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HomeMy WebLinkAboutBuilding Permit #379-2017 - 70 MARTIN AVENUE 10/7/2016 NORTy 1p Ir,Jy'/''Ifv BUILDING PERMIT 0`4t LED qHo TOWN OF NORTH ANDOVER . APPLICATION FOR PLAN EXAMINATION Permit No#: 7�' ®t Date Received t U 7 ' 0 1 �p"�R.7ED c5 gSSACHUS Date Issued: 7 4-0 tB IMPORTANT: Applicant must complete all items on this page Lf�;CA�TION1 ->mt PR c.PE-RFTY OWNER Er b' yes, nod PARCEL: Z®Nt{NG®;hS�TRIC His ric D strictk y/0 no) Machine Sop,Villagey yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family El Addition El Two or more family ❑ Industrial ❑Alteration No. of units: [I Commercial epair, replacement ❑Assessory Bldg [I Others: ❑ Demolition ❑ Other _ - 0 Septic; ❑1Nell+ ❑ FloodplaimWetl'ands-0 L-0-V41ate:�/5eweFL-1 DESCRIPTION OF WORK TO BE PERFORMED: Identification- lease Type or Print Clearly OWNER: Name: Phone: Address: - _� w Contractor Name.:, one E-'1 `Ph< 7� ter Email` a ZtUl S° ervisor�'s, Constructioni License:._ -__ , Exp, . wP H:ome�Lm rouement.L'ieenset—. -- Exp;:; Rate.:, ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING P RMIT:$12.00 PER$9000.00 OF THECAL ESTIMATED COST BASED ON$925.0 ER S.F. Cost: FEE: $ `K Total Project $ Check No.: 1 �.O-S Receipt No.: 3 / 0 l 3 NOTE: Persons contracting with unregistered contractors do not have access to the gu ranty fund 5ignature�-ffAgent/Owner _ :; z _ Signaturefof cor tractor _ _ _ 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 pPlication ❑ 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/Cross Section/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 2014 i 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 Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes r Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/signature& Date Driveway Permit DPW Town Engineer: Signature: 'EIRE DEPARTMENT Tem Osgood- Street : - - mpster� site` y �n Located g reet Located at1 "` Du oresa� .x . 24��aintStreet: z �- xFire,+fie nt s . ignature/date t Ji I I 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 Electrical Inspector pp I of Yes No DANGER TONE LITERATURE: Yes MGL Chapter 166 section 21A—F and G min.s100-$1000 fine No NOTES and DATA — (For department use) f I I ❑ Notified for pickup Call Email Date Time Contact Name ------------ Doc.Buildiag permit Revised 2014 r Location 70 M A47-1/V A V rt�i /G No. -� ` / � Gf� _ � Date /U ' 7- a'a F , •'- TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# n j 1 Building Inspector NORTH .q - 441 Auc ve' .. O No. 1 � goll0 h ver, Mass, / 7 • 2-0t A_ coc"Ic Nt WICK 7�S RATED P,'? U BOARD OF HEALTH LD Food/Kitchen Septic System RMIT T PE BUILDING INSPECTOR a� s ..... THIS CERTIFIES THAT .............................. V ( "...... C"�"" "•-� 7 �• Foundation has permission to erect bui dings on ............O•••••1.'"`••••• ••••••••••••••••• •••••••••••"""' ...............`......... Rough to be occupied as ....,..... Tpoop ,,,. Chimney p .....K.....�!....... ......... :................. provided that the person accepting this permit shall In every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and PLUMBING INSPECTOR Construction of Buildings in the Town:of North Andover. Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO STARTS Rough •••• Service ... j ... ........................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupv Building Rough Display in a Conspicuous Place on the Premises - Do Not Remove Final FIRE DEPARTMENT No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. -� u r CAE5�-N CP.L.G Painting & Carpentry (978) 404-6648 PROPOSAL SUBMITTED TO PHONE DATE T'7A 11 b STREET JOB NAME —k CITY, .TATE AND ZIP CODE JOB LOCATION " Am gic-:6 ARCHITECT DATE OF PLANS JOB PHONE WE HEREBY SUBMIT SPECIFICATIONS AND ESTIMATES FOR: i 5U--q'e J V¢3prOP00 hereby to furnish material and labor-complete in acc rdance with above specifications,for the sum of: dollars($ ) Checks Payable To Lemmie Greenhalge All material is guaranteed to be as specified.All work to be completed in a workmanlike Authorized manner according to standard practices.Any alteration or deviation from above specifi- cations involving extra costs will be executed only upon written orders,and will become Signature an extra charge over and above the estimate.All agreements contingent upon strikes, accidents or delayrs beyond our control..Owner to carry fire,tornado,and other necessary Note: This proposal may be insurance. withdrawn by us if not accepted within days. 0cceptance of j3roponlThe above prices,specifications and conditions are satisfactory and are hereby Signature accepted. You are authorized to do the work as specified.Payment will be made as outlined above. Signature Date of Acceptance: 0a �-� �' '"'L_ J, w F AC40 CERTIFICATE OF LIABILITY INSURANCE FDATE(';6;)16 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 AMEN, 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 hdder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terns 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: LTB Insurance Agency PHONE 7811 365-1800 F^'1 N : (781) 221-0031 85 Wilmington Road E-MAIL lisa@ltbinsurance.com Burlington, MA 01803 INSURE S AFFORDING COVERAGE NAICP INSURER A:Nautilus Insurance MURED INSURER B: Lion Services Inc. INSURER C; 11 McDonald Road INSURER D: Wilmington, MA 01887 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 PAN CLAIMS. UCY EFF LTR TYPE OF INSURANCE ASLWM POLICY NUMBER M /Y IIPi1MMWf Y LIMITS A GENERAL LIABILITY NN636510 12/11/15 12/11/16 EACH OCCURRENCE $ 1,000,000 $ COERCIALGENERALLIABIUTY DAMAGE TO RENTED MM $ 100,000 CLAM-MADE ®OCCUR MED DIP(Ary one person) $ 5 000 PERSONALBADVINJURY $ 1,000,000 GENERAL AGGREGATE $ 2.000,000 GEN'LAGGREGATE LMITAPPUES PER PRODUCTS-ODMP/OP AGG $ 2,000,000 $ POLICY PRO-JECT LOC AUTOMOBILE LIABILITY CONE accident) SINGLEL R $ ANYAUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTYDAMAGE $ HIRED AUTOS _AUTOS eraccident $ A UMBRELLALIAB $ OCCUR AN031346 9/9/16 9/9/17 EACH OCCURRENCE $ 5,000,000 $ EXCESS LIAS CLAIMS-MADE AGGREGATE $ 5,000,000 DED RETENTION$ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N EEL ANY PROPRIETORIPARTNER/EXECUTIVE —^, N/A E.L.EACH ACCIDENT OFFICERMENBER EXCLUDED? _i (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ IFyes,describe under DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,AdMonal Rerrerks ScIvedtde,if more space is requi red) Job Description: Roofing Repairs Job Location: 70 Martin Ave, North Andover MA The Workers Compensation certificate has been ordered and will be sent to you directly from the carrier. CERTIFICAME. CANCELLATION 777�"" SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE TH—: 0F, NOTICE WILL BE DELIVERED IN John Doherty ACCORDANCE WITH THE POLICY PROVISIONS. 70 Martin Ave North Andover, MA 018 AUTHORIZED REPRESENTATIVE Lisa Tucker ©1988,2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) T" "^^R^ c.-z stered marks of ACORD Cowl f W3 > - 9 - 1 r t ' 1 { 1'ize Commonwealth of Massachusetts F Department of IndustrialAceldents M X Congress Street,Suite 100 Boston,MA.02114-2017 • � - �r www.mass.gov/dia 9,d�Al SJ.y3 Workers,Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMLTTINO.A.UTSORITY. Elease Print Le 'bl A ' licant Information Name(Business/Orgarlization/Individual): Address: Phone#: 7 City/State/Zip: :: . . .. : : . Are you an employer?Check the appropriate box: Type of project(required): em to ees full and/orpart-time).•` 7. [1New'constritction 1.❑lam a employer with P y 2.❑I am a sole proprietor or partnership and have no employees working forme in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9, ❑Demolition 3.E]I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10❑Building addition I am a homeowner and will be hiring contractors to conduct all work on my property. I will 4• ion insurance or are sole 11.❑Electrical repaixs or additiops ❑ o ensat workers'c m r have wo P ensure that all contractors either proprietors with no employees. 12.Qpjuinb ng repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 11❑Rb6f repair§ These sub-contractors have employees and have workers'comp.insurance.t Other 6.❑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'comp.insurance required.] *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 flus Box must attached additional sheet showing the name of the sub-contractors and state whether or pot those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. X am an employer that is pro viding-workers'compensation insurance for my employees. Below is the policy and job site information. 1 Insurance Company Name: t Expiration Date: Policy#or Self-ins.Lic.#:. . & A.w ,-, � M.. _ _ �.. . r.� City/State/Zip: Vv v�i— lob Site Address: /v � . ,. Attach a copy of the workers' compepsation policy declaration page(showing the policy number and expiration date). is a criminal violation punishable by a full up to$1,500.00 Failure to secure coverage as required under MGL a.152,§25A s in the form of a STOP RK ER and a fine of UP to and/or one-year imprisonment,as well as civil atl be forwarded to the Office o0£TnvOesgat ons of the DIA for insuran 0 a day against the violator.A copy of this statementY coverage verification. X do Hereby certify under fire pains and penalties of perjury that the information provided above is true and correct. _ Date: Si ature: Phone#: q 7 official use only. Do not write in this area,to he completed by city or town official. Permit./License# City or Town: Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Phone#• Contact Person: 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"...eve person in the service of o iY p an then 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 enferprise,and including the legal representatives of a deceased employer,or the receivotbr.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 b6 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 certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members orartner p s,are not required to c 'workers compensation insurance.. H 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 permit 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 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 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 bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia sVlass achusetts -bepa trilent of f'tab#ic Safety a ! Board of Suilctn Re ulations : d Standards = i Constrc�rtiog Su.P n,ist)r 41 icense: Cs-108082 Tk JAIME I LAYON # 11 MCDONALD LOAD Wilmington MA 01881 I Expiration Commissioner 03/06/201 8 _ f;-/1!G (�'f3)Ih7YtO)7C[K'C!/tEt 4�C'iL4,{IJ.IQtNYtlff��. 4 Office of Consumer Affairs K Businers Regulot}on ME-IMPROVEMENTCONTRACTOR__J_J ;eegistration 173813 hype: xpiration } 11715/)01-i DBA , ' g­ LION ScRVI ,ES I JAIME LAYON " 11 MCDONALD RD ' WILMINGTON, MA 01.887~ t. _ Under"secfCfi4