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HomeMy WebLinkAboutBuilding Permit #646 - 776 GREAT POND ROAD 3/8/2012TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO:('4(a_ Date Received Date Issued: 23=9- 11- -IMPORTANT: Applicant must complete all items on this page LOCATION # �%� C� �� �J6' Avsl .5'a s«, hla4ti -e- Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes o . Machine Shop Village y s no 100 year-old structure ye no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration N of units: ❑ Commercial I—KRepair, replacement WAssessory Bldg &&4 ❑ Others: ❑ Demolition ❑ Other S� 'fic ®We P t s®(oodplam 1DMY— lands ,.�� r® WN ershed i ici i'_ ..t-_a.<->..,+..cc�'r",�-�•.w�_k. f :I a~` a DESCRIPTION OF WORK TO BE PERFORMED: siJ �n� c1�ss ATT -4 Je-Prs•. 16,X68" r� row laic U. AM Y w ;1 -v -4P,,' 01 - 'S , w: ��. ri1AI (Identification OWNER: Name: Address. 7 7 bcfCi�v�vlSw�n�1 or Print Clearly) g,u; 6 a rA N1 SSG 7F,&sF•g2-.i,,i CONTRACTOR Name: �� �''�')7 1 L Phone: 7 �'/'�G`� Address: -ea r•d-A � Supervisor's Construction License: �L%S�� `T Exp. Date: Home Improvement License: Z)11 IQ Exp. Date. ARCHITECT/ENGINEER Phone: 8 6 LOIJ? Address: Reg. No. FEE SCHEDULE: BULDING PERMIT.• $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ /7f L- c o FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access io t4e guarq#OL6.6und Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑Swimming Tanning/MassageBody Art ❑ 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 DATEAPPROVED PLANNING & DEVELOPMENT ❑ COMMENTS ND W if /P CONSERVATION COMMENTS a it HEALTH COMMENTS Reviewed on Signature Reviewed on Signature I 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 DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS, 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— DAN 3ER es DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$10041000 fine Doc:.Building Permit Revised 2011 June/mi 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 ❑ 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) ❑ 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 o Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit o 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 khat 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 2008mi Location iqk,/ /Zot, No. Date Check# I qq� - 25081 TOWN OF NORTH ANDOVER Certificate of Occupancy 4 - -- Building/Frame Permit Fee $ Foundation Permit Fee Other Permit Fee TOTAL Building Inspector PROPOSAL Page # / of & pages 6 1,41 1111 d 9� ���i' 27-ly�v Proposal Submitted To: Job Name Job # r3� Al Zq/<s. cc Y-0 2242._/4 Address f % / Job Location P 776 /' 7 04r- yl Hoy&a tom" Date � Dat f Mans Phone # '�i Fax # Architect f P0-Zk8r-7.;L4 W�e,hereby � submit specifications and1-4estimates for: � L/r t%�` `� �/ 4C. �� 4(1 A A a.J a' Q �4/ % 4Ir WA s l�t�,r', ���; � � ,til ��: �r��� �ths� �� Ztisu �•c'f I�, ud1�S,4`�U Ge���rLs ( 4�2 c' g rim V 0 400 •t Of b e4r`- ,4 4-f, -C P T_ (:'I i r/,:, ? � cu; s{. CSe ��.� r.JEb�Q q'PInP ��F• 1' i /© �'f��C r�+1.CiVl, °L� 3 ��� j_._._���°, t� CR C�OC'.S`� . % 't X.�� �(_ a 6 �r �' (�.t.,,, r3 s� �e� eG i C. ��.v_ C , �. t �✓i �i C. �•�. ef,,, Q% � .n i We propose hereby to furnish material and labor—complete in accordance with the above specifications for the sum of: Dollars with payments to be made as follows: Any alteration or deviation from above specifications involving extra costs will Respectfully submitted: ' 6 /) be executed only upon written order, and will become an extra charge over and 1' i h PIAM above the estimate. All agreements contingent upon strikes, accidents, or delays beyond our control. Note—this proposal may be withdrawn by us if not accepted within ACCEPTANCE OF PROPOSAL The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payments Signature ��`�t�{4 � will be made as outlined above. ov l Date of Acceptance: �✓ t Signature A-NC3819 / T-3850 PROPOSAL Page # ;Z of 6� pages Proposal Submitted To: / Job Name Job # Address Lft$y ?vimrC Location � I'i4 "ordf/-� � � t D2 Date te$ans l'�6 4L Phone # Fax # Architect OU -1 'r-_ - , . A „ i — we nereby{� submit specifications and estimates for: l VL. S3 ,jf V� t 41 p� I 0 + 'Ne- A k e C'[• l i�O <i -77C� ��C� �ae5d` lo��t<a� t i�0 /li �'rf 7 �i ��"1�t tJ ee „�. ��� / r -c li�� 4.19 5:.U"( Jo;�J j %bora L,iT Ac r 4;•S%C-�f Mare- Sffd SX>ST•`4 C���4 cte Floe r S0 S t2!- 0% _J� C? 0 1� t ��i� Pr �CZ ��G//<ff J �t I s dI VGr,h•►. _ — i Gi'Is 1r,- i✓►dL_tUte' -.calk Qtkr tL010aj01 ;S 170W-I_cp j 67 �7I� _ ��/<•�J� B -S' ctft,5� Ci /�f^�r ds7S t��' 4S r+.t�f �{7 �!� Cid i ►�® 1'ZG4 741.7 W 1AGE�! -W�if.� %'� Gs� �i ll�y / ` �yJ aL � R f�✓_� 7C7 r�.��/ `�f � G� Gt >°061 be�p!',� �i�! �l..ed�. C.� �5��'� L-�:oz We propose hereby to furnish material and labor—complete in accordance with the above specifications for the sum of: /;7, S tt C s J `� c -�G 747o&t Sall !L 14 Py g r c - Q r0 Dollars with payments to be made as follows: , eS ��j py /� e t�iq 070WrP0�� I'M Any alteration or deviation from above specifications involving extra costs will Respectfully submitted be executed only upon written order, and will become an extra charge over and ` above the estimate. All agreements contingent upon strikes, accidents, or delays beyond our control. Note—this proposal may be withdrawn by us if not accepted within 30 days. ACCEPTANCE OF PROPOSAL The above prices, specifications and conditions are satisfactory and are / hereby accepted. You are authorized to do the work as specified. Payments Signature` will be made as outlined above. nn p� Date of Acceptance: l�c�C= q [a Signature A-NC3819 / T-3850 \2 �22 a & _ \ }\ zLo .. Lu $� 2 v . ,§ - : .ƒce o#® �g\EEj,.y� 3CLae_«mjz . t § Mm 7 0 D ° o »`* % CC J fav cƒz k 4f§ LU / ) Lu 2 ,\ �22 a }\ zLo .. Lu $� 2 v . ,§ § l .: �g\EEj,.y� 3CLae_«mjz t § Mm / a a = 2 D ° o »`* % J / \ ®,4 \ \ Zz k 4f§ & \ / CL ►bgi`..11 C� w O O O a w I . a wz o O w a v cn G, p O G p 0 G 0 coG H .�. co i O cn i c c m c c Q o 0 c y i OC C.2 C � O in V O. C d W I,. O O O H C Ea • L C. � is V yam+ 0. Eco of cc:" o s c �+ o c 4movaj ce m a O ,`• � H Z 4.3 N O :EE rn N1 O c O E o cm 4J� ' .445 = O r% "-' On V / . c oa -o O CS 2 Z . O cm oCs.o c 1- p mom~ o ti eHa � m W LL.O •ca dt c Z x E 5 o'y Q vm ooE c . VD ®' m O 'O x tyv CD CD Q H t ad* -m zip - U O i -j •'A ,am 2 O Q Q L Q v Z m CL Q y D � W tm I Q CD — CO) CD m m CL _ 3� CD Q � ; Q L m o a CL tmQ y C 4-0 C Q Q c Z s CL �..± coo Q C 'lift C _c Q. ulU) W W ce W N O ACORD CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 02/10/2012 PRODUCER 978.887. 4900 FAX 978.887. 2404 Edward F. Sennott Insurance Agency, Inc. 16 South Main Street P. 0. Box 457 Topsfield, MA 01983 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 Peter A Surette dba P & P Building & Remodeling 1 Lakeview Rd. Middleton, MA 02149 INSURER A: Acadia Insurance 31325 INSURERB: Continental Casualty Co. 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. INSRDD' LTR NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MM/DD/YYYY POLICY EXPIRATION DATE MM/DD/YYYY LIMITS GENERAL LIABILITY BOA 0076922-19 04/26/2011 04/26/2012 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $ 50,000 CLAIMS MADE [XI OCCUR MED EXP (Any one person) $ 5,000 A PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 POLICY PRO LOC �71 JECT AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT $ (Ea accident) ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY $ (Per person) HIRED AUTOS NON -OWNED AUTOS BODILY INJURY $ (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO AUTO ONLY: AGG $ EXCESS / UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION WC STATU- AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVEF—j OFFICER/MEMBER EXCLUDED? I JOTH- TORY LIMITS ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ (Mandatory in NH) If yes, describe under E.L. DISEASE - POLICY LIMIT $ SPECIAL PROVISIONS below OTHER 6S59UB-9824L74-7-12 01/01/2012 01/01/2013 B DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES/ EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS E: Work to be done at the home of Susan Worthen, 776 Great Pond Road, North Andover, MA 01845 CERTIFICATE HOLDER CANCELLATION Town of North Andover Town Hall 1600 Osgood Street 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 10 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 Robert Sennott/KATH ©1988-2009 The ACORD name and logo are registered marks of ACORD All rights reserved The Commonwealth o fHassachusetts Department oflndus&WAccidents Office o. flnvestigationg 600 Washington Street 5� Boston, MA 02111 wrvw,massgov/dia Workers' Compensation Insurance Affidavit: Builders/Coutractors/FIectrlicians[Plumbers V11cant fnfor.m afian Name (Business/OrganizationLCndividual): �q l Address: 1)1A Ctr/State/Zip:. Z -Z- Phone #: �9'7$� J%7 029 7p Are you an employer? Check the appropriate box: L ❑ I am a employer with 4. ❑ I am a general contractor and I �mployees (fuH and/orpa4-time).* 2• I am a sole proprietor or have hired the sub -contractors listed partner ship and have no employeeshese on the attached sheget. x sub -contractors have Working forme in ay capacity. workers' comp, insurance Workers' comp, insurance. 5. We are a corporation and its reeqq uired.] 3. I am a homeowner doing all work .officers have exercised their right of exemption p or MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] 7 employees. [No workers' comp, insurance re uir d Type of project (required): 6. ❑ New construction 7. [9�emodeling 8. [l Demblition 9. [] Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roofrepairs MEM Other =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 indigating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policyinformation. Iam an employer that isproviding rvofkers'com information. pensation insurance for my emflo employees.Below is e po1'icy and job site Insurance company Name: Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: _% 79 C r _, J �a P Q V eJ � Attach a copy of the workers' compensation policy declaration page (showing the city/state/zip number� ?allure to secure coverage as required under Seotiou 25A of.MGL c.152 can lead to the imposition of criminal pe aloexpirationes of a ne 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 efup to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of'the. D9 for insurance coverage verification. do Hereby ceqly y un der tliepainsf ndpenalties ofperjuYy fltatilie infora7zationptovidedaboveis true ande rrect. Wfrcial use only. DO not Write in this area, to be cornpletedby city or town ofpciat. City or Town; Permit/I,icense # [ssuing Authority (circle one): [-:Board of Health 2. Building.Department 3. City/Town Clerk i Other 4. EIectxicaI inspector 5. Plumbing Inspector �nformation and histructi®ns 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, orA 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 "everystate 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 ofpublic 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) andphone number(s) along with their certificates) of insurance. Limited Liability C.ompauies (LLC) or Limited Liability Partnerships members or partners, are not required to carry workers' compe(LLP) with no employees other than the nsation 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 coaafirmatiou.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 Iicense 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. PIease 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 array beprovided -o 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 notrelated to any business or commercial on e (i.e. a dog license or permit to burn leaves etc.) said person is NOT`required to complete this affidavit. vtur The Office of Investigations would no to thank yo -din. 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 Cone uoAwalth of tvil sac" use s Do pafteiat of Tudustriad .A.ccidcgts Office of InVeSVg_ of 0).Rs 600 Washington Street Boston; M:A. 02111 Ted. # 61.7-727�4.9QQ ext 406 or 1-8.77-Mt4��A�� iil-F T 7-1 o \--6li . ... ... . .. . 0 6 all 114