HomeMy WebLinkAboutBuilding Permit #816-2017 - 8 WALKER ROAD 3/2/2017Permit NO: M — )# 17
BUILDING PERMIT 3?o`t�eo 6�by�
TOWN OF NORTH ANDOVER °
APPLICATION FOR PLAN EXAMINATIO +-
Date Received
I r rC ur iivtrmuvtivitiV i FJKUFUSEU USE
Residential Non- Residential
I New Building ❑ One family
Addition ,A," -Two or more family bubo Su;k, J Industrial
!_Alteration No. of units: 11 Commercial
Repair, replacement I Assessory Bldg s=i Others:
l Demolition Other
Septic'We)I 1=l0odpin I iietlands Watershed Distrie#
l
OWNER: Name:
Address:
Identification Please Type or Print Clearly)
BUILDING PERMIT
TdWN ®F NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
?�.
r 1:
Permit No#• Date Received 3y A°RArev ,.4R` ,
SSgC us��
Date Issued:
LVOORTANT: Applicant must complete all items on thus page
PROPOSED USE
Residential
Non- Residential
❑ New Building
.. t
❑ Addition
❑ Two or more family
❑ Industrial
e. c
PROPERTY OWNER
_
"
__
a r
Pnnt 10&Year�StFuctufe
`r!^
yes no
r
`MAP �_ PARCELS -s: _
_
ZONING'DISTR1CT.t: �Histonc'Distnct4 7
yes no
❑Septic 0 Well
rin•
IIesB nn
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑Septic 0 Well
❑Floodplain El Wetlands '
0 Watershed Disffict .
p Water/Sewer.
_ _...
DESCRIPTION OF WUKK I U Int FtKruKiviCv:
Identification - PIease Type or Print Clearly
OWNER: Name:
AAA, ----
Phone:
ARCHITECT/ENGINEE
Phone:
Address: Reg. No.,
FEE SCHEDULE: BULDING PERMIT: $92.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F.
,Total Project Cost: $
FEE: $
Check No.: Receipt No,,-
NOTE:
o,.NOTE: Persons contracting with unregistered contractors do not have. access to the guaranty fund
Si nature of contractor
Sigratu�e_of.Agent/Owner ,�,_: ._.,_._g_____:: --......-_.....
Plans Submitted ❑ Plans Waived 0 Certified Plot Plan ❑ Stamped Plans ❑
TyPF-bF SEWERAGE DISPOSAL
Public Sewer ❑
Tanning/Massage/Body Art ❑
Slimming pools ❑
Well ❑
Tobacco Sales ❑
Food Packaging/Sales ❑
Private (septic tank, etc. ❑
Pennanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
Reviewed On Signature.
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH
COMMENTS
Reviewed on
Zoning Board of Appeals: Variance, Petition No:
Planning Board Decision: Comm
Conservation Decision: Com
nature
ing Decision/receipt submitted yes
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
FIRE DEPARTMENT - Temp Dumpster on site yes
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Locatea db4 usgooa Street
no
iimension
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
®ANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
Doc.Building Permit Revised 2014
i
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
r
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 Pian
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
❑ Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Mass check Energy Compliance Report (If Applicable)
o 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)
o 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
o Engineering Affidavits for Engineered products
DOTE: 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 L
Doc: Building Permit Revised 2014
Location
LU A) !L t;_ i2 Pb t!
No. Vito. 9017
Check #
Date 0 1
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ `.7 l'
Foundation Permit Fee $
Other Permit Fee $ '
TOTAL $
L; Building Inspector
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E B Window and Siding LLC
756 Western Ave
MA 01905
Name / Address
Nhan Hoang
PO BOX 583
Peabody. MA 01960
Estimate
Date
Estimate #
2/22/2017
10074
Phone #
Project
E-mail
Description
Qty
Rate
Total
8 Walker Rd 45. North Andover
Remove existing patio door and prepare opening to accept new door
0.00
0.001'
Furnish and install 6106 Patio Door white
1
1,700.00
1,700.00
Patio door is have Low 1:;, Argon Gas and carry a lifetime warranty.
0.00
0.001,
Seal door in and out using Tite Bond lifetime sealant
0.00
0.001
Cover full casing with custom bent aluminum.
0.00
0.001,
Take away all job related debris.
0.00
0,001'
Any building permit required to complete project is to be added at
0.00
0.001'
cost to the final payment.
Note: 'fo change to I larvey door price will stay the same, however
the Alside door is recommend d for your project.
Authorized Signature �'��
0.00
0.001,
Customer Signature A
Total $1,700.00
Phone #
Fax #
E-mail
Web Site
781-592-9747
781-592-9746
ebwindovvcJmsn.com
www.ebwindow.com
Property Address
The Commonwealth of Massachusetts
Department of Industrial Accidents
M. I Congress Street, Suite 100
Boston, MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): E.B. Window and Siding Co.
Address: 756 Western Avenue
City/State/Zip: Lynn, MA 01905
Are you an employer? Check the appropriate box:
Phone #: 781-592-9747
l .E] I am a employer with 6 employees (full and/or part-time).*
2.❑ I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3.F_1 I am a homeowner doing all work myself. [No workers' comp. insurance required.] t
4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5.❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance3
6. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c.
152, § 1(4), and we have no employees. [No workers' comp. insurance required.]
Type of project (required):
7. F] New construction
8. ❑ Remodeling
9. ❑ Demolition
10E] Building addition
I I.❑ Electrical repairs or additions
12. ❑ Plumbing repairs or additions
13.[]Roof repairs
14.ROther 0
*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 and state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and, job site
information.
Insurance Company Name: Berkshire Hathaway Guard
Policy # or Self -ins. Lie. #: EDWC705625 / �Expiration Date: 12/13/17
Job Site Address: f 11 f !/ 5 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 MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certi nder the pains and penalties�ofVerju that the information provided above is true and correct.
Signature: `=nate &/�/� ,
781-592-9747
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 #:
.:�'�" CERTIFICATE OF LIABILITY INSURANCE DATEIMWDD/YYYY)
'/2/2017
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RJGHTS UPON THE CERTIFICgTE HOLDER, THIS
(CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT 6ETWEEN THE ISSUING GEAF ORDED BY HE POLICIES
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER,
IMPORTANT: If the certifloate holder is an ADDITIONAL INSURED, the P000Y 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
certlflcate holder in lieu of such endorsement(A1.
PRODUCER NTACT
NAME- Commercial Lines
Admir&l Insurance AgenCy,Ina, PHONE (781)599-2000 FAX
70 Munroe StreetE•M °E No:
Suite D ADRREBS:
Lynn MA 01901 INSURER 9 AFFORDING COVERAGE NAIC
INSURED INSURER A -Providence Mutual Fir® Ins Co 15040
INSURER B NorGuard Ingur&nce Co 31470
`1;DMUND DBA BYRNE & ED SYRNE OPiNDOW COMPANY
-7,66 WESTERN AVENUE INSURER C:
INSURER 0:
LYNNINSURER E
Mh 01905
COVERAGES CERTIFICATE NUMBER:CI,173124890 R I - ..)
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 REDUCEXW�MD BY PAID CLAIMS.
L TYPE OF INSURANCE UWVD P L CY NUMB( !DD/VYYYI MM1D0 LIMITS POLICY POLICY
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MA EACH OCCURRENCE $ 1,000,000
:A DE a OCCUR
PRE E8(Ea eccu Ce ✓S 1,000,000
BOPOO63101 6/21/2016 6/21/2017 MED EXP (Any one oarsonl S g 000
is
GEN'L AGGREGATE LIMIT APPLIES PER;
POLICY ❑ JECT 0 LOC
AUTOMOBILE LIABILITY
ANY AUTO
ALLOWNEO SCHEDULED
AUTO$ AUTOS
HIRED AUTOS NON -OWNED
AUTOS
I UMBRELLA DAB
OCCUR
F%r.'ESS LIAR CLAIMS MADE
DED RET NTION
WORKERS COMPENSATION
ANO EMPLOYFAS' LIABILITY Y I N
ANY PROPRIETORIPARTNER/EXECUTIVE
$ OFFICER/MEMBER EXCLUDED9 11
N/A
(Mandatory In NH) r
A TSDWC705626
,., _.._ __- --
PERSONAL & ADV INJURY I $
OENERAL AGGREGATE g
PRODUCTS-COMP/OP AGO $
FLL $
C INED SIN IMIT &
Ea Gocident
BODILY INJURY (Per person) $
BODILY INJURY (Per a=kIent) $
PRRTY DAMA $
er eCCideM
EACH OCCURRENCE Is
,
1,000,000
2,000,000
2,000,000
50 , 0'00
E.L. EACH ACCIDENT b 1 000
12/13/2016 12/13/2017 E.L. DISEASE - EA EMPLOYE $ .11000
EL. DISFAsF-POLICV I me1T c .1 Ann
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Addiliongl Remarks Schedule, may 6e attaCh6d If more apace is raqulred)
(978)688-9542
Town North Andover
120 Main Street:
North Andover, MA 01645
\CORD 25 (2014/01)
N8026 (2D1401)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS,
AUTHORIZED REPRESENTATIVE
IJ S Scholnick/MPH ��--..P --,-
0 1988-2014
--,-01988-2014 ACORD CORPORATION. All rights reserved,
The ACORD name and logo are registered marks of ACORD
Z/T:e6gd Z:V969?98L6T:01
Board of Building Regulations and 5tanoards
z Construction $uPersicar
� '
License: CS -010870
EDMUND J BY
18 Woodrow Terriice
Lynn MA 01904
Q%�•r .,1�1. '�':''�
Expiration ;
Commissioner
07/09/2017
F
r_ ha
Uffice•*f Consumer Affairs +& Business RegO,lation
OkOMPROVEMENT CONTRACTOR
Registration: ."'1'26634 Type-
Expiration.-
ype- s
Expiration,:.•:,:5W2.017,; DBA
F -Q BYRNE WINDOW`00
EDWUND BYRNE
756 WESTERN AVE—
LYNN, MA 01902 Undersecretary
9i'L6 Z69 T9L -00 MoutM S g:mo.z3 LZ:EZ LTOZ-TO-F