HomeMy WebLinkAboutBuilding Permit #141-11 - 726 GREAT POND ROAD 8/20/2010 BUILDING PERMIT F NORrh
TOWN OF NORTH ANDOVER o �1a ED X6'91
APPLICATION FOR PLAN EXAMINATION '
Permit NO: '/
y ` «
Date Received
Date Issued: " /0 3�5�"�rED a•���5
SACHUSE
IMPORTANT:A
pphcant must complete all
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TYPE OF IMPROVEMENT PROPOSED USE
Residential
One family 4
New Building Non- Residential_ _
Addition Two or more family
Alteration Industrial
No. of units: i
Commercial—
Repair, - —
re
la
ce~
p ment Assesso Bld
Demolition ry Bldg
Others:
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i DESCRIPTION OF WORK 10 BE PREFORMED
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,Identification Please Type or Print _
OWNER: Name: - ; �o Clearly)
Phone:
Address:
. `N�a �„a`3��7-�Saatt '"-'�"��-- ^-+ Olt` `1; ."�"7r r
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ARCHITECT/ENGINEER
Phone:
Address:
Reg. No. '• �
FEE SCHEDULE:BULD/NG PERMIT:$12"00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. �
Total Project Cos • $ q. L10 3 n®
FEE= $ �—
Check No.:
�� di
Receipt
o
NOTE: Persons contracting with unregistered contractors do not have acc
—�
ess to the guarantyfund o ANjent/ uvner
• .5,gnature�f�con actor r r
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Swimming Pools
Public Sewer Tanning/Massage/Body Art
• .`
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
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CONSERVATION Reviewed on Signature
COMMENTS
r
HEALTH " Reviewed on Signature
COMMENTS
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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
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DPW Town Engineer: Signature:
1 Located 384 01sgood Street
z n;iR E� ►5R ' lE f er�a�'Du, jes
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Locatedt�� . lfain Street m
1
Fere aear en Igna ure�date
s d
Y
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)
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❑ Notified for pickup - Date
,
Doc.Building Permit Revised 2010
Building Department
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The following is'a list of the required forms to be filled out for the appropriate permit to be obtained.
i
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 +
o 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)
o 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
o Deified 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
i
Doc:Building Permit Revised 2008
i
Location
No. f Date
�aRTM TOWN OF NORTH ANDOVER
3?0' . o
F - Y
Certificate of OccupancyjP
_
9
�s "° <�' Building/Frame/Frame Permit Fee $
swcMust
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #✓s�30
233
Building Inspector
ORTH
ONM over
o - 110
,. ,. ..
No. 12
_� LAKE -O dower, IVMass.,
co C M I C HE WICK
AORATED
S ` BOARD OF HEALTH
Food/Kitchen
IT T Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT...C% ......4t)...e,,— ............................................................................................... Foundation
has permission to erect.........:.............................. buildings on .......
........� .. �! ::.../ ••• Rough
to be occupied as..............: .. �a ........ /' ✓+ ..... ....
Chimney
� �
provided that the person accepting this permit shall in every respect conform to the terms of the application on fi 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
PERMIT EXPIRES IN 6 MONTHS
ELECTRICAL INSPECTOR
UNLESS CONSTRUC N ST TS Rough
D .-
Service
.............................................................................................
BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Finalyi
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.
BUILDING-PERMIT of µORTN
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TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
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Permit NO: ld Date Received °a #
AC US
Date Issued:
IMPORTANT:Applicant must complete all items on this page
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TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
f` New Building One family
Addition ' Two or more•family Industrial
terat' No. of units: Commercial
Repair, replacement Assessory Bldg Others:
Demolition Other
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I OWNER: Name:�l y. C`� � /� d i .s �i Phone:0,9 J� �'
$ Address: Lv IF t11_,19K,0 O_ IR CMZ_
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ARCHITECT/ENGINEER�'I�.
Address: l,/ S Z7-r S1 �, y� Reg. No.
FEE SCHEDULE.-BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
40Total Project Cost: $ FEE: $
ea
v
Check No.: � �--� Receipt No.:c) '-3 2
NOTE: Pe>^sons contracting with unI•ea�stel�ed contJ•actors do not have access to the u •ants fund
l natures x1 ent/t0 nanl
F ..
4 The Commonwealth of Massachusetts
_ f Department of Industrial Accidents
Office of Investigations
• t it 7'�'f 1
911�.tu i 600 Washington Street
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1f Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): rmA C-6^S }✓ie76A L,,4ee
Address: a2) I'ct ftR� �`J
CQ'99 f Phone#: C60,?)3aq-6909City/State/Zip: s�eA
Are you an employer?Check the appropriate box: Type of project(required):
1.[J�I am a employer with 1 _ 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. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.]f employees. [No workers' 13.❑ Other
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 this box must attached an additional sheet showing the name of the sub-contractors acid their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site
information.
Insurance Company Name: N [5,e rp{ 7ASrr e®A*paPy
Policy#or Self-ins. Lic.#: d tO'C 1 / I 4./® Expiration Date:
Job Site Address: 7a6 6 tec,'I F&LA RA City/State/Zip: J/OPX Wa_., �� afikr
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 the information provided above is true and correct.'
Signature: 247e2:��:, Date: Zd 2�J0
Phone#• 6c53 3029 - `%-O I
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
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-contractors)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 cant'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 confinnation 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 pen-nit 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 pen-nit/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 pen-nits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or pen-nit 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. #617-727-4900 ext 406 or 1-877-NIASSAFB
Revised 5-26-05
Fax#617-727-7749
www.mass.gov/dia
Nlassachusett -Depai-tinent of Public Safety
? , Btu t-d'o Buildin- Re- lations anti Standar-ds
Construction Sunerviscr License.
License; GS- 47989 7 __
Restricted to.. 00jil
JOHN V HORAN
21 EVERGREEN DR
HAMPSTEAD,NH03841
�-�---�� Expiration: 3/2/2012
(`omnii<si+,ncr Tr=: 20522
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Otike of Coasomer Affairs B sines itegutafioa
HOME IMPROVEMENT CONTRACTOR
Wm
Registration 4.0207t...
Type:
,' Expiration:=S/30L2012 DBA
J-t 9NN V.HORAN CONST#2(jGT#£3N
Joan Horan =
21EVERGREEN
HAMPSTEAD.NH 03841
Undersecretary .
John Moran Construction, L.L.C.
Buifding and Remodefing
21 Evergreen Drive tel. (603)329-6209
Hampstead,NH 03841-2342 fax (603)329-6209
June 23, 2010
Eric Worthen
Susan Worthen
776 Great Pond Rd.
North Andover,MA 01845
Dear Mr. Worthen:
This is a contract for a roof on the carriage house,#726, as follows:
1. Remove skylights.
2. Close opening with 2"x12"rafters and 5/8"CDX plywood.
3. Insulate openings with R-30 insulation.
4. Strap interior and drywall openings.
5. Taped and sanded finish on drywall.
6. Strip existing roll roofing.
7. Install a %2"insulation board to roof deck and cover with .060 Firestone EPDM black
rubber roof.
8. Roof perimeter to receive new white drip edge.
9. Reinstall corner boards and siding around dormer after roof is completed.
10. Install new roof shingles around dormer after rubber roof is flashed. (shingles to
match as closely as possible.)
11.No interior painting included.
12. Disposal of debris included.
13. I will apply for permit.
Cost: $4,403.00
Payment due upon completion.
Signature of Homeowner(s) Si afore of Contractor
Date ate
Client#:490547 JOHNHORA
ACORD- CERTIFICATE OF LIABILITY INSURANCE 06104/o° ")
PRODUCER - THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
USI Insurance Svcs of NE,Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
PO Box 6360 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Manchester,NH 03108-6360
603 625-1100 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A. Maine Mutual Group Insurance Company 15997
John Horan Construction LLC INSURER B: EastGuard Insurance Company 14702
21 EVERGREEN DR
INSURER c:
Hampstead,NH 03841
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 TYPE OF INSURANCE POLICY NUMBER POLICY ffFECT1VE POLICY EXPIRATION LIMITS
LTR S DATEI== DATE MMIDD
A GENERAL LIABILITY SCI 0955638 04/01110 04/01/11 EACH OCCURRENCE $1,000,000
X COMMERCIAL.GENERAL LIABILITY PREMISES(Ea occurrence)DAMAGE TO RENTED $250,000
CLAIMS MADE a OCCUR MED EXP(Any one Perm) $5,000
PERSONAL&ADV INJURY $1.000,000
GENERAL AGGREGATE $2 O00 000
GEN1 AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG s2,000,000
EIPOLICY PRO-JECT LOC
A AUTOMOBILE LIABILITY KA1095508 04/01/10 04/01/11
COMBINED SINGLE LIMB $5OO 000
X ANY AUTO (Ea accident)
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Par person) $
X HIRED AUTOS
BODILY INJURY $
X NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY-FA ACCIDENT $
ANY ALTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
A EXCESSIUMBRELLA LIABILITY KU10955638 04/01/10 04/01/11 EACH OCCURRENCE $1,000,000
X1 OCCUR D CLAIMS MADE AGGREGATE $1,000,000
$
DEDUCTIBLE $
RETENTION $ $
TH-
B won KERsrnMP13LSATION AND JOWC118140 04/01/10 04/01/11 X OR LIMIT FR
EMPLOYERS'LIABILITY EL EACH ACCIDENT $100,000
ANY PROPRIETORIPARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? Yes E.L DISEASE-FA EMPLOYEE $100,000
If yes,describe under
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $500,000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
Excluded officer: John Horan,NH S MA
"FOR INFORMATIONAL PURPOSES"
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
John Horan Construction LLC DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL In DAYS WRITTEN
21 Evergreen Drive NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
Hampstead,NH 03841 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
REPRESENTATIVES.
FOR INFORMATIONAL PURPOSES AUTHORIZED REPRESENTATIVE
ACORD 25(2001108)1 of 2 #S4416759/M3384195 LCACA v ACORD CORPORATION 1988