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HomeMy WebLinkAboutBuilding Permit #012-15 - 85 LANCASTER ROAD 7/12/2014 i NORTH BUILDING PERMIT of TOWN OF NORTH ANDOVER �� h ''- °� APPLICATION FOR PLAN EXAMINATION Permit No#: v I Z Date Received TED c5 9SSACHl15�� Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION /1a ! - Print PROPERTY OWNER (9JL.)AWJ Print 100 Year Structure yes (no o. MAP PARCEL:. ZONING DISTRICT _ Historic )istrict yesno Machine Shop Villa`e es, TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential El Building AKOne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition B•Other D Septic ❑1Nell ❑ Flood plain 0 Wetlands ❑ Watershed.District Water/Sewer- _ DESCRIPTION OF WORK TO BE PERFORMED: b�t 9C4wh1 JDIA V L.v� (/�-`T lt. �./dLS 4740 i Kc — .c�rri�o do r.or Identification- Please Type or Print Clearly OWNER: Name: 1214AJ 14%1 It a;L4 Phone: 0.1 Address: �s K. /�.� s ,ANGi : otavr i G.ontractor NameiUtei► Jrb,f44w_ Phone: Address: _ c�iw. t. MF .�ti� _ _yt*o.• o104y___ Supervisor's Construction License _ aS7��►Y—_- z Ex _. Date: l 3o,/ p . Home Improvement License:_ _16.), p.._ p., D'ate:_ 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: $ Ea �U 67, FEE: $ Check No.: 7 Receipt No.: ��' NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of,Agent/ er _ _ Signature of contractor,._ - � Building Department artment 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 o Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract o 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 Li 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) 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) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses o 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 ❑ 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 ors special permit was required the Town Clerks office must stamp the decision from the Board of Appeals P P 9 P PP 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 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 PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS a e c a `'HEALTH. ` - Reviewed on Signature.- 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: Located 384 Osgood Street FIRE DEPARTMENT Temp Dumpster on site . yes __. no Located at 124 Main Street Fire Department signature/date COMMENTS' __ 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) i ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Pennit Revised 2014 Location No. Date Z s - TOWN OF NORTH ANDOVER • qD ,,� _- Certificate of Occupancy $ Building/Frame Permit Fee ${n;kl Foundation Permit Fee $ Other Permit Fee $ � -U,Ea TOTAL $ Check# 27740 Building Inspector NORTII Town of t_ Andover COik' 10 No. 115 h ver, Mass, Z. COC LAK "1C"1WjCN ��• S V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ......... . .�.:.I..Q ......... ... .. BUILDING INSPECTOR has permission to erect ...................... buildings on ....... ....... Aft V% ...Old... Foundation it ., Rough led as . to be occupied .....� ....+....... ... .�r!...�.L;.4.. .......................... Chimney provided that the person accepting this permit shall in eve respect conform to the term f thea application p p g p every p pp 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 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI TA Rough Service ................. . ..... . .. ......................... Fina 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. POLABEA-04 KSKA CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDONYYY) 12/30/2013 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(les)must be endorsed. if SUBROGATION IS WANED,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: Automatic Data Processing Insurance Agency,Inc PHONE FAX 1 ADP BoulevardMo. n E uC No: Roseland,NJ 07068 ADDR SS: INSURER(S)AFFORDING COVERAGE NAIC Y NSURERA:NorGuard Insurance Company 11111 INSURED Polar Bear Insulation CO Inc INSURER 0: 51 South Canal St INSURER C: PO BOX 958 INSURER D: Lawrence,MA 01843- INSURERE: INSURER F: 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. � S TYPE OF INSURANCE Policy EFF POLICY EXP N POLICY NUMBER MMIDO NIDD LINKS GENERAL LIA81LFTY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS•MADE F OCCUR MED EXP(Any one person) $ PERSONAL 8 ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ POLICY PRO• LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO BODILYINJURY(