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HomeMy WebLinkAboutBuilding Permit #337-15 - 79 ROCK ROAD 10/6/2014 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: r(� Date Received Date Issued: to I4 IMPORTANT:A licant must complete all items on this age LOCATION �� d\� �-K �_x - - Print PROPERTY OWNER VC-)0t_,q ��A 0/� -- Print lbb Year Old.structure. yes no MAF NO: ._ 1_- ,PARGEL:�_ZONING DISTRICT: -,,,---.Historic District yes no. Machine Shop Village yes- r no - TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 'IP4644e family El Addition El Two or more family 11 Industrial eration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic ❑Well •. ElFloodplain Q Wetlands 0 Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: s Identification Please Type or Print Clearly) OWNER: Name: ,S04� � N\NW )iV0NE- Wtj-L1A-mS Phone:ct�7��7_3 �'� Z- Address: 1Poc-K eq,aAI) /QC)RTU N-D©V& Phone: CONTRACTOR Name:._ } - -Z _ CC-2-7793Y Address: Supervisor's Construction License 6 Exp. Date: f v"Z 4/ ( / - __ Rv Home Improvement License: �_j _ Exp ARCHITECT/ENGINEER Phone: Address: Reg. No. s FEE SCHEDULE.BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ C �� �Q FEE: $ Check No.: y Receipt No.: 0 Z NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signatu b,6fAgent/O�wner" 'V _ �S ure_ofcontractor. Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans Building Department The fol;owing 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 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 o 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 apw,al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submAted with the building application Doc: Doc.Bui?ding Permit Revised 2012 I Plans Submitted ❑ PlansWaived-11 -Certified Plot Plan ❑ Stamped Plans ❑ -TYPE_OF-=SEWERAGEDiSPOSAL - 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:APPR.OVED PLANNING & DEVELOPMENT ❑ ❑ f 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 Conservation Decision: Comments Water & Sewer Connection/signature Date Driveway Permit DPW Tow:z ]Engineer: Signature: Located 384 Osgood Street FIRE DEPARTttliE-Af - Temp Dumpster on site yes no Located-at�l24SMair, Street:-. -Fire Departiner�t signature/date f ` W< b r. .. : 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 DANGER ZONE LITERATURE: Yes No MGL Chapter-166 Section 21A-F and G min.$100-woo.fine NOTES and DATA — (For department use I El Notified for pickup - Date S +y I Doe.Building Permit Revised 2010 1� i F Location No. Date • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee .rn4kFoundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# y6 Ri V 28102 - Building Inspector A ® DATE(MMlDD1YYYY( CERTIFICATE OF LIABILITY INSURANCE F10/06/2014 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 requlro an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s), PRODUCER CONTACT Erlk Hays Hays Insurance Agency Inc. (AIC-No Ex0i PHONE (978)686-3162 ac N.I: (976)689-4425 36 Hawthorne Ave. EMAIL haysinsuranca@comcaSLnet INSURERis)AFFORDING COVERAGE NAIC 0 Methuen Ma, 01844 INSURER A: Norfolk B Dedham Mutual Fire Insurance Company INSURED INSURER B Robert D Kangevin INSURER C: 795 Dale St. INSURER D: INSURER E: North Andover Ma 01845 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. NOTWITH$TANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIE$ DESCRIBED HEREIN I$ SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES-LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE POLICY NUMBER MMIDD/YYYY MMIDPOLICY EFF D� LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000. CLAIMS-MADE F OCCUR PREMISES Ea.0 100,000.$ 100,000. MED EXP(Any One person) 5 5,000• A R0514357A 10/25/2014 10/25/2015 PER50NAL&ADV INJURY S 2,000,000. GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000. POLICY PRO.JECT 17LOC PRODUCTS-COMPIOPAGG $ 2,000,000. OTHER: $ AUTOMOBILE LIABILITY - COMBINED SINGLE LIMIT S Me acdoent) ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS AUT09 NON-OWNED PROPERTY DAMAGE 3 HIRED AUTOS AUTOS Per acaderl UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCE86 UAB CLAIMS-MADE AGGREGATE S DED RETENTIONS $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILrrY Y/N STATUTE ANY PROPRIETORIPARTNERIEXECUTIVE E,l-,EACH ACCIDENT $ OFPICERIMEMBER EXCLUDED? El N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYE S IIy95,dgWrIbe under DESCRIPTION OF OPERATIONS below E.L.DISEASE,POLICY LIMIT 1$ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 1D1,Additional Remarks Schedule,may be attached If more space Is required) Carpentry CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN North Andover Building Department ACCORDANCE WITH THE POLICY PROVISIONS, 1600 Osgood St. AUTHORIZOO PRIISBN�rATIV11 Building 20 Suite 2035 Y .n North Andover Ma 0184.5 -~� ®1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are reglstered marks of ACORD DATE(MMIDDIYYYY) �. CERTIFICATE OF LIABILITY INSURANCE 10/06/2014 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 pollcy(les)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 NAME CT Erik Hays Hays Insurance Agency Inc. PHONE (978)686 3162 ac Na: (978)689-4425 36 Hawthorne Ave. fi-MADDRESS: haYsinsurancaCcomcast.net INSURERS AFFORDING COVERAOE NAIC# Methuen Me. 01844 INSURER A: Norfolk&Dedham Mutual Fire Insurance Company INSURED INSURER 0: Robert D Kangevin INSURER C: 795 Dale St. INSURER D INSURER E e North Andover Ma 01845 INSURERF: 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 INDICATEO. 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. TR TYPE OF INSURANCE POLICY NUMBER MMtDD1YYYY MM1DD-POLICYEXP LIMITS I COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000. CLAIMS-MADE 1-1 OCCUR PREMISES E amurrance -S.-100'000- MED 100,000.MED EXP(Any one person) $ 5,000. A R0514357A 10/25/2013 10/25/2014 PERSONAL&ADV INJURY $ 2,000,000. GEN'LAGGREGATELIMITAPPLIESPER,. GENERALAGGREGATE S 2,000,000. POLICY[:]JECT PRO• F7 LOC PRODUCTS-COMPIOPAGG S 2,000.000• I OTH R: I S AUTOMOBILE LIABILITY COM91NFD SINGLE LIMIT S Ea macidenl) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per eccdent) S HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTO& Per ecc' S UMBRELLA LIAe ROCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE § DED I I R ELATION S $ WORKERS COMP12NSATION SPER TATUTE ER - AND EMPLOYERS'LIABILRY y/N ANY PROPRIETORIPARTNER/EXECUnVE LL EACH ACCIDENT $ OFFICER/MEMSEREXCLUDED9 N/A (Mandatory In NH) E.L.DI$EASE-EA EMPLOYE $ Kai describe under DESCRIPTION OP OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Addldonal Remarks Schedule,may be attached It more space Is required) Carpentry CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN North Andover Building Department ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood St. AUTHORIZED ESENT 71V@ Building 20 Suite 2035 North Andover Ma 01845 m 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD ROBERT LANGEVIN E] Building& remodeling, LLC Homeowner Information Contractor Information Name Company Name Street Address(do not use a Post Office Box address) Contractor/Salesperson/Owner Name -79 Kerrie Po A_D .-7 1DA4.jC- �-r �T , N,),vVr_ /VIA at P Cityfrown State Zip Code Business Address(must include a street address) � Zi� I Daytime Phone.. Evening Phone _ state ode 6,2-3 2- 6f1 "o7 - G 16'- ;� r_;_7quc.:a:rry m aF.T.z) — rsusmess rnone 1 reaeral csmpioyer llJ or b.b.tvumper Home lmprovemerd Contactor Reg.Number Expiration date Lem requires that most home improvemeut contractors havef a valid registration number / i 1 7170 �� l "The Contractor agrees to do the following work for the Homeowner: [ (Describe in detail the work to completed,specifying the type,brand,and grade of materials to be used,use additional sheets if necessary.) Required Permits-The following building permits are required Proposed Start and Completion Schedule-The following schedule will and will be secured by the contractor as the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of /D 6 Date when contractor will begin contracted work. MGI,chapter 142A.) U �4�PRr�c)�ri, Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule The Contractor agrees to perform the work,furnish the material and labor specified above for the total sum of: j 3, 000-- Payments 00nPayments will be made according to the following schedule: u exceed 1/3 of the total contract price or the cost of special order items,whichever is greater) $ 5 U on or u completion of IPS�-�—�11N 6- �`—_— P P or up $ c;Z0 00 upon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) The following material/equipment must be special at ordered before the contracted work begins in order to meet the completion schedule.(**) $ .NOTES:(*)Including all finance charges(•;)Law requires that any deposit or down payment required by the contractor before work begins may not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Express Warranty-Is an express warranty being provided by the contractors igNo❑Yes WI terms of the warranty must be attached to the contract) Subcontractors-The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be.solely responsible for all payments to all subcontractors for materials and labor under this aareement Contract Acceptance-Upon signing,this document becomes a binding contract under law. Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract • Don't be pressured into signing the contract Take time to read and fully understand it Ask questions if something is unclear. • Make sure the contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plaza,Room 5170,Boston,MA 02116 or by calling 617-973-87$7 or 888-283-3757.. • Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage,or ask to see a copy of a"proof of insurance"document • Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing of this agreement See the attached notice of cancellation form for an explanation of this right DO NOT SIGN THIS CONTRACT IF THERE ARE ANYBLANK SPACESM Two i tical copies of the contract must be completed and signed. One copy should go to the homeowner. The other copy should be kept by the contractor. �eowner's ignature ontractor's Signature ' 61- Date Date ®BERT JL ANGEVIN Building& Remodeling, LLC 795 Dale Street North Andover,MA 01845 (978)686-3607 HIC#111990 FID#26-0816298 www.LangevinBuilding.com Job Description Mr.&Mrs.John Williams 79 Rock Road North Andover,MA 01845 Bathroom"Upgrade and Room Reconfiguration • All necessary permits,cleanup and trash removal • Demolition of floor and affected wall areas • Reconfiguration of partitions as shown on submitted plan • Rough and finish plumbing—no location changes • Rough and finish electrica"FI upgrade and fixture reconfiguration • New blue board and skim coat plaster on affected walls and ceiling • Insulation upgrades to code on outside wall and ceiling where exposed and accessible • Copper pan and file mud job on shower floor • Durock and tile on shower walls • Plywood subfloor,durock,and file on floor • New window trim as needed • New covers on baseboard heat • Install bath accessories--dowel bars,paper rollers,etc. • Installation only of finish plumbing and electrical fixtures,tile,and vanity • Painting will be by others • Shower door and installation by others Signed Date T 01 -f- Signed Date 5 An VA in AU ow OH h V1 - ... ._...... ... .. .._..i.. ...._.-.. coo M!V C4 1\VU _ F1,8-vim ('PCNL _ PA*3Cl { z, �:; ,mss _•Ufie�,mnzoozureal��o��/;�acfutveltt E' Office of Consumer Affairs&Business Regulation d 'kq ME IMPROVEMENT CONTRACTOR egishation: 1.19990 Type: j iration 2!1.1!20:15:. LLC -E ROBERT LANGEVIN BLflG`$iiEN{OLDING LLC. ROBERT LANGEVliti` 795 DALE ST N ANDOVER,MA 01845 : ff Undersecretary Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor . License: CS-002685 ls ROBERT M LANgtVIN �•,. 795 DALE ST N ANDOVER MR 01845 X` ` Expiration 02/24!2016 Commissioner The COltlMOnwwam o,f m Msael.-Usaa �,, - ?epardnent of`Iridusirfal Accidenfs Office oflnvestigaions �► 600 WasUngton Street .�, Boston,MA 02.712 �`�'� wn+tvmas�gov/dia Workers' ColmpensatioH InS1t r=ee Affidavit:Buiiders/Contractors/Eleciricians/pinmbers ApIoNcant Information Please Print Le0bly Name.(Business/Ocg�i�tionllad}vide�at}: f�L��2T /-•/���/� 1.� 8��' �' ��y�,lpl�k:�l iii G- 1-�- � Address: —7cK_ City/swriZip: !�0 1J l7UY MA G/9tA_Phone#: -e`FY 3 eeo 7 Are you an employer?Check the appropriate box: I.0 I am a employer with 4 0.1 am a general contractor and I Type of p'rOIea (required): employees(fill and/orpart_time).# have hired the sub-contractors 6. ❑New construction 2.0 I am a sole pmprietDr G rparWer- listed on fhe attached sheet 7 odeling and have no employees These sub-c ontiactors have 8. 0 Demolition.. worming for me in any capacity. emploYees and have wodwn— . [No worimrs'.comp-insur-ance comp.msi rance 9.i 0 Bn$ding addition required.] 3. 0 We are a corporation and its 10-11 Electrical repairs or additions 3.0 I am a homeowner doing an work officers have exercised their 11-0 Plumbing repairs or additions myself[i�To vvorktrs'cutup; right of exemption per.MGL Z Roof insurance required-]t m 152,§1(4),and we have.no mP=jrs employees:(No workers' __.- 13--0 Other comP:msuwm=required.]' J, '�Y appticaut tbM checks bore#1 mmm alm f ll ont the section brow stowing titeirvnni rs• policy i tion. Homeowners who submit this affdovit irolicating They cern doing aA svauit mrd thio hire outsde cantrmtms nmg submits new oHrdavk m " snch. Contssctors that deck this bine mrrsE.attm��arWitio�t sireetshawi»g the name of the snbfos mrd state whether m'�t tbo�eatihnve err*toyees. Irthe sub-mnftamm b am eagdoyaes,they nn=*rav a their workers• °°mP-Zm� bn. I am an employer that rsprowfi fttg work=,compensation ft=a Ce f®r my employees Belmn is ihepolicy and job site informatTom Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: �aty&fairij3: Attach a copy of the workers'cnmpeissation policy declaration page(showing the policy number and expiration date). . Failure to secure coverage as required under Section 25A cf MGL c-152 can Iced to the imposition of criminal penalties of a fine up to$1,500-00 and/or one-year' eni;as well as civil penalties in the fort of a STOP WORD ORDER and a fine of up to MO.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 c +,p and penalties ofpedkuy dart the information prnvided above is true and correct Si tune: Date: Phone#: Off ectal use onl,R Do not write in tkis urea;to be completed by E&y or town offuxal City or Town: PermidLicense# Issuing Authority(circle one): 1.Board ofHealth 2 Building Department 3.CitYfTown Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone .