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HomeMy WebLinkAboutBuilding Permit #656-16 - 75 SHERWOOD DRIVE 11/25/2015SCW,*vsy,,!; FD f .; � - 3 --,/ S - BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: —L(,,o Date Received Date Issued: . I IMPORTANT: Applicant must complete all items on this page LOCATION by Print PROPERTY OWNERWF-11,(s�L3P %os=e I Print 100 Year Structure yes MAP '2tV, PARCEL: b -o-7 2 ZONING DISTRICT: Historic District yes Machine Shop Village yes /NORTpl� /tt`Eo X69 tiC no no no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building PQne family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial 4Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other mSep�W Ntands Iel ;4, IWa#ershed Dtsri£:$ €s = DESCRIPTION OF WORK TO BE PERFORMED: Identification - Please Type or Print Clearly OWNER: Name: VE11w&,(=f&iekz-f-- Phone:27f•b•St7-973 Address: '7S' Contractor Name: 1 hone: &Z4Si Email Address:LIS �/�� Supervisor's Construction License: �I �S^a Exp. Date: Home Improvement License: f 83 )--7 Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING'tPERMIT.• $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ S -6F04 -' FEE: $ 0, Check No.:6 (P Receipt No.: NOTE: Per ons contracting with unregistered contractors do not have access to the guaranty fund Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Taming/Massage/Body Art ❑ Swimming Pools ❑ well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF m U FORM PLANNING & DEVELOPMENT Reviewed On Signature. COMMENTS CONSERVATION Reviewed on Sianature COMMENTS HEALTH Reviewed on Signature A COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decisionfreceipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Fater & Sewer Connection/Signature & Date Driveway Permit ]®PW Town Engineer: Signature: Located 384 Osgood Street .,..�-.sr+-�P+.r.«.=�..,.,..:. - fiKvlx.& "'�y,4 G:!i2 v X17 "r ,.+i ♦ -�' {:"��`�+ �•`��: E DEPAII ENI" TemptDumpster.on site, y�esE�Ash& ' * _ tt4�Located at 124 Main Streetb ����', Y. t >'if'�"•'+ 4 h �t'f :,44�'{'-;-e"iij1..,Y�e�+.i �t i fir`' °- i e*'+•- t Fire Departmentsignatu a/"`date ,�Ii:A tJj, +,j. cls .{�a°,,...4k y+s } ,, i,; 4a �r h�` 1� >•:'- P a `,+, tp F • $ tiCt4` �T * r r.. r Ni .. �`° f` � 'a =�,-r 1,r.-:+4.ay4;�c "�{-i�,r'�Z*3iK�' *• } {, y�, s �^< _ � �.s� h� �i7d � �.T s �a'7"4 'COMMENTS#::� _ �y,f �,., ,�, # ,,; :' •, y,- �, -���_. tda``� ��� �-�. �; r. �; �.��<, �,3:� .�► e,a•_-ei..�.+-.��dt.:::.i,t..:.e+.:."h`a...,........�...m,w:a:,aS'.+,:.,%�.r7:uj-d x 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.$1oo-$1000 fine NOTES and DATA — (For department use) ® Notified for pickup Call Email Date Time Contact Name Doc.Buildinb Permit Revised 2014 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 4. Building Permit Application 4. Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract Floor Plan Or Proposed Interior Work 4. Engineering Affidavits for Engineered products IOTE: 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 TOTE: 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 4, 2012 IECC Energy code Engineering Affidavits for Engineered products TOTE: 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 Doe: Building Permit Revised 2014 Locatio. 0 at . . I /,:;� No. D e _v y, C � t/1 0 O CD n Z N CD CL rm CL �• N O vCD oQ cr � S CD CDD Oca � CD CD N. occ„ O O o � z CD O CD 0 " — __MU y :5. CD N _ CD �,CL 0CD 0 rt Q' C., m �•��-0 vi O O CL 0 m W C N p CD <D 2 Q. O 4 —N D O' O O rt CD (O Q• O U) O O ,+ S C O D Rob 0 to � O O cn :i 0,H 1 y CD OCD 0. 3 Smom, c CL D v' �0Q U2 CD 0 O — CD H �' O O ID O CD CL CDW U) � ?o► CD 0 y O � O CTD 0 NCDCD � CD • 3 Cf y vCD _ :• cD •a n A) o CL In (n W OO C T a7 _ (n A a' -) T A T n 70 T O (n T X- O C UO C C C _S C OCO 'a - O Q .�-t m � z 0 �' � '. = S 3 C 3' o_ n N -- 7C rD O _ O S �o G1 m C y C3 :30 m N W > Z A D Z Z G1 G y v+ r 1 1 O T n(AN M vvii = m m O t? _ m m m A 0 O s 1. 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C CD : a a C CD ::Pl cn \. � @ O =3 f m o 0 c'/ ƒp 0 0 � ƒ ? . k / / / ® ( © 0 7 7 / /o �C) CD z ;s� n A. k ( ƒ 2 2 \ _0 k : C) E « 3 ('0 / > G K 7 / (D/ f1l) ; E # k � � w •! \ _ m / 2 / $ § k $ d E / $ ¢ CL C CD ::Pl cn \. � @ O =3 f m o 0 c'/ ƒp 0 0 E ƒ ? . k ® ( © 7 7 7 / /o CD (PD A. ( ƒ 2 2 � _0 k : CL E « > 7 7 / f1l) # k � � w •! \ ? / 2 / $ ® k $ d E / $ 2 k § M _ m _� NOTICE OF CANCELLATION Date of transaction: 10/19/15 You may cancel this transaction, without any penalty or obligation, within three business days from the above date. If you cancel, any property traded in, any payments made by you under the agreement, and any negotiable instrument executed by you will be returned within ten business days following receipt by the seller of your cancellation notice, and any security interest arising out of the transaction will be