A.11 Y! OF V,. �.,l I )AILY RAs1111_1' INY, kf-AlAININ(i OR SJR,,�,Y NAT!,, BE Pj(`jjJ) UP USING, A NIA(iNFT, TM!" IS OF 10 PRF,��T_N[Tl I HLANTNRJO. WE AMIK'N" M -K-W DO[A-ARS 1,1,- llq 411()Ni'"I `w URAN THIS 1s; PRI-SINY11,11- ANI) TO "IR MD'Dl AT F,'VSfF KNOLVIN(" THAT I TRUILY PUT, FORTH EVERY ITF."AT TO PROVIDIC, 'NIA, -t NTONN ?[L& I.AT ANU) PROi _",ST( INAL STRV PRICT,' SIX-A—EE11 OF WF Alt'I V) WATER SI-IfEIT) I.A1'Nif) THRI'T FUT A`U)11�iG A F A!._)D1T10N1.rkL i'Os'll f-riR 4 F R 1 1UN P -TT) 5-STJRFSTAF*�T I j OF Wfif; . I A 11vCl 1,T)ES VOR 2;ti 'VEARS' ON DWRATION `,T_.AR-(A-,F". NPOSAL AND ACCrjJtaUCr, Of PrO]JOSA - The prices, specifications and conditions listed above and on the back of this form are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. Three day cancellation rights under section forty-eight of chapter ninety three, sec- tion'fourteen of chapter two hundred and fifty five, D or section ten of chapter one hundred and forty D as may be applicable. Date of Acceptance: Do not sign this contract if there are any blank spaces: Signature Signature