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HomeMy WebLinkAboutBuilding Permit #1113-15 - 804 FOREST STREET 6/29/2015 TOWN OF NORTH ANDOVER 1 APPLICATION FOR PLAN EXAMINATION Permit NO: 1 Date Received t/ Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION _ N c (z, Print. PROPERTY OWNER j�_,a_ CA rc.,' ,tL/,4 �--� Print 100 Year Old Structure yesnno MAP NO: ��PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT, PROPOSED USE Residential Non- Residential ❑ New Building c5A One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial c4�41epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other El Septic 0 Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED- !2 c IP O 77 b-0 Identification Please Type or Print Clearly) OWNER: Name: TA C-A Cz-,-,0 t,-1.4 I, Phone: / / -7 z1 --S;R 14 0-1 Address: 0 `-l( ��� s CONTRACTOR Name:j,.P,,� 6t6-04-VC OAT- Phone: 9g CS '3') Address: _ w .�- P-0A t�n� Supervisor's Construction License: "7 G 3 Exp. Date: - 19 16 Home Improvement License: t Exp. Date: 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: $ O FEE: $ Check No.: N Recei t No.: �0 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature ofge Owner Signature of_contractor Plans Submitted ri Plans Waived 0 Certified Plot Plan ❑ Stamped Plans Location -1 No. �7 Date i . - TOWN OF NORTH ANDOVER • S��TL�D��6 . Certificate of Occupancy $ - Building/Frame Permit Fee $ = 2 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# `�' Building Inspector - Plans Submitted ❑ '.Plans-Waived-11- - . ..-..Certified Plot Plan ❑ .. Stamped Plans ❑ TYPE-O'1{:SE WERAGE DI SP OSAL Public Sewer ❑ Tanning/Massage/BodyArt ❑ Swimming Pools ❑ Well ❑ Tobacco Sales E ;•Food Packaging/Sales ❑ - rivatesePtic tank etc. . Permanent Diunpster on-Site ❑ THE-.FOLLOWING SECTIONS FOR-OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM -DATE. REJECTED DATE:APPR-OVED PLANNING& DEVELOPMENT ❑ ❑ 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 `J Conservation Decision: :Comments. Water & Sewer Connection/Signature& Date Driveway Permit DPW Towi-! Fngineer: Signature: Located 384 Osgood Street FIRE DEPARIIlKHIVT Teriip Dumpster on site yes no .-Located-at 124,Mair Street Fire"Depafimdrit-signatufe/date �v - . • . : : �" COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions._ :Total land-area; sq. ft.: ELECTRICAL: Movement of.Meter,l.ocattora, rinast-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 Ll Notified for pickup - Date f Doc.Building Permit Revised 2010 Building Department The fol awing isa=list of theerequired.forms to be-filled outfor the appropriate.permit to.be obtained. Roofh,g, Siding, Interior Rehabilitation Permits - o B,ailding Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or G.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 ❑ 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 subm.tted with the building application Doc: Doc.Bui?ding permit Revised 2012 NORTH own of EAndover No h ver, Mas w� 21S coc-acts WICK ��• S IJ - BOARD OF HEALTH Food/Kitchen PER IT T LD Septic System i THIS CERTIFIES THAT AwlCAmt BUILDING INSPECTOR ............ ................ .............. .................. ................... ........... ..... ....... .. Foundation has permission to erect ....... .................. uildings on ..... ...... ...................................... Rough tobe occupied as ........... ...... ......... ....... ..................................................................................... Chimney provided that the person accepting his permit shall in every respect conform to the terms of the application Final on file in 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 PERMIT EXPIRES IN 6 MO HS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIORough Service ..................... ..... ......... ...... ............................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. ' ( k8POSAL of Pages LEN GIBELY GU"w'i�r:.�T,��vu CO., INC. 2615 23R Winter Street PEABODY, MASSACHUSETTS 01960 All home Improvement contractors and subcontractors (978)531-8234 Fax(978)531-9304 engaged in home Improvement contracting, unless www.lengibelycontracting.com specifically exempt from registration by Provisions of Chapter 142A of the general laws,must be registered SubmittedX�O v, with the Commonwealth of Massachusetts. Inquiries To: about registration and status should be made to the �-, Director, Home Improvement Contract Registration, /244,'T One Ashburton Place, Room 1301, Boston, MA 02108 l (617) 727-8598. Owners who secure their own construction related permits or deal with unregistered v contractors will be excluded from the Guaranty Fund Provision of MGL c.142A. P NEn DATE REGISTRATION NO. MA.REG, 100811 JOB NAME/N0. JOB LOCATION We hereby submit specifications and estimates for work to be performed and materials to be used: n_ ��A r / Jiro lo All 6- i WORK SCH D UL� Contractor ill nbeg the —rNr e 1 Is before the third day following the signing of this Agreement,unless specified herein writln C ill begin the work on or about (date).Barring slay causetl by circumstances beyond Contractor's control,the work will be completed by ate).The Owner hereby acknowl ges"and agrees that the scheduling dates are approximate and that such delays that are not avoidable by the contractor shall not be considered as v lions of this Agreement. Hidden rot or conditions not seen at time of estimate that are required to be repaired in order to complete this contract,will be completed at$ per hour(MAN HOUR). WARRANTY The Contractor warrants that the work furnished hereunder shall be free from defects in material and workmanship for a period of Mowing completion and shall comply with the requirements of this Agreement.In the event any defect in workmanship or materials,or damage caused by the Contractor,his su con a tors,employees or agents,is discovered within one year after cc plelion of any job,Including clean up,the Contractor shall,at his own.expense,forthwith remedy,repair,correct,table e,or cause to be remedied,repaired,or replaced, such damage or such defect in materials or workmanship.The foregoing warranties shall survive any inspection performed in connection with the agreed-upon work. We Propose hereby to furnish material and labor-complete in accordance with above specifications,for the sum of: dollars($ a OU Payment to be made as follows: Remove all job trash. All guarantees on all products from manufacturer. / ($ C)OO )upon signing Contrac Add permit cost If needed-we pull permit. ($ )upon completion of Noq'na eement for horn improvement contracting work shall require a do (advent depos f more than one-third of the total contract ($ )upon completion of pril amou all d sits or payments which the contractor mce,to rd and otherwise obtain deliveryof sp order ($ )shall be made forewith upon muipme t, completion of work under this contract. Note:This proposal may be withdrawn by us if not accepted within days. Author) I re- Acceptance of Proposal I have read both sides of this document and ac ept l e is s specifications and conditions stated.I understand that upon signing,this proposal becomes a binding contract.You are authorized to d the o as ecified. Payment will be made as outlined above. You,the Buyer,may cancel this transaction at any time prio to i fight of the third business day after the date of this transaction.Cancellation must be done In writin . DO NOT SIGN THIS CONTRACT IF THERE R ANY BLANK SPACES. Signature "'c�%lC Date!/J Z Signature Date ilyJIMPORTANT INFORMATION ON BACK 1111111- J AI t • r The cdmmoi►#wealtlr.ofMass¢chusetts Department oflndustrialAccidents Office of Invesdgations 1,047;i Stri Suite 100 Boston,MA 02114-2017 www,massgoy/dit#. Workers'.Compensation Insurance Affidavit: Builders/Contractors/Electricians/P Applicant Information lumbers Please Print1e ibl Name.(Business/Organization/Individual): Com,. .. Address: i�il ►-' .e ,t 5�-- Ci /State/Zi .. . Phone#: Are you an employer?:Check the appropriate box: 3 3 1.(�I am a employer with 4: [� I am a general contractor and Ie of#rojeet(required): employees(full and/or part-time).* have hired-the sub-contractors 6.. .[]New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling emodeliag .ship And haveno employees These,sub-contractorthave. Demolition working forme in any capacity: employees and have workers' 8: [No worker$' comp. insurance comp. insurance.: 9• ❑Building addition required.) 5 ❑ We are a coipoTationand.its 10:[]Electrical repairs or additions 3.❑ I am.a homeowner doing,all work officers have exercised their m self. 11.0 plumbing repairs or additions Y [No workers comp. right of exemption per MGL insurance required j t c. 152,'§1(4),and we have no 12,Q Roof repairs employees. [No workers' " 13.0 Other comp.'insurance required.! *Any applicant thpt checks box#I must also fill out the section below shgwin�their workers'comQepsation policy!�onnation. t Homeownyrs who submit this affidavit mdicaihi th g ey are doing all wodc and then hire outside confiad Lois must submit a new affidavit indicating such. :Contractors that cl eek this box must attached an additional sheet s ll employees. If the subcontractors have employees,they must.provideame mp. number and state whether or not those entities pave I am an employer that is providing workers'compensation insurance for my employees. Below is the o and iaformahon. P lky Job site Insuranceorripany Policy#'or Self-ins. tic. #: '��t/C•�i 1y d- p l C') et''1 9' QL11GAiExpiration Dater Job Site Address: city/Statpzp: Attach a copy of the workerscompensation policy declaration page(s6owin the he Failure to secure Coverage as st Po Y pumber and expiration date). 8 required uuder,S.ection 25A of MGL C. 152 can load to.the imposition of criminal penalties fine up to$1,500.00 and/or one-year imprisonment,as well.as:civil.penalhes'n the form of a STOP WORT{ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of*;DtA.for insurance:covera$e;verification. I do hereby J ��r�e•wrrdf y.steer me pain and enalt[es o P jperJury that the jnformau0n:prov4ed above:is true.and correct Si D — Ph (4 1 Q 41= \ Official use only. Do not write in this area,to be completed by city or town official.. City or Town: Permit/Llcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Tovvn Clerk 4.Electrical In 5.Plumbing Inspector ti.Other Contact Person: Phone#: 4 ACORD CERTIFICATE OF LIABILITY INSURANCEF01/30/2015 DATE(MMlDDIYYYY) PRODUCER 978.887,4900 FAX 978.887,2404 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Edward F. Sennott Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 16 South Main Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P. 0. Box 457 Topsfield, MA 01983 INSURERS AFFORDING COVERAGE NAIC# INSURED Len Gi bel y Contracting Co., Inc. INSURERA: First Mercury Insurance Co 23R Winter Street INSURERB: Safety Indemnity 33618 Peabody, MA 01960 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. LTR INSRE TYPE OF INSURANCE POLICY NUMBER 1 DATE MN/DD/YYYY DATE MM1D0 LIMITS GENERAL LIABILITY " _ MA-CGL-0000051263-01 01/29/2015 01/29/2016 EACH OCCURRENCE $ -1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 100,000 CLAIMS MADE M OCCUR MED EXP(Any one person) $ 5,000 A PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 POLICY PRO- JECT LOC AUTOMOBILE LIABILITY 6221693 COM 02 01/29/2015 01/29/2016 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY B X SCHEDULED AUTOS (Per person) $ X HIREDAUTOS BODILY INJURY X NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR EICLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY - 101H- ANY PROPRIETOR/PARTNER/EXECUTIVE Y/NN TORY LIMA I ITS ER OFFICER/MEMBER EXCLUDED? E.L.EACH ACCIDENT (Mandatory in NH If as,describe under E.L.DISEASE-EA EMPLOYE $ SPECIAL PROVISIONS below OTHER E.L.DISEASE•POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Proof of insurances. CERTIFICATE HOLDER CANCELLATION 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. b(1 AUTHORIZED REPRESENTATIVE Robert Sennott/RP ACORD 25(2009101) ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ACCORH CERTIFICATE TE(MMIDDIYYYY) � OF LIABILITY INSURANCE DA(,6/g,/zg,a 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 require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 01634-001 CONJJ>,CT Edward F Sennott Insurance PNNAHA^OM�tNEo FAX 16 South Main Street A1C N Topsfield,MA 01983 ADDRESS: RrR1SIAFrnRnimnrgR INSURED R : A.I.M.Mutual Insurance Company 26158 Len Gibely Contracting Company Inc JtISLJRER B: 23 Winter Street Rear INSURER C Peabody,MA 01960.6941 IJRER D, INSURER E: 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. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICHTH15 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 ppCLAIMS. ��pp IN TYPE OF INSURANCE I s O POLICY NUMBER MOMIDDIY� MMlDD/Yl YY LIMITS GENERAL LIABILITY EACH OCCURRENCE y COMMERCIAL GENERAL LIABILITY DAMAGE TO R TED $ CLAIMS-MADE ❑OCCUR MEOEXP,(Any one person) $ PERSONAL 8 ADV INJURY $ - -- -- GENERAL AGGREGATE $ EN'L AGGREGATE LIMIT APPLIES PER:OLICY ECT PRODUCTS•COMPIOP AGG S O OC AUTOMOBILE LIABILITY COMBI E I GLE LIMIT $ t ANY AUTO ALL OWNED SCHEDULED BODILY INJURY(Per person) Y AUTOS AUTOS BODILY INJURY(Per accident) S HIRED AUTOS NON-OWNED AUTOS PR TY DAMAGE '— le $ f UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE AGGREGATE $ DED RETENTION f yypRKERS _ E ANNyDpERMpPLRO���8�/pgR7NER/ A OFFICERPMEMBER ptCLUpE j ECLITIVE YIN X TORY LIMITS OER �N NIA VWC-100-6010979-2014A 8/3/2014 8/3/2015 E.L.EACH ACCIDENT $ 500,000.00 (Mandatory In NH) — - �ffy�s f E.L.DISEASE-EA EMPLOYEE $ 500,000.00 DESCIION 0�OrPERATiONS be. E.L.DISEASE•POLICY LIMIT $ 500,000.00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,H more space is required) CERTIFICATE HOLDER CANCELLATION 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 ACORD 25 2010/05 ©1988-2010 ACORD CORPORATION.Ail rights reserved. ( ) The ACORD name and logo are registered marks of ACORD ' Massachusetts -Department of Public SafetyM Board of Building Regulations and Standards Construction Super%kor License; CU94765 THOMAS K DOBpW..log ,",� ?: N � ��+ �� • " �'� Expiration Commissioner 05/14/2016 �e warivaiaiuuecr�v`'�w;�u�rwet� !lice of Consumer Affairs&Business Regulation y TRegistrati ¢ Licenseor registration valid or individul.use only OME IMPROVWNT CONTRACTOR before the expiration date, If found return to: _.. ti Office of Consumer Affairs and Business Regulation . 'Y.,. Type; Ex Ir —' 10 Park Plaza-Suite 5170 p . .- k / Supplement Card Boston,MA 02116 LEN GIBELY COW INC. THOMAS DOBBINN✓�k 23 R WINTER ST ''i' PEABODY,MA 01860 Undersecretary Iyot valid without signature ,.- J ' r