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HomeMy WebLinkAboutBuilding Permit #693 - 78 PHILLIPS COMMON 6/15/2009TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteratio No. of units: Commercial epair, replacement Assessory Bldg Others: Demo ition " Other Septic Well Floodplain Wetlands Watershed District, . . Water/Sewed e a s ULbUKIF1 IUN OF WORK TO BE PREFORMED: TnSrd( c560 0AJ - b(tr rnOM plot" ' Identific tion Please Type pr Print Clearly) OWNER: Name:, 1, M ares IV c,\Y\tu ZIP PhnnP•41-9 o,1 _ 0 zxcA/ Address: nb 1 \k I\%g CovtAotko CONTRACT IJI 'Name Address.. Supervisor's Construction License.` .i Hornelmnrovement°License. *-11-,O,�. ARCHITECT/ENGINEER >� Exp. Date..(`r;�... S Exp-- Date:70 Phone: Address: Reg. No. FEE SCHEDULE: BULDING P71,6000 T: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. 1 Total Project Cost: $ FEE: Z.._ — � $ ��� ��% C l` Check No.: Receipt No.: NOTE: Persons contracting,with unregistered contractors do not have accesp to the zuaranty fug 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. 1 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 'E COMMENTS HEALTH , COMlkNTS Reviewed on Signature i Reviewed on Signature Zoning Board of Appeals'Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments. Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signaturev r . 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 iof -;r Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes MGL Chapter 166 Section 21A —F and G min.s100-s1000 fine NOTES and DATA — For department use ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 M 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 El:' Photo Copy Of H.I.C. And/Or C.S.L. Licenses Q 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) ❑ 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 ❑ 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 Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 Location No. Date Of 40RT1y TOWN OF NORTH ANDOVER •"6O ,a,1•C 9 Certificate of Occupancy $ ��s'•^° • E<�' Building/Frame Permit Fee $ YZ s�cMus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ y Check # Ido 22113 Building Inspector Location��,//��� ?�- No. Date NORTh . TOWN OF NORTH ANDOVER 3? OL Certificate of Occupancy $ J'MUS <� BuildinglFrame Permit Fee $ `. Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # _ '__�OBuilding Inspector 6, b en x p �� O w Cf) aAi cn ° U �w z ►� a co w w ', a U m C x U c� O w G x a w � U w O a: v cn C w p U w O w G x w w x I cQ o cn v O o E cn co O m c o i U o � C y O C C [ i-+ O QCJ CJ ; p CL C O O !t Ccc A O m m Cf) 0 a EE m O z ets O O Qo� m c E H m 3 w c c acn z 'Em � ('� m c Qr V: y m D V J O cm ts O m CJ N Z.O O V c O a Q imc .o = m O 3 N ;a o W_ CCc O N dL Z Lu E c go) y o m !E cm y O. m O fl Z ce ` w � d..- CA :w CO CM o_ CO2 •� ECD mm CLCD 3.0 CD O L cc 0 CL EL— cna c CO) Cts CO2 Z c C CD CL CD NA !c C C •= •� C _c �. CO2 uj W 0 /WLI U/ W • m O G G z • m V G G °� z o � W U W.' � W x W x � O vV Z W x NiQ C e0 A m G i ;Z O V W • Q o cn a mto C c° a Z coco W °°° 5 °�° W z o o n C x C ° w 4 C w°' cn u. a°' w V \0 �z w0 U U) CD O 0 ■ L .� Z y O CD cm ca p 'O C MO E mm O CD 0 CD O D C g 0 L CD Cc C CL �a Ce Cc Q wCD CL V CO) Oc c ■ c cc Q. COD is G G : � C ;;G O o � C y O G 'r O vV NiQ C e0 A m G i ;Z O O ` • 90= E a o n E G :oma .00 o E E om a O � NJ y cm m N G G U) O O �E m co CD :rr o � c C'SC �o y m O 'J m C-3:0 O C3 Z O O O ' ••■� •r G a O Qf G •p Q y m G = m 3 C3::, N ~ v0+ N m m CO2 r0+ CD LLWw. •y G w f. W �E a caCD �� c CD C.2 CD 10 h Z d O� O� .0C2 y C F- .I-. a.=.. m � \0 �z w0 U U) CD O 0 ■ L .� Z y O CD cm ca p 'O C MO E mm O CD 0 CD O D C g 0 L CD Cc C CL �a Ce Cc Q wCD CL V CO) Oc c ■ c cc Q. COD is Scott Robichaud 17Draper Drive Wilmington, MA 01887 978-658-6509 978-857-0646 (Cell) scottjrobichaud@verizon.net TO Nancy Zeil 78 Phillips common N. Andover FOR Shower renovation PROPOSAL DATE: MAY 7, 2008 DESCRIPTION PRICE TOTAL Demo old shower and install new.Re-tile bathroom floor. 6000 6000 Price does not include any fixtures tile or cabinetry TOTAL This Proposal is valid only at time of issue and is subject to cost increases (within 30 [thirty] days). THANK YOUI $ 6000.00 The Commonwealth of Massachusetts Department of Industrial Accidents Offcce of Investigations 600 W-ashington Street Boston, MA 02111 c j www mass gov/dia . Workers' Compensation InsW ance Affidavit: Builders/Contractors/Electricianstpfumbet-s pplicant Wnrmotinn Name (Business/Organization/Individual}; Address: Diu aer City/State/Zig: 60t'lH4,�dr(, M4, 0/9Y7 Phone #:. Are vou an employer? Check the appropriate box: 1. 211 am a employer with - - j 4, ❑ I am a general contractor and I employees (full and/or part-time).* 2. M I am .a.sole proprietor or have Dred the sub -contractors listed partner. on the attached sheet. _ ship and have no employees These sub -contractors have working for me .in any capacity, [No workers' comp, insurance workers' comp. insurance. 5. ❑ We are a corpomfion and its required.] K ❑ I ant a homeowner doing officers have exercised their all work right of exemption per MGL myself. [No•workers' comp, c. 152, § 1(4), and we have no insurance required.] t .employees. [No workers' comp. insurance required_] Type of Preled (requimd): 6. ❑ New construction 7. [ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions I l .❑ Plumbing repairs or additions 12.❑ Roof repairs 13.7 Other ;Any applicant that checks bozo i� I must also fail out the section below showingtheir workers' compensation� I Homeowners who submit this affidavit indicating they are doing all work and than hire outside contractors must submit a new affidavit indicating such. - tContractors that check this box must attached an afttional sheet Show tag tete name of the sub -contractors ana their workers' c-•r.;p. ps?ice ir,{om�tion. 1 ant an employer that is provlding:workera' compensation tt7surance or a la ees: B"clow is the alt mrd 'ob site information. ,,p �� f �' mP Y P cY J Insurance Company Name: " 1 fWYjjY-0 t..CC C� Policy # or Self -ins. Lie. #: 03 96A177# a� �� Expiration Date``::' M Job Site Address:_ $ " t if 1 PS Common city/state/zip: N• Phc�eV6� Attach s copy of the workers' "compensation policy declaration page (showingthe policy I tai 01 iT�% p y 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 5250.00 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 certify der the p�aiitu and penalties of perjury that the infarmWon provided above is true �r correct Si time: Date. 5� `2 00q Phone #: cS % - o4 6 [E6.Oth6r only. Do not write in this area, to be completed by city or town official n: Permit/License # ority (circle one): ealth 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector on: Phone #: r JL R CERTIFICATE OF LIABILITY INSURANCE OP ID T16 DATE(MM/DD/YYYY) PRODUCERSCOTT- 1 04/23/09 Wilmington Insurance Agency THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Five Middlesex Avenue Unit 14 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P. O. Box 1010 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Wilmington MA 01887-0580 Phone: 978-:658-3805 Fax: 978-657-5724 INSURERS AFFORDING COVERAGE INSURED - NAIC INSJRERA: Hartford Insurance Com an 22357 _ INSURER B: Scottsdale: Insurance Co ' Scott Robichaud INSURER C: 21 Draper Avenue Wilmington MA 01887 INSURERO: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOWHAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOT .'WHSTANDING ANY REQUIREMENT. TERM DR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO VAiICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITICNS OF SUCH POLICIES. AGGREGA E LIMITS SHOWN MAY HAVE BEEN REOJCEO BY PAID CLAIMS. LTR NSR TYPE OF INSURANCE POLICY NUMBER GENERAL LIABILITY B I COMMERCIAL GENERAL LIABILITY I PENDING 04/02/09 CLAIMS MADE I X I OCCUR GEN'- AGGREGATE L [MIT APPLIES PER: POLICYF--] PRO- F-1 LOC JEC7 AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS VON -OWNED AUTOS GARAGE LIABILITY I ANY AUTO EXCESS 1 UMBRELLA LIABILITY —1 OCCUR 1-1 CLAIMS MADE I I I DEDUCTIBLE RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN A ANYPROPRI=TORIPARTNERIEXECUTTVE038ON774 OFF.CERTAEVIBER EXCLUDED? (Mandatory in NH) If yes, describe under CERTIFICATE HOLDER Nancy & Mark Ziel 78 Phillips Co=on P. Andover HA ACORD 25 (2009101) 0 EACH OCCURRENCE LIMITS S 04/02/10 urirylNUt IU KLNItU �� PREMISES(Esocmrance: $ MED EXP (Any one parson) $ PERSCNAL & ADV INJURY $ GENERAL AGGREGATE _ PRODUCTS-COMPIOPAGG S _X TORY LIMITS I ER 02/22/09 02/22/10 E.L. EACH ACCIDENT $ 200000 E.L. DISEASE - EA EMPLOYEE: $ 10 0 0 0 0 E.L. DISEASE - POLICY LIN11T I S 500000 CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE INE EXPIRATIO Z IELNAN DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TD MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO 50 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. ©1968-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD L -d tZL9L999L6 COMBINED SINGLE LIMIT I (Ea accident) S BODILYINJURY $ (Perperson) BODILY INJURY ;Par accident) - - i PROPERTY DAMAGE ;Per accidoni) $ AUTO ONLY -EA ACCIDENT S OTHER THAN EA ACC S AUTO ONLY EACH OCCURRENCE S .AGGREGATE g i — $ �S _X TORY LIMITS I ER 02/22/09 02/22/10 E.L. EACH ACCIDENT $ 200000 E.L. DISEASE - EA EMPLOYEE: $ 10 0 0 0 0 E.L. DISEASE - POLICY LIN11T I S 500000 CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE INE EXPIRATIO Z IELNAN DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TD MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO 50 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. ©1968-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD L -d tZL9L999L6