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HomeMy WebLinkAboutBuilding Permit #229-11 - 76 BOXFORD STREET 9/16/2010 BUILDING-PERMIT o�soO DT" TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: aw IDate Received Date Issued: . d ��SSACHUS��y IMPORTANT:Applicant must complete all items this page ,y, . on P g _tom +s': -xMez =-1 _ -„-�.• -' �-=r•-. - .:rat,. :.wrc - - v€ �-':�.:,a:..,._._ loom - - � - - :�.,_ Fe �•-,. _a by .+r X41., .,e%sti -.++.c. - - - =fi`=%-;� - .y..., :i:^ :.:u - = '>•r_.r,N- .cT ' '..�•`'� -�'- eiT: .y�C.. :1�;! ` ,}. •,cr�M1.,T:.. �f%'b'•rr__�'u4;��`..�'^L'. -.l'='� . -- -�s. &A•i! r'E�^''T � K �`” = "YS: - - .�.o-.��.���.c. _'.'�:Lr�i�•.1, L �u•4^r c*.s'S',;-,.� �+• JE't.- � MAY 10,E v j ,�... moi:•.-.- �.n-e-�a.esu �y ,�_ - :..M-• .,maw• S :PTJ - T? T.r. _ -' -- 'r'r'v-.. r� - - ,..�..a E" ' ,`r'"7^e:=T`' -+''.r-z-'r_.,;,'•� = _ r.�;tgi>-wr�,?n�• 7:ei::=ue„ - - -,�'w{u:C.' v .x ,.` +t '? 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G-r`Jv�_.-2 acedy i �Yle _ee � X2.4 r #.�, if1 'ceM� _ _ _`:T:m ..��1-',_•L,f�MY,'?�'.L :•=itis - - r� `�•'.: Wit:: ". . a_ ..cs• NT - _ I Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land areasq. 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 I NOTES and DATA— (For department use) k ❑ Notified for pickup - Date Doe.Building Pemn t Revised 2010 i I i Building Department The following is•a list of the required forms to be filled out for the appropriate permit to be obtained. j 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 ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ ivi NORTH 0 0 . TAndover . 0 No. o -o dover, Mass., ' (to • (C) COCHICHEWICK 7�S RATED p' �� BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR I THIS CERTIFIES THAT ............ladr.11 ..... .................................................. Foundation has permission to erect........................................ buildings on ..416.......so.w.. ......I Rough to be occupied as..................... .. . . . .�0.. Chimney . . . .. . . .. ... ................................................................... provided that the person accepting t permit shall in every respect co m 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 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCT TS Rough ........... ......... ....................................................:.......................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on thet 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. 8/25/2010 7:49:12 AM PST (GMT-8) FROM: insurancevisions.com-TO: 19786889542 Page: 2 of 2 AC a® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 8i25i2010 PRODUCER PLANRIGHT INSURANCE &FINANCIAL LLC THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 224 MAIN STREET STE 3C ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE SALEM, NH 03079 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 603 912-5646 603 912-5647 INSURERS AFFORDING COVERAGE NAIC# INSURED EDMUNDS GENERAL CONTRACTING LLC INSURERA: Liberty Mutual Grou PO BOX 2214 INSURER B: SALEM NH 03079 INSURER C: 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 DD'L POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATIONLTIR 'NSRDI TYPE OF INSURANCE DATE(MMIDDIYYYYI LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $ CLAIMS MADE 0 OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO-JE 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 (Peraccident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ 1 EANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ A WORKERS COMPENSATION WC2-31 S-369752-020 1/26/2010 1/26/2011WC STATIU OTH- AND EMPLOYERS'LIABILITY Y/N I ER TO ITS ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT 1$ 100000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 100000 It yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Workers Compensation Insurance:Part One of the policy applies only to the Workers Compensation Law of the State of MA. PHYSICAL ADDRESS: 114 OLD VILLAGE ROAD, NORTH ANDOVER,MA 01845 CERTIFICATE HOLDER CANCELLATION SHOULD ANYOFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE EXPIRATION TOWN OF NORTH ANDOVER DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRrrTEN BUILDING INSPECTOR NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL 1600 OSGOOD STREET1 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR BUILDING#20, SUITE 2-36 REPRESENTATIVES. NORTH ANDOVER MA 01845 AUTHORIZED REPRESENTATIVE Jeff Eldridge ACORD 25(2009/01) ©1988-2009 ACORD CORPORATION. All rights reserved. CERT NO.: 6109390 CLIENT CODE: 1338660 Anne Chandler 6/25/2010 7:47:13 AM page 1 of 1 4 tili"EvELt .iciautiC;tts= De.pai-tmeni.�i1'1?iablic,:.Sitt'tt%.. 9 .'gtiartl'cit:'Buitcliai�� Re�kal.ttion itntt'$tanclua'tI�',. Construction Supervisor License License: CS'..104290 GREGORY BUCHANAN 23 EAST NASHUA RD WINDHAM, NH 03087 Expiration: 11/29/2013 t'uuniis i un i Tr#:'104290 Office of Cons m Affair &`B ness Regulation _ HOME_IMPROVEMENT CONTRACTOR Registration:,,166661 Type: Expiration: ::'6/2:1:/2012 Corporation ENDS GENE5RAL CONTRACTfNG,LLC. s . n•r,._ t_ sem:_:= '`�\ �� DAVID EDMUNDS; 1 SHAKER LN HAMPSTEAD,NH 03841 = Undersecretary Fully Licensed and Insured Member of MA Better Business BureauO w��T Member of NH Better Business Bureau GAF-ELK Cert.ME16226 IV, 1 HIC Reg#159028 ...............wwkyjGeneral Contracting 51 S. Broadway#2214•Salem, NH 03079•(603)890-0084 PROPOSAL SUBMITTED TO PHONE - DATE STREET _ E-MAIL CITY,STATE,AND ZIP CODE . JOB LOCATION L Y- t � � kk- y 1 , r r I e- 1. I r. �i I� �h.;� t � � •��� - 1 z li � � � "1 1 � Edmunds General Contracting will: •Obtain all necessary permits to complete work. " — ' ( , Furnish and install all necessary materials to complete work. �� r, • Perform work as efficiently as possible without sacrificing quality. • Provide a daily clean up and disposal of all debris generated with our own dump trucks. NO LARGE ROLL OFF CONTAINERS will be used. •Guarantees all workmanship performed. ADDITIONAL NOTES: Edmunds General Contracting prohibits smoking on custom eF's property. Ask me about Smart Money financing. "Root IJow..Pay Later." Thank you for the opportunity to bid on your roof replacement work. Ve Vropoge hereby to furnish material and labor- complete in accordance with above specifications, for the sum of: • ,� r` F t�:� r/ '�/%� / �/c !� �t t/ 11 t -dols Payment to be made as follows: All material is guaranteed to be as specified.All work to be completed in a workmanlike manner Authorized Signature: / according to standard practices.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 Note:This proposal may be withdrawn/ control.Owner to carry fire,tornado and other necessary insurance.Our workers are fully covered by us if not accepted within �' - days. by Workmen's Compensation Insurance. Rtreptante of Vropo5al -The above prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized to Authorized Signature: .I s�✓O!1 / card �� do the work as specified.Payment will be made as outlined above. Date of acceptance: Authorized Signature: The Commonwealth of Massachusetts ' I Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Uw a �• 3=� www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legji h Name(Business/Organization/Individual): '� 'u' A0 LM V 6 "C VV Address: ) SLi w1C edZ JA City/State/Zip: Hc.TS ' A) V 031/ Phone#: 663 30- Armee youanemployer?Check the appropriate box: Type of project(required): 1.�1 am a employer with `:7 4. ❑ I atn a general contractor and I 6. ❑Newconstruction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. ❑ 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.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.E] Roof repairs insurance required.]t employees. [No workers' 13.F-1 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 the policy and job site information. j --�� Insurance Company Name: [1'F� A4tJ'tJ�l .1..�Sv Mn4(eoA A A�.jO�l V Policy#or Self-ins. Lic. )-319 3 6 7 7 5-,20 c_�<n Expiration Date: Q Job Site Address: 76 g,X� fb b City/State/Zip:/) u'2 , d�I 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. Ido hereby cert'y u derl. pains antipenalties ofpeijury that the information providelab Zo ' true and correct.' Si nature: Date: Phone#: 03 CJS 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-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 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 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 Deparhnent 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 pen-nit/license applications in any given year,need only submit one affidavit indicating current policy infonnation(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 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. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia