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HomeMy WebLinkAboutBuilding Permit #472-16 - 84 PEMBROOK ROAD 10/13/2015BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received Date Issued LO IMPORTANT: Applicant must complete all items on this page LOCATION 1�G rv� V� FZC�ca1 R - Print PROPERTY OWNER 0&,,(a-... Print 100 Year Structure MAP O�2- PARCEL: bt2-� ZONING DISTRICT: Historic District Machine Shop Village ryeve TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family . El Industrial ❑ Addition ❑ Two or more family ❑ Alteration No. of units: ❑ Commercial ❑Others: ®',Repair, replacement ❑ Assessory Bldg ❑ Demolition ❑ Other she'd ®lstrrc��¢ io Sept a® "Welly ', eUV tla��". =,Water Floodplain h'�, P nP"/wAAAP1'1. 1 ut= lLomir i ivim yr vv%jtxI\ - •�• '•-•- - Please Type or Print Clearly OWNER: Name: Address: Ph -146 Contractr Name:%O_ � hone: `Ka- 3 3 7 3 Email roc,(. C-, VLz Qk 0-1 CC -,w,4 a' r,2" - Address: Q21 ,2-Address:Q2j rte, 1r� Supervisor's Construction License: CSQ CO 0,0 6 Exp. Date: I( / j 5 � ( Home Improvement License: . Date: � J 19 11 ARCHITECT/ENGINEER N. Pr- Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cost: $ QU 0D _ ©¢ FEE: $ !3 1 Check No.: Receipt Noj 9 9- 1 _74— NOTE: Persons contracting with unregistered contractors slp not h ve a cess to the guaranty fund --- -- W„J�” - - -- -- - - cr i i=A�r�,M_ _� ��(7 fMr.Pl OfKC_0 - Flans Submitted ❑ flans Waived ❑ Certified Plot Man ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ TanningWassage/Sody Art ❑ Swimming Pools ❑ well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Pennanent Dempster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF m U FORM PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS Reviewed On Signature. Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Drivewav Permit DPW Town Engineer: Signature: Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Dieter 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 The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation P Building Permit Application Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S icen es Copy of Contract Floor Plan Or Proposed Interio ork Engineering Affidavits for En eered products IOTE: All dumpster permits require sign �, from-F•ire`DepartmE Addition Or Decks TOTE: or to issuance of Bldg Permit Building Permit Appli ation <�' Certified Surveyed Plo Ianlk.r c Workers Comp Affidavit _ f 46 Photo Copy of H.I.C. And C.S.L. License Copy Of Contract yk Floor/Cross Section/Elevation Plan Of Proposed=..Work With Spri:nkl Plan And Hydraulic Calculations (If Applicable) t Mass check Energy Compliance ReporV(If Applicable) , Engineering Affidavits for Engineered products 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 2012 IECC Energy code Engineering Affidavits for Engineered products TOTE: 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 Doc: Building Permit Revised 2014 Location VY6, )L, No Date Y • - TOWN OF NORTH ANDOVER IL"ED f J Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $_ ^~ ' Other Permit Fee $' r ©Rg ER TOTAL $ r a� Check Building Inspector _. 4 J Q LLI LL. O m O Nm u Y Y \ O LL N N U a. (n o w ? z C O Y C6 "a 7 LL t : �' 7 d C E U _ LL O a z z m J d t = K _ LL 0 aui z Q V W J W L � d' U i In _ LL a z !� L � d' _ LL z Q 0. LLI 0 LLI LL i m O Z Y v N N N Y O N v O w it w f lw O O O Q d d Q lo: .2 N v L Q U) L- .�' • D m `7 ~+ rtr O o= V L M CL � J CJO > CoCo v O w it w f lw To: Date: Re: Scope of services Back River Development 231 North End Boulevard Salisbury, MA 01952 1978 852-3733 Contract Christa PaImisano September 19, 2015 Renovations of decks Pembrook Rd. N. Andover, MA Replace 8 sections of rails on front and rear decks C" P" l O izIkgO Christa Palmisano, Homeowner $2600.00 GJJ,L "� Willi J. Ferris, Back River Development ACORO® CERTIFICATE OF LIABILITY INSURANCE °"'�`�'°""'°° "1"' �/ 10/13/15 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 CONTACT NAME: M.P. Roberts Insurance Agency PHONE (978) 683-8073 FAX No): (978) 683-3147 1060 Osgood Street ADDRESS: Paula@mprobertsinsurance.com North Andover, MA 01845 MED EXP (Anyone person) $ 15,000 PERSONAL&ADV INJURY $ INSURERS) AFFORDING COVERAGE NAIC# INSURER A: Merchants Mutual Insurance