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HomeMy WebLinkAboutBuilding Permit #21 - 71 PEACH TREE LANE 7/11/2007 F BUILDING PERMIT "°RT"qti TOWN OF NORTH ANDOVER 0i44` '`- '° o APPLICATION FOR PLAN EXAMINATION *1► i -ea � Permit NO: C Date Received gSSACHUs���� Date Issued: J -//-0 IMPORTANT:Applicant must complete all items on this page LOCATION Print PROPERTY OWNER Print MAP NO: 9 PARCEL,. 'ZONING DISTRICT: Historic Distric# yes no Machine Shop liigege ayes no�l TYPE OF IMPROVEMENT PROPOSED USE . 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 Septic ; Well Floodplain Wetlands Watershed District WateraSeV e' r F : e DESCRIPTION OF WORK TO BE PREFORMED: V Identification Please Type or Print Clearly) OWNER: Name: Phone: 3 Address: UE CONTRACTOR Name: Phone: - -49 Address: " , r s . t Supervisor's Construction License:/ Exp. Date: Al Home improvement License. A 1 fg 4 Exp. Date: ARCHITECT/EN , IN e: Address o FEE SCHEDULE:BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER Total Project Cost: $ FEE: Check No.: t r -I Receipt No.: oL NOTE: Persons contracting with unregistered contractors do not have acces to thearan i g ry fund `_ igriaturebof Agent/Owner' "`F . �� ;Signature of contractor Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Swimming Pools Tanning/Massage/Body Art Well Tobacco Sales Food Packaging/Sales " t Private(septic tank,etc. Permanent Dumpster on Site I 1 THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS i i DATE REJECTED DATE APPROVED CONSERVATION COMMENTS DATE REJECTED DATE APPROVED HEALTH COMMENTS .a Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments I Conservation Decision: Comments Water & Sewer Connection/Signature &Date Driveway Permit Located at 384 Osgood Street FIRE DEPARTMENT, Temp turd stetbh 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 2 1 A—F and G min.$100-$1000 fine NOTES and DATA— (For department use ❑ Notified for pickup - Date Doc.Building Permit Revised 2007 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 W t'uildin9 PP Permit Application ❑ Vorkers Comp Affidavit o/ oto Copy Of H.I.C. And/Or C.S.L. Licenses py 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 i Addition Or DecksJ. ,1 ❑ 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 Application Permit A lication ❑ 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 thea appeal period is over. Th PP P e 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 Location No. Date MORTM TOWN OF NORTH ANDOVER # ; ; Certificate of Occupancy $ v *7S •E<� Building/Frame Permit Fee $ „� cNus ` Foundation Permit Fee $ j Other Permit Fee $ TOTAL $ Check # 203vl U Building Inspector 4 G 1- a � UYIoma . f r NORTH Town of _ Andover 0 �.. ti.». No. � 0 i..,- LAK o over, Mass.,__ I� COCHICMEWICK 7,9 ADRATED `S BOARD OF HEALTH Food/Kitchen Septic System PERMIT T D • BUILDING INSPECTOR THIS CERTIFIES THAT............0400-�.....�<. lP................................................................................................... Foundation has permission to erect........................................ buildings on ../ ....... G`, -C................................... Rough to be occupied as... i�srT....... ,C.N,o' i4.> o./' Chimney .... .............................................................. ........................... provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final 36 Z — PERMIT EXPIRES IN AOTHS ELECTRICAL INSPECTOR UNLESS CONSTRUTS Rough ........................................................................ .................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. The Commonwealth of Massachusetts Department of Industrial Accidents 1. Office of Investigations 600 Washington Street Boston MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly _Name (Business/Organization/Individual):�4u t Address: City/State/Zip: I��Z@,�(J Y11 d , Phone #: ��-(�� V 7 SriAre you an employer?Check the appropriate box: Type of project(required): I.ElI am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2 am a sole proprietor or partner- listed on the attached sheet. 1 7.remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 11 ,9K required.] officers have exercised their Olectrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 1 IR. 'Plumbing repairs or additions myself [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks boz#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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: 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 cert' der the pains and p !ties o;perju drmation provid abo a is true and correct Si ature: Date: . Phone Official use only. Do not write in this area,to be completed by city or town o i Ytat 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 6.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 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 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 600 Washington Street Boston, MA 02111 Tel. # 617-7274900 ext 406 or 1-877-NIASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number. CS 064384 Birffidate: 04/2.4/1957 Expires: 0.4724/2008 Tr. no: 25498 Restricted.:?00 KEVIN M BROUILLARD SR 101E ST C 4_= LAWRENCE, MA 01843- Commissioner — �—� , fie vammwozu�P� o�,/�avaac�zuaP,lYd� Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registratidn: ,137695 Expi�iWW--2/1:9/2008 Tr# 124418 YType:, Indi�i'dwal YWs,�rt KEVIN M BROUILLA D KEVIN BROUILLARU4 101 EVERETT ST LAWRENCE,MA 01843 Administrator— ACORD TM. CERTIFICATE OF LIABILITY INSURANCE DAT052212007�� PRODUCER Phone: (978)475-0400 Fax: (978)475-2171 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION THE HOWE INSURANCE AGENCY ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 4 PUNCHARD AVE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ANDOVER MA 01810 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC#. INSURED INSURER A: National Grange Mutual K M BROUILLARD REMODELING INSURER e: C/O KEVIN BROUILLARD INSURER C: 101 EVERETT STREET LAWRENCE MA 01841INSURER 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. R LTADD' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LTR INSR DATE MMIDD DATE MMIDD LIMITS GENERAL LIABIUTY MP017108 04/14107 05/11/07 EACH OCCURRENCE $ 500,000 X COMMERCIAL GENERAL LIABILITY - DAMAGE ToR PREMISES(EaEoccurence) $ 500,000 CLAIMS MADE FX] OCCUR MED.EXP(Any one person) $ 10,000 A PERSONAL&ADV INJURY $ 500,000 GENERAL AGGREGATE $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: I PRODUCTS-COMP/OP AGG. $ 1,000,000 POLICY JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION$ $ WORKERS COMPENSATION AND oRVTAT Ts OTHER EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ ANYCERIMEMB R/PXCLUDEDXECUTIVE / . If yes,describe under 1/ E.L.DISEASE-EA EMPLOYEE $ if yes,describe under svecwL rRowsloes below E.L.DISEASE-POLICY LIMIT $ OTHER: DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE BUILDING DEPARTMENT EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN 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 Attention: ACORD 25(2 JUC%rlstine 4Trange 001/08) Certificate# 3106 ©ACORD CORPORATION 1988 Lic. # CS 064384 PROPOSAL - CONTRACT SATISFIED Hic. # 137695 CUSTOMERS Reliable K.M. BROUILLARD are Our best Service FINISH CARPENTRY & REMODELING ADS Kitchens• Decks • Additions & More SHEET NO: COMPLETE DRYWALL SERVICE DATE: °1 � o't�9o7 978-794-0247 Proposal Submitted To Work To Be Performed At Name n if, Street Wt Street G City State City O Date of Plans State Architect Telephone Number _, We hereby propose to furnish all the materials and perform all the labor necessary for the completion of 52YYLP_.,/11 'den v (ion c lene t o i �3 ' � 5 ,e C, . A CAX q T'i i ` ' ti 6,4 e Tji 5 1 o p a UCom- ,0_,;4h 6P RAoM AA Aid .3 A4M LOA P) 3 ,7 ub-5- e 14"MA�t' e i&koah . FL,00 &.0 >� /914 E6 - W41 16e D 6� ^ All material is guaranteed to be as specified, and the above work is to be performed in accordance with the drawings and specifications submitted for above work and completed in a substantial workmanlike manner for the sum I t9�917 t7b r1� I;' mop h iRTr R_ <r1R� a Dollars with payments to be made as followsrark 5 U� 17 y/nb0 , $ r1 L 2 e-O S � ' � C �� . -� >D b M to I to 44 61✓1 6M • Parties agree that any change.order/amendments to this agreement made at the request of the Customer/Homeowner, shall be made in writing, sent by certified mail to Contractor's address: 101 Everett Street, Lawrence, MA 01843. Parties agree that Contractor shall charge/bill Customer.$ . /hr. to'incorporate said changes. Thereafter, all changes/amendments shall be incorporated into this agreement and shall be treated as part of the original agreement, dating back to its original signing. Any alteration or deviation.from above specifications involving extra costs, will be executed only upon written orders, and will become an extra charge over and above estimate. Owner to carry fire, tornado and other necessary insurance upo aboye work. Respectfully submitted by Note-This proposal may be withdrawn by us if not accepted within days. ACCEPTANCE OF PROPOSAL The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. Accepted Date Signature