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HomeMy WebLinkAboutBuilding Permit #532 - 72 SUGARCANE LANE 3/4/2010TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: rl/ Date Issued: �liy IMPORTANT: Applic 4 Date Received must complete all items on this page 14 WT a Residential Non- Residential °s, �Jtoc l.rlil �-' nAN in.7Pi tr .._ _-u�^,rCJ iUlarfiin".Shisllm "aes.. gno TYPE OF IMPROVEMENT PROPOSED USE 10,CflNTRACTOIZ Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial Repair, reolaraffmrd Assessory Bldg Others: Demolition Other ._ Exp Date xy.: A: .S s fei %loodpldin Weil 1i 1JV!a1i 'd,'Dlstrict ,1later/Sere'_JF . w DESCRIPTION OF WORK TO BE PERFORMED: ,�_ f'C�.1t-✓ ��"wry n �'�. - Please Type or Print Clearly) OWNER: Name: 19 Address: v 10,CflNTRACTOIZ "�` h©ne � RZ Address: ' a, Supervisor's Cc r st i a cense. i ' ' � xb Detbi: , a = Horne Irnpro�enaen n a ._ Exp Date xy.: A: 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: $ . X120, FEE: $�( Check No.: � �� Receipt No.: 71 NOTE: Persons contracting with unregistered contractors do not have access to the guVfnty fund 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature M COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: 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 21A —F and G min.$100-$1000 fine NOTES and DATA — For department use ❑ Notified for pickup- Date Doc:.Building Permit Revised 2008 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 o 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 Li 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: Doc.Building Permit Revised 2008 Location ,An'C No. Date Date Of NORTH TOWN OF NORTH .ANDOVER ••eO .•,�O i • OL , Certificate of Occupancy $ '�S'^••° • Eta' cNus Building/Frame Permit Fee $�� sw Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # �66,3- 22533 Building Inspector h z .f rA W cc ui : c r- 0 O U C O O U C� . O N x ,F, C H wz �p O wv o O w a vp C/)w a C O rx C U G w" O w C w p w ol C/5w p d O rz cz G w w r. cin Q cn ui E r N 0 N C O cc CD CD cc cm m 0 cm c C N m Z 0 2 co 0 C/) 1.0 0' a� O E 02 � O s Z O O. O y D C — O cm COD O O � .g MW MM W G3 0 co CL I--*" L O CD 0 CD e—ov `O MQ: a - cma COD c Cl 0.0 c �� C.i 'FL o C; c Z co CD C.7 CO) O C .0 C c CO3 : c r- 0 C O . O N ,F, C �p O wv aC �v eo m c :t o � cc o CD N � ECDQ =� o f o c N O m c� :COo C N mm .�: o �3 N m N m Q` m 4.boa N CL CCD O i co m o ,� Co a o m N m C W = W.2 O:5 =c L .y O go dt C •m cm ti O m',C C CA m� O� N _ Cp .0 O aim E r N 0 N C O cc CD CD cc cm m 0 cm c C N m Z 0 2 co 0 C/) 1.0 0' a� O E 02 � O s Z O O. O y D C — O cm COD O O � .g MW MM W G3 0 co CL I--*" L O CD 0 CD e—ov `O MQ: a - cma COD c Cl 0.0 c �� C.i 'FL o C; c Z co CD C.7 CO) O C .0 C c CO3 Cr9g Rf k d.�i -= Desmond Construction, inc. P. O. Box 41 North Andover, MA. 01845 (978) 682-2279 Date: 2/27/10 Page 1 of 2 TO: Jodi & John Curtin Job Site: 72 Sugarcane Lane same N. Andover, MA 01845 . 5-� / IZ-0 A4% aE�i 44 se Desmond Construction,tft- Oft P n, Box 41 !North Andover, MA. 01845 47R-892-2279 Date 2/27110 TO: Jodi & John Curtin 72 Sugarcane lane N. Andover, MA 01845 978.687-2370 W71717-TVAK Job Site: same All material is guaranteed to be as specified, and the above work to be performed in accordance with the drawinn _ specifications submitted for above work and completed in a substantial workmanlike manner for the sum of $20.320 25 % upon signing 25 %® upon 50 % completion of project 50 % upon completion of project $5,080.00 $5,080.00 $10,160.60 An interest charge of 1.5 % per month will be applied to any balance due 30 days after completion of this project. 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 the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to cant' fire, tomado and other necessary insurance upon above work. Workmen's Compensation and Public Liability Insurance on the above work to be taken out by Desmond Construction, Ir NOTE: Tile and grout All light fixtures Appliances, kitchen/bath sink and faucets Cabinets by others Respectfully submittea Per Matthew Desmond NOTE: This proposal may be withdrawn by us if not accepted with days. The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payr will 76dels outlined above. Signature: Date: Signature: Date: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations kvi 600 Washington Street Boston, M4 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le�bly Name (Business/Organization/Individual): d�.�.vcl„d✓✓ Address: �'rr G�.i6;l7i"9 Irr City/State/Zip:dZQ, 0Y4 a/,P& Phone #: i7�-�4/;p -�177 Are you an employer? Check the appropriate box: L I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ I am a sole have hired the sub -contractors listed proprietor or partner- on the attached sheet. $ ship and have no employees These sub=contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] 3. ❑ 1 am a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No workers' comp. C. 152, §1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions I I.❑ Plumbing repairs or additions 12.0 Roof repairs 13. ❑ Other a:aV tut L•;Sl LL•e Se�Rat o�e!ow --nowma theiT Wom'—s' coFL't:-:.SA Ot. Y..:iC� 2n'O WaLiOn. 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. policyinformation. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Z;A,-,- &-a viji c c Policy # or Self -ins. Lic. #: �y(,t/G ?>� f�J'f'� Expc.�� 7� ation Date: Job Site Address: 7.2— Jac eAr/rol Ci /State/Zi l' t3' P �r`'G ae 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 p ins andpenalties ofperiury that the information provided above is true and correct: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 3 6. Other Contact Person: Permit/License # City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector 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 a plica'ion for the permit or license is being requested, not the Dep arr:3e tt 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 m 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 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. # 617-72.7-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-72.7-7749 vvwu,.mass.gov/dia � an' M If 4k am N 9 O 40 V ». uw E U LLi � M 00 6+ 9 O O 9 m a i+, = I w L z o } CA x cc Z� �1 C1 = It Z W N 0 z M If am N 9 O 40 V C o 'e E U LLi � M 00 6+ 9 O O 9 m a i+, = I w L z o } CA x t- O Co �1 C1 = It Z W N 4 ZZ j _ CL Z QQ W p '- Z AC40RDVCERTIFICATE OF LIABILITY INSURANCE 2/24/°D'Y""' 2/24/2010 PRODUCER (978)372-2790 FAX: (978) 373-2281 Sullivan Insurance & Financial, Inc. 487 Groveland Street Haverhill MA 01830 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED Desmond Construction, Inc. 19 Upland Street North dover MA 01845 INSURER A: Commerce Insurance 34754 INSURER B: Citation 40274 INSURERc:AIM Mutual Insurance Company 33758 INSURER D: INSURER E: GOV 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. NSR IL ADWL POLICY EF ACTIVE POLICY EXPIRATION TR INSR01 TYPE OF INSURANCE POLICY NUMBER LIMITS . GENERAL LIABILITY EACH OCCURRENCE $ 500,000 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTEDPREMISES a occurrence $ 50 000 A CLAIMS MADE OCCUR ZS1282 7/7/2009 7/7/2010 MED EXP (Any one person) $ 5,000 PERSONAL 8 ADV INJURY $ 500,000 GENERAL AGGREGATE $ 500,000 GEN'LAGGREGATELIMIT APPLIES PER: PRODUCTS -COMP/OPAGG $ 500,000 X I POLICY PRO- LOC AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT (Ea accident) $ 100,000 B ALL OWNED AUTOS BCNZGZ 9/12/2009 9/12/2010 X SCHEDULED AUTOS BODILY INJURY (Per person) $ 300,000 HIRED AUTOS NON -OWNED AUTOS BODILY INJURY (Per accident) $ 100,000 PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ — E ANY AUTO AUTO ONLY: AGG $ EXCESS! UMBRELLA LIABILITY EACH OCCURRENCE $ AGGREGATE $ OCCUR FICLAIMS MADE DEDUCTIBLE $ RETENTION $ C WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY YIN TRY LI ITS E EACH ACCIDENT $ 100,000 ANY PROPRIETOR/PARTNER/EXECUTIVE ❑E.L. OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYE $ 100,000 (Mandatory in NH) ALWC7019598 8/23/2009 8/23/2010 If es, describe under E.L. DISEASE - POLICY LIMIT $ 500,000 SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS I LOCATIONS/ VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Construction Operations Town of North Andover North Andover, MA 01845 ACORD 25 (2009/01) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 20 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 Diane Fraioli/KJG ©1988-2009 ACORD CORPORATInN All rinhfa INSUZ* (200901) The ACORD name and logo are registered marks of ACORD