Co GEN'L AGGREGATE LIMIT APPLIES PER POLICY X PRO- F I LOC INSURED INSURER B: Associated Employers Insurance INSURER C: 13ACKRIVER DEVELOPMENT LLC INSURER D: 231 NORTH END BLVD. INSURER E: SALISBURY, MA 01952 INSURER F : CNED SINGLE LIMIT MAUTOMOBILE ident $ 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 TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF M/DD/Y POUCY EXP MM/DDIYYYY LIMITS A GENERALLIABILITY X COMMERCIAL GENE RAL LIABILITY CLAIMS -MADE F_x1 OOCUR AA ly 1 &-4& BOPI080037 6/20/15 6/20/16 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED occurrence $ 500,000 MED EXP (Anyone person) $ 15,000 PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER POLICY X PRO- F I LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ LIABILITY ANYAUTO ALL O WNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS _ AUTOS CNED SINGLE LIMIT MAUTOMOBILE ident $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTYDAMAGE $ eaccident) UMBRELLA LIAR EXCESSLIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICE RIMEMBER EXCLUDED? (Mandatoryin NH) If yyes describe under DESG�RIPTION OF OPERATIONS below N/A WCC -500-5014220-201 1/12/15 1/12/16 X WC STATU- OTH- E R E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE -EA EMPLOYE $ 500 , Ofl0 E.L. DISEASE -POLICY LIMIT I $ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Rena rks Schedule, if more space is required) CERTIFICATE HOLDER CANCELLATION © 1988-2010 ACORD CORPORATION. All fights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: E -Mail: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CHRISTA PALMISANO ACCORDANCE WITH THE POLICY PROVISIONS. 1B4 PBNBROOKE ROAD AUTHORIZED REPRESENTATIVE NORTH ANDOVER, MA 01845 AA ly 1 &-4& Michael P. Roberts © 1988-2010 ACORD CORPORATION. All fights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: E -Mail: The Commonwealth of Massachusetts . F Department of IndlustrialAccidents 1- d 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov1dia SJ+ Workers, Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual): Address: O'�� N. Z� LS I VLA City/State/Zip: � (-,Ld.a=t�s_! Are you an employer? Check the appropriate box: Phone #: 93cb -q 5zz- g- 3 3 1. 1 am.a employer with 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.. ❑ 1 am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4.❑ 1 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. ❑ 1 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. insurance.# 6.FJ 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. [] New construction 8. Remodeling 9. ❑ Demolition 10 [] Building addition 11.[] Electrical repairs or additions 12. [] Plumbing repairs or additions 13. F1 Roof repairs 14.0 Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must siibmit a new affidavit indicating such. tContractors 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 fiave employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees.' Below is thepolicy andyob site information. Insurance Company Name: Policy # or Self -ins, Lie. #: wc(-- Expiration Date: Job Site Address: b9 City/State/Zip: V km�lQ oefl__ 014 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. X do hereby certify under the vain and penalties ofpefjury that the information provided above is true and correct. to- t3 -- is Phone # • � 5.�7 Official use only. Do not write in this area, to be completed by city or town offacial. . 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 #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of Wre, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or Iocal licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill -out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and -phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance: If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents foi• confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you'are_ required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should'enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia IM Massachusetts - Department of Public Safety Board of 8uildincq Reg.ulations.and:Standards License CS -06q005 ` BRMN A LYNCH 31 SEVEN STAR 9D A , GROVELAND Ma 018.14 J � WilkA Expiration Commissioner . 11/15/2015