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Home My WebLink AboutBuilding Permit #122 - 80 HOLLY RIDGE ROAD 8/15/2007 BUILDING PERMIT o*"°oT bgti TOWN OF NORTH ANDOVER 0 p APPLICATION FOR PLAN EXAMINATION x 1y* h T n 4 Permit NO: a Date Received ACHU`+E�� Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION s 'Print PROPERTY OWNERPrint MAP NO 994, PARCELZONING DISTRICT:�'i � Historic District _ MachineShnp Village +es no 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 r Other Septic 1Nell Floodplain Wetlands ,Wetlands -W tershed District r 1Nater'Sewer r E a r - DESCRIPTION OF WORK TO BE REFORMED: 7,�4 aee- &01,11 - l,11—f- e- 51W e r/1/-G`i1/Gf GC4 /yeoris i2 x r Identification Ffease pe or Print Clearly) OWNER: Name: /C /'��, �i-d , ' %'/97 r�O�J/` Phone: Address: / / CONTRACTOR. Name: rU r � �r��Z Phone.' x a Address: 2 Al4- d. ✓' .G'1 s Supervisor's Construction License:_ 7, Ex-p.j Date; - - ' Home 11miprovement License.. Exp: Date:L 2 _ ,g_!--aJ ARCHITECT/ENGINEER Phone: Address: -Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: /S/ SGG FEE: $ X l� Check No.: �;-YS Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund �gnature'of Ag�ent/Owner :� . - °' � ' Signature of�contractar' '; t t 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 i PLANNING & DEVELOPMENT COMMENTS DATE REJECTED DATE APPROVED CONSERVATION COMMENTS DATE REJECTED DATE APPROVED HEALTH 1 �� r- 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 Located at 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster:on site yes ,� - -no located at 124 Main Street40' 77 77 Fire bepartrri 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 =---- ----.....__._.._......................................................_..-------.........--------....................................................._ _ . ..__........._........._..---............................................_.__..._......__.............................-_.......... , Doc.Building Permit Revised 2007 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 1 ❑ 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 ❑ 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 i Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 Location No. C��— Date NORTiy TOWN OF NORTH ANDOVER L Certificate of Occupancy $ Building/Frame Permit Fee $ s�CHU Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check #-- 20493 Building Inspector From:Linda At.Norwood Insurance Agency,Inc. FaxiD:(Norwood Insurance Ag To:Town of No Andover Date:8/152007 09:18 AM Page:1 of 2 l�6eOl�� CERTIFICATE OF LIABILITY INSURANCE OP ID L anTE1MDYYwI RKAND-1 08/15/07 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Norwood Ins. Agency, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 293 Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Groveland, MA 01834 Phone:978-372-5921 H'ax:978-521-0242 INSURERS AFFORDING COVERAGE NAIC# INSURED (INSURER,P: The Travelers insurance Co. INSURER B: National Grange Mutual R. K. Anderson INSURER C. Richard K Anderson PO Box 433 INSURER D: West Boxford MA 01885 WSURER 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. INUK""' POLICY EFFECTIVE F LTR NQ TYPE OF INSURANCE POLICY NUMBER DATE(MMIDDIYY) DATE(MM/DDP/Y) LIMITS GENERAL LIABILITY EACH OCCURRENCE $2000000 UNN B COMMERCIAL GENERAL LIABILITY MPS88750 LP2EMISES(Ea occurence) $500000 CLAIMS MADE OCCUR XP(Any one person) $10000 X Business Owners 05/04/07 05/04/08 PERSONAL&ADV INJURY $ GENERAL AGGREGATE $4000000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY f7 PERQ LOC AUTOMOBILE LIABILITY _ COMBINED SINGLE LIMIT ANYAUTO (Eaaccident) $ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per Gerson) $ HIRED AUTOS I 901—ILY INJURY I$ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE (Per ecadent) $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR LICLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND TORY LIMITS ER EMPLOYERS'LIABILITY A ANY PROPRIETOR/PARTNERJEXECLTIV, 61=-7917Al2-9-07 07/31/07 07/31/08 EL-FACHACCIDENT $100000 OFFICERtMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $100000 If yes,describe under SPECIAL PROVISIONS below E L.DISEASE-POLICY LI5d!T $500000 OTHER PROPERTY 50000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES!EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS JOB: Marroni, 80 Holly Ridge Road CERTIFICATE HOLDER CANCELLATION TONOAND SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Town of North Andover IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Building Inspector REPRESENTATIVES. North Andover MA 01945 AUTHORUED REPRESENTATIVE ACORD 25(2001/08) 0 ACORD CORPORATION 1988 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 9i<<ii 1 600 Washington Street Boston, MA 02111 \\ I r iw www.rnass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ' Please Print Legibly Name (Business/Organization/Individual):-1/J� l �� Address: Gt/cRS�i y T City/State/Zip:C,/,Qdrl— %'�/� Phone #: 97 _ 17'1,y Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction mployees(full and/or part-time).* have hired the sub-contractors 2. . I am a sole proprietor or partner- listed on the attached sheet. t 7. Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.E] Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself.[No workers' comp. c. 152, §1(4),and we have no 12.0 Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks boz#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 their workers'comp.policy information. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: A4�i.X�0h4 IY'2y L- , Policy#or Self-ins. Lic.#: j'✓�.��,/� ,�G Expiration Date: Job Site Address: Sfl/ /�`® !/�y dl_ City/State/Zip:/Y&,P-7`� 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 DIA for insurance coverage verification. Ido hereby certi/fyy and to painsandpe Ities of perjury that the information provided above is true and correctSi ature: �� -------- Date: Phone#: 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#: R.K. Anderson Co. 126 Washington Street P.O. Box 433 West Boxf6rd, MA 01885 President: Richard K. Anderson Massachusetts Construction Supervisor License# 036148 Home Improvement Contractors License# 116589 Contract agreement This Agreement was made on between R.K. Anderson Co. and R.K. Anderson�o. agrees ty perform th following services: 1 x R"491k / til�/i s�i/O r/S A I riIn C9'�`,�sc� w�,7�//rc.� "A 'V""4 '�^G'✓Y^✓' 0�.`/�!C//'� �Ov/ /�OK SG 7 '�S� r /7�C� �(U �%GSL L.. �X� R.K. Anderson Co. agrees to complete these services on the date agreed upon between both r ;parties. Payments: In consideration of Contractors services, clients agree to pay contractor as follows, an amount for total job will be determined or agreed upon between homeowner and contractor. The agreed upon amount will only change if Contractor come across any unforeseen obstacles in which this will immediately be brought to the homeowners attention: First Payment: (deposit): V'<-,Goo } 12Z Second Payment: ��gf aad Final Payment: Do upon completion of job 20, Gw do),),j � a 3, czU f5 Permits: Contractor will obtain any permit�equired Invoices: Contractor will submit invoices.for all services performed. Contractor will present invoices, receipts for all materials used. I Independent Contractor: The parties intend Contractor to be an independent contractor in the performance of these services, Client shall not have the right to control or determine such method or means. Other Clients: Contractor retains the right to perform services for other clients. Assistants: Contractor may employ such assistants, as contractors deems appropriate to carry out this agreement. Contractor will be responsible for paying such assistant, on the hourly rate quoted to homeowner. Homeowner owner will pay Contractor leaving it the Contractors responsibity for paying assistants. Equipment and Supplies: Contractor, will provide all equipment, tools and supplies necessary to perform the above services, and will be responsible for the cleaning of all debris after completion of job. "The Contactor and the homeowner herby mutually agree in advance on the agreement of work to be performed as written above" The homeowner has a three day cancellation right under MGL c 93 s 48; MGL c 140D s 10 or MGL c 255D s 14 as may be applicable. Massachusetts Regulations(CMR)in the Massachusetts State Building Code as 780 CMR R6. � V Homeowner: Date Contractor: G ' ��i`� Date 9`q70 NO R T!y Town of, Andover No. Z ZMMMAM'.. _ to �... _ , dover, Mass., 110 T LAKE COC KIC KE WICK ��ADRATED PP��S S ` BOARD OF HEALTH PERMIT, T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT ...........Ma .. ........... Cj v n I....... ..................................................................................... Foundation has permission to erect........................................ buildings on � 0./ ....1 "caw.................... Rough to be occupied as../ ....�.........Arp. A.r.......�.l.i�r��. ..................................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final 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 �G PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI.QNL STARTS Rough Service DING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To BeDone FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det.