cancelled. If you cancel, you must make available to the seller at your residence, in substantially as good condition as when received, any goods delivered to you under this agreement; or you may if you wish, comply with the instructions of the seller regarding the return shipment of the goods at the seller's expense and risk. If you do make the goods available to the seller and the seller does not pick them up within twenty days of the date of your notice of cancellation, you may retain or dispose of the goods without any further obligation. If you fail to make the goods available to the seller, or if you agree to return the goods to the seller and fail to do so, then you remain liable for performance of all obligations under the contract. To cancel this transaction, mail or deliver a signed and dated copy of this cancellation notice or any other written notice, or send a telegram to Pella Windows and Doors, at 45 Fondi Rd., Haverhill, MA 01832 not later than midnight of transaction above). 10/22/15 I hereby cancel this transaction. (Date) (Buyer's signature) (three business days from the date of The Commonwealth of Massachusetts _ _-- Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston, MA 021.142017 144M. trtass.gov/dia Workers' (Compensation Insurance Affidavit: builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): PE11A 44 ) S 4 otic;Kf LL(! Address: 45 gn /State/Zip: 14&vr tz4. L I m*A- j * Phone #: 9 7?= Z63 Are you an employer? Check the appropriate box: 1. U&I am a employer with --,7S 4. ❑ I 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, ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself [No workers' comp. insurance required.] These sub -contractors have employees and have workers' comp. insurance.+ 5. ❑ 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.] Type of project (required): 6. ❑ New construction 7. PRemodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below slowing their workers' compensation policy information. 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 state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: N4 _" D LcQ-,e ez_s :TN Policy # or Self-ins..Lic. #: 4000 L4 0 10 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 certify under the pains andpenalties of perjury that the information provided above is true and correct. Phone #: 926-- ZJ,,—�7a5_S' Official use only. Do not write in this area, to be completed b_y city or town official. City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Cii A ® CERTIFICATE OF LIABIN U ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT NCS F0612ILITYOE5MNUDDIYYYY) 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 AMEND, 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 holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. 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). PRODUCER Fred C. Church, Inc. N A Dorothy A Cadet, CIC, RPLU NAME: 41 Wellman Street Lowell, MA 01851 (800) 225-1865 PHONE 978 3227231 FAX (978) 454-1865 °AIC No E-MAIt ADDRESS: dcadett@fredcchurch.com INSURERS) AFFORDING COVERAGE NAIC # INSURERA: Citizens Insurance company of America 31534 INSURED New England Window 8 Door LLC INSURER B : New Hampshire Employers Insurance Company 13083 INSURERC, 45 Fondl Road INSURER 0 : Haverhill, MA 01832-1302 INSURER E: INSURER F: - -- -"— "---"" RGYIJIVry rvUMOrm; 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 PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL SUBR VJvn POLICY NUMBER POLICY EFF MMIDD POLICY EXP MWDD LIMITS GENERAL LIABILITY X EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 100,000 COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ MED EXP (Any one person) $ 10,000 CLAIMS -MADE OCCUR X CG0001 A ZBN8161407 7/1/2015 7/1/2016 PERSONAL &ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 X POLICY PRO- X LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS HIREDAUTOS NON -OWNED AUTOS PROPERTY DAMAGE $ Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED I I RETENTION $ WORKERS COMPENSATION $ AND EMPLOYERS' LIABILITY X WC STATU- OTH- T E B YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? N / A 400040101 7/1/2015 7/1/2016 E.L. EACH ACCIDENT $ 500,000 (Mandatory in NH) If yes, describe under E.L. DISEASE - EA EMPLOYE $ 500,000 E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) r+corrrrr+AT0 unr - ---- ------------•- �.ArvlrC6LA l 1U14 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ant # Zt1ouMet # r,..r u,.r,a.._ u --•- 1. -w I M%'Urcu 11unrumA I IUrv. All rignTs reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD 41 _ � m m r m 0 3 1. rn i v z � z (] F r 0 o N Z @ n m o oO z In U3 9 N o d o N g o O' m z O .*':..N' m . m � N-- Z - C) y 0 -4 O r m 0 ro `4 ro i; O A ro I y aroq �. a a 13 0 N y4 'o. e1 y ® �' 1 rn cq V1 0 tv L a O e �� m g cm o C o m 93 o'