Loading...
HomeMy WebLinkAboutBuilding Permit #125-13 - 77 PLEASANT STREET 8/14/2012 _ I BUILDING PERMIT ,kORTFpORTFi i TOWN OF NORTH ANDOVER O A APPLICATION FOR PLAN EXAMINATION � 1 Permit NO: Date Received �q Qj ogw7e° �SSAGHUS�� Date Issued: IC �y IMPORTANT:AAVlicant must completqq items on this page l LO.CATIQN' AAx : XA PROPERTY.OWNER Pant 'MAP.,140:0 ;P ZQ ONG QISTRICT Historic District yes: no Machine Shop Village; ye j no,., , . ;. TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building O Addition <17wo or more famil Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic Vllell Floodplain: Wetlands Watershed District" Water/Sewer q DESCRIPTION OF WORK TO BE PREFORMED: 3 Identification Please Type or Print Clearly) f OWNER: Name: Phone: Address: - CQNTRACTQR Name: - _ new. 7� Add ress: lv"zr� Supervisors,Coristructlon License / �-�J _ -Exp. Date:_ - Lrw ., _ ,,Date: Home Im rovement License 1=xp ARCHITECT/ENGINEER Phone: Address: Reg. No. a FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF,THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ d�-(0, FEE: $ Receipt No.: � Check No.: � 3 P NOTE: Persons contracting with unregistered contractors do not have access to uaranty fund Signature of Agent/Owner Signature sof contractor Building Department artment � 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 Eduilding Permit Application Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses ZCopy 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 ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Ma�s 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 Affidavit's for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit I 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:INSPECTIONAL SERVICES DEPARTMENTMFORM07 Revised 2.2008 1 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 COMMENTS 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 DPW Town Engineer: Signature: Located 384 Osgood Street FIREaDEPA T RTMENT Temp Dumpster on saey yes.: no ' Locatedtat 124�Main Street' Fire"Departinent`signature/dateR 3 COMMENTS rr 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 I I Doc.Building Permit Revised 2008 Location17 - No. J Date ��""•'_ • • TOWN OF NORTH ANDOVER Certificate of Occupancy $� . Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ ',,ATM. TOTAL $ Check# 25611 Building Inspector Jastings Holdings/Shawne Robinson ("01"7451111114001 O! " 77 Pleasant St North Andover, Ma lu y . All labor, material and travel costs to replace approximately 207 sq. ft. roof-estimated one day job a. Pull a roof permit b. Strip back shingle edition down to the sheathing wood (excluding flat roof) c. Replace any rotted boards if needed at an additional cost of $6.00 per linear ft. for 1"x 8" boarding f d. Install 8" white drip edge along all leading edges and up all rake edges-use roofing nails to attach all materials to roof t e e. Install 3' of Ice and Water Shield along all leading edges and 18" up side walls against main house f. Install 15lbs.felt paper on remainder of roof deck g. Install GAF ELK (Timberline Limited Life Time Warranty Shingles) over prepared roof deck Color: Fox Hollow Grey) h. Install Cobra Venting System at peak of main roof so heat escapes properly L Take away all debris from Job Site Q2 -7t 3 -73 C Jastings Holdings/Shawne Robinson 77 Pleasant St North Andover, Ma Total Cost of Job: $2,000.00 Signatures: owner: os hG Sign: ' Date: i Customer�p'rint : Date: Jp Sign: Mill A,° 41, w , N. i9ll01 ii1si�.M, lid a I t '° �- F. NpRTN F own of - ndover 0% O 1 ~ ~ No. h ver, Mass, c OCNICH&WC. y1' S U BOARD OF HEALTH PER Food/Kitchen T D Septic System THIS CERTIFIES THAT ,,,_, . (( `, ,,,,,,,, ,,, ,,,,,,,,, BUILDING INSPECTOR has permission to erect ................. ....... buildings on ..... ..... ..... .......4� Foundation Rough to be occupied as .......... ......... .... ...... .... � .. ...................�................ Chimney provided that the person accept g this permit sha in every respect conform the terms of the application Final on file in 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 MOP UNLESS CONSTRU RTS Rough Service .......... .. ... ............ ................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final fat : ng or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building,Inspector. Burner Street No. Smoke Det. } SEE REVERSE SIDE I M A`' „' CERTIFICATE OF LIABILITY INSURANCE j DATE(PAPAfDDYYYY) 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 CONTACT NAME: PHONE _-__ FAX A1C No Ext): - AtC.No): - - -' E-MAIL :.... _ ADDRESS: i INSURERS)AFFORDING COVERAGE NAIC# INSURER A: INSURED INSURER B: INSURER C: _.... _ INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: ` REVISION NUMBER: 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 TYPE OF INSURANCE ADI UBR POLICY EFF POLICY EXP LTR! INSR WVD POLICY NUMBER MMIDOfYYYY MMIDDIYYYY LIMITS GENERAL LIABILITY _ - _A. AUTOMOBILE LIABILITY _ - •--=- UMBRELLA-LIAB v . EXCESS LIAB DED WORKERS COMPENSATION .y:, -„'_- -_--_ AND EMPLOYERS'LIABILITY _ YIN - (NlandatoryinNH) - - -- - - - -- DESCRIPTION OF OPERATIONS/LOCATIONS 1 VEHICLES (Attach ACORD 101.Additional Remarks Schedule.it more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. i AUTHORIZED REPRESENTATIVE 21631 Cert Holder# Oc 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD 05/03/2012 9 : 49 : 25 AM FRED C CHURCH INC - 978-454-1865 PAGE 5 OF 5 RightFax N3-1 5/3/2012 8 :20 : 26 AM PAGE 3/003 Fax Server CRTIFIC�' E OF �iZ .V1\l�E ISSUE DATE 5/3/2012 THIS CERTIFICATE IS ISSUED AS A MATTER OF L\'FORMATION OhZY 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 CONTACT FRED C CHURCH INC NAME: PO BOX 1865 PHONE FAK (AIC,No,Ext): (AJC,No): LOWELL,MA 01853 E-MAIL ADDRESS: PRODUCER CUSTOMER ID#: INSURED INSURER(S)AFFORDING COVERAGE NAIC# GYS,JOSEPH DBA INSURER A HARTFORD UNDERWRITERS INSURANCE ABCO CONSTRUCTION COMPANY COMPANY 10 MEGHANN LANE INSURER B LOWELL,MA 01852 INSURER C INSURER D INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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 INSLMANCE 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 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD f?M DfYYYY) D GENERAL LIABILITY EACH OCCURRENCE $ .DAMAGETO RENTED $ 11 COMMERCIAL GENERAL LIASILITY PREMISES(Each occurrence) MED-EXPENSE(Any one $ CLAII,/IS MADE [IOCCLR. En S'NAL&ADV. $ INJURY GENERAL AG GRE GATE $ GEN'L AGGREGATE LIlV_T APPLIES PER: PRODUCTS-COMP/OP $ O POLICY (]PROJECT LOC AGO AUTOMOBILE LIABILITY COMBINED SINGLE S LEv07 (Each accident) 0 ANY AUTO BODILY INJURY S (Per Person) 0 ALL OWNED AUTOS BODILY IRJURY S (Per Accident) 0 SCHEDULED AUTOS PROPERTYDAMAGE S (Per accident) 0 HIRED AUTOS $ 0 PION-OWNEDAUTOS $ 0 0 UMBRELLALIAB 0 OCCUR EACH OCCURRENCE $ 0 EXCESS LIA.B 0 CLAWS-MADE AGGREGATE S 0 DEDUCTIBLE S 0 RETENTION$ S WORKERS'COMPENSATION WC A AND EMPLOYERS LIABILITY N/A I STATUTORY Y/N L=S ANY PROPRIETOR/PARTNER/ EXECUTIVE OFFICER/MEMBER Y N/A 6S60UB-0448X539 05/01/12 05/01/13 E.L.EACH ACCIDENT S100,000 EXCLUDED? MANDATORY INT NH) E,L.DISEASE—EACH $ EMPLOYEE 100,000 II yes,describe under DESCRIPTION OF E L.DISEASE-POLICY OPERATIONS below I= $50(],00() DESCRIPTION OF OPERATIONMOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,iPrnere space is.ecuired) THE WORKERS'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR JOSEPH GYS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE CE12T'1>W TF1ETM i) R CM4 SLI ATI03Y CITY O L OF WELL 375 OF LOWELL ST,RM 55 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN LOWELL,MA 01852 ACCORDANCE WITH THE POLICY PROVISIONS. At,MORIZED REPRESENTATIVE brignL Maclean ACCORD 25(2009(09 1939-2009 ACORD CORPORA110IN All r Q i1sYe;erred. :05/03/2012 8 : 21AM (GMT-04: 00) i I r s Massachusetts- Department of Public 'Safetc Board of Building) Re Mations and Standards Construction Supervisor License License.: CS 92469 ..-JOSEPH.. .10 MEGHANN LANE LOWELL,NIA 01852 109. Expiration: 9/27/2013 Comniissiuncr Tr#: 1339 I JL, L-�J/ua onmao�tcuea t o/� a rccaeCCd --Office.of Consamer.Affairs&Bnsitjcss'Regnlatioo DME.IMPROVEMENT CONTRACTOR e istrat' g ion: ,1`OB424 Type: "�) -8/9 x iration: p _. .8120.3. 'DBA ABCO'ROOF.ING.8 C0135T# 17C3;JON . = Joseph Gys 10 MEGHANN LANE =- LOWELL,MA 01852 '`"' Liodersecretary The Commonwealth of Massachusetts Ln Department of Industrial Accidents 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 Le ibl Name (Business/Organization/Individual)' Address: Z City/State/Zip: Phone#: 9 7 �� /7,707 7 Are you an employer?Check the appropriate box: Type of project(required): 1. am a employer with �5 _ 4• ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet. # �• E]Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9• [J Building addition No workers' comp. 5. El are a corporation and its � insurance officers have exercised their I0.❑Electrical repairs or additions required.] right of exemption per MGL 11.❑Plumbing repairs or additions 3.El I am a homeowner doing all work g p myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑woof repairs employees. workers' comp.insurance insurance required.]t nce required.] 1311Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i 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'compe ation i urance for y employees. Be w is the pol'y and job site information. Insurance Company Name: ` Policy#or Self-ins.Lic.M 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 insurance coverage verification. I do hereby certi under th pains d p al s of perjury that the information provided a"boove is t rend correct. 5i nature: Date: Phone#: 33 � 3 7 Official use on . 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 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.#617-727-4900 ext 406 or 1-877-MASSAFE - Fax# 617-727-7749 e vrsed 5-26-05 �xrtzni>mnnn n..