HomeMy WebLinkAboutBuilding Permit #690-2017 - 81 PEACH TREE LANE 1/4/2017Permit NO:. t , j�
Date Issued:
LOCATION
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
'Date Received
Applicant must complete all items on this
Print
PROPERTY OWNER Aidiana .inrips
• Print
MAP NO:PARCEL; _ ZONING DISTRICT: Historic District yesno x
Machine Shop Village yes no
TYPE -OF aIMP.ROVEMENT
PROPOSED USE
Residential_. _
BUILDING PERMIT
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Permit NO:. t , j�
Date Issued:
LOCATION
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
'Date Received
Applicant must complete all items on this
Print
PROPERTY OWNER Aidiana .inrips
• Print
MAP NO:PARCEL; _ ZONING DISTRICT: Historic District yesno x
Machine Shop Village yes no
TYPE -OF aIMP.ROVEMENT
PROPOSED USE
Residential_. _
Non -.Residential
❑ New' -Building
14015ne family
-
El Addition
❑ Two or more family
o. Industrial
El Alteration
No. of units: -, _,_
❑ Commercial
epair, replacement
❑ Assessory Bldg _:.:
o Others:
o Demolition
❑_ Other.
Septic ❑ Well
Floodplain ❑ Wetlands
Watershed District
Water/Sewer
OWNER: Name
Address:
Identification Please Type or Print Clearly)
;Ii�liana..InnPs P.hOne:_ 978-R28-9442..
CONTRACTOR Name: Phone:
RENEWAL BY ANDERSEN
508-351-2214
Address:
30 FORBES ROAD NORTHBOROUGH, MA 01532
Supervisor's Construction License: Exp. Date:
90125 10-06-18
Home Improvement License: 170810
Exp. Date:
12-23-17
ACHITECT/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: $ _ 6,815_ FEE: $
Check No.:. a61 191�, .21 Receipt No.: 140--3 .
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
i nature of Agent/Owner Signature of contractor Jaime Morin
� � Y
Permit No#:
Date Issued:
BUILDING PERMIT '
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
EYRORTANT: Applicant must complete
L®Ci TION
�
PR OFERtTY.®�IVNIX
'1=R
NiAP`-•-:PARCEL �= ZONIfVG{
)TCT
all items on this
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RATED AQ¢
9SSACHU
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
❑ Two or more family
❑ Industrial
❑Alteration
No. of units:
0 Assessory Bldg
❑ Commercial
❑ Repair, replacement
❑ Others:
❑ Demolition
❑ Other
?5-7_ 0 Septic `Well
0 Floodplain 1Net(ends
Watershed ®st ict ..
DESCRIPTION OF WOKK I U tit FtMt-UKidiCu:
Identification - Please Type or Print Clearly'
OWNER: Name: Phone:
A rlrlrooc
Contractor Name: __ Phbi e
i` �• .. _ — — wr'<%..G'.._.-c •�:� h��'�2�'r+•o+`1S •a _, ` ..'J _
Su ervisoi's Construction Lieense: �:- _ _ _ __ _}.�a Exp:.
•Home;Imp ".mv, t ent License:_.
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BULD/NG PERMIT. $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
___,notal Project Cost: $ FEE: $
Check No.: Receipt No.
NOTE: Persona contracting with unregistered contractors do not have: access to -the 12 aranty fund
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
o 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
❑ Floor/Cross Section/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
10TE: All dumpster permits require sign off from Fire Department prior to issuance of BIdg. 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 4
Doc: Building Permit Revised 2014
r-
Plans Submitted ❑
Plans Waived ❑
Certified Plot Plan ❑ Stamped Plans ❑
-TYPB 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
PLANNING & DEVELOPMENT Reviewed On
COMMENTS
Signature_
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Siqnature
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 Town Engineer: Signature:
FIRE DEPARTMENT" -.Temp Dumpster on site
Located at 124 Main Street
Fire Depa tm. qnt signatureldate
nen nn nt—t.tTn
yes
Located 384 Osgood Street
no
-Inlenslon
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 Z®NE.`LIT.ERATURE: Yes
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
No
Doc.Building Permit Revised 2014
Location �J
No. � nb lj � Date
Check # (A s� 0)
1403
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $�i
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
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APPNfeamt Ino-Matlan
I%aw Punt Ledbly
Name ):
RENEWAL BY ANDERSEN
Address: 30 FORBES ROAD
civ/stadzi NORTHBORO. MA 01532 Phone #: 508 -MI -2214
Are you an employer? Cheek the appropriate bay:
1. I am a employer with 30 4• [] 1 am a gtwrel contractor and I
Type d pm1ect (reQuira)'
employees (fall and/or Part-time).*
have hired the sub-conbracbors
[:]Now condruction
2. E I am a sole proprietor' or partner-
listed on the attached sheet.
7. Reanodsliag
ship and haute no employees
Ibese sub-eoubwiars have
S. Demolition
working for me in any capacity
employees end have workers'
: insarsaoe s
9• ❑ Building addition
[No workers' gip. hmuw ce
l
5. ❑ We are a oorporstion and its
10.❑ Eleahical repairs or additions
3: D I am a homeovuner doing all work
officacs carve wwrcisad their
11. 0 Pigg repay or additions
win, [No workers' comp,
right of examptkm Per MOL
12.E Roof repairs
insacarce m9uhid] t
c-152, § 1(4), and we have no
13:0 Otbeu
employees. [No workers'
oaanp. inenraace requited.]
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Instuence Conqmy.Name. OLD REPUBLIC INSURANCE COMPANY
Policy # Of Self-inN. UG. M. MWC30823100 10/01/2017
Bxpiratia�n Date:
job Site8.1-Peachtree Lane ({y/g ,North Andover, MA.01845
Attach a copy of the workers' eompensad n policy declaration PW,(dwwft the pommy n=bar and espirsdon date).
Failurn to secure coverage as regaitcd, ander Section 25A of MGL c.152 can lead to the imposition of Mfininal peoahies ofe
fine up to $1,500.00 and/or one-year imprieo eM4 es well as civil penalties is the &M of a STOP WORK ORDER and a fine
of up to $250.00 a.day.agW= *or violator. Be advised that a copy of flits statement maybe forwarded to the Office of
IA fez insurance coverage ved$cation
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11/08/2016
ANDECOR-01 DUBEAA
CERTIFICATE OF LIABILITY INSURANCE
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), AUTHORDMD
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the cortlNcab holder Is an ADDITIONAL INSURED, the polky(ks) must be endorsed. IF SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A shltelnent on this eerMicate does not conker rights to the
cordiffcate holder In lieu of such endorseme s .
PRODUCER
Willis of Minnesota Inc.
do 26 Co BiQ
P.O. Box 205191
Nashville, TN 37230-5191
Nw E: Wlllls Tawara Watson Certificate Center
PHONE 8 943.7378 No : 888 487-2378
ADORE : certtflcates&MIlls.cOm
s AFiORDING caveRar.E HMO
INSURER A:Did Republic Insurance Company 24147
MWZY 308284
INSURED
INeURER B :
INSURER C :
Renewal by Anderson LLC
INSURER D:
104 Otk Sbad
Northborough, MA 01532
INSURER E :
USURER F:
PROOUCTa_-(�MPIOPAGG S 4,000.00
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 WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TOALL THE TERMS,
EXCLUSIONS AND COMMONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
L
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFF
M
Po
UNITS
A
X CDIIMERCIALOE-LIABILITY
CLA Ms-LNAoE rK OCCUR
MWZY 308284
10/0112016
10/0112017
EACH OCCURRENCE f 1,000.00
$ 500,00
MED EXP cn. PmrW S 10.0
PERSONALaADVINJURY s 1,000.0
GEN9.AGGREGATELIMIT APPLIES PER
PRO -
X POLICY ❑ JECT ❑ LOC
OTHER
GENERAL AGGREGATE f 4,000,00
PROOUCTa_-(�MPIOPAGG S 4,000.00
A
AUfOMOBRELUIBIUTY
X ANYAUTo
OWNED AUSCHEDULED
HIRED AUTOS AUTOS
MWTS 808282
1010112016
1010112017
COMBINED I UMR f 3,000.0
BODILYINJuRY(Perpmm) s
BODRYIKVRY(Pera=WmQ $
pyr f
f
uNeRe u LU1BOCCUR
mosum
HrLAIRIS-MADE
EACH OCCURRENCE s
AGGREGATE f
IDED1 1RETENTIDN$__
f
A
NORIUM COMPENSATION
ND
AEMPLOYERS' LIABILITY YIN
ANY momETomPARTmERmxEcuTmWC30823100
= EXCLUDED? N❑
===
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W011 OF
NIA
101002016
10101/2017
X L37t
E.L. EACH ACCIDENT f 1,000,004
EL DISEASE • EA EMPLOYEE$ 1,000,00
E.L. DISEASE - PONICY UMTT = 1,000,00
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORO 101. AdclM W W Reim Scbedda, meyM naldmi If m" qqx b required)
Evidence of Imurencs.
SHOULD ANY OF THE ABOVE DESCRIED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED M
ACCORDANCE WITH THE POLICY PROVISIONS.
Town of North Andover
120 Main Street AU`rHORIZEO REPRESENTATIVE
North Andover, MA 01845_ IA
®1988.2014 ACORD CORPORATION. All rlahts rommed
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
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I. 9Massachusetts Depadment of llublic Safoy
W Board of Building Regulations and -Standards
Licahse:. CS -080I25
Construcition S�upervisor j!
JAIME L MORIN
99-GARDINMST
LYNN MA 01905
Expirafien:
Commissioner
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Consbuclilon Supervisor
Rertticted to:
Uhresticted - Buildings of any use group which contain
.less #van 35,000 cubic feet (991 cubic meters) of
enclosm space.- I
ftlium.ft possess a current edition dfthe MessedWsift,
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ME,IMPROVF.MENT CONTRACTOR
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Supplement Card
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RENEWAL BY AN
JAIME MORIN
30 FORBES RD
NORTHBOROUGH, MA 0153
Undersecretary
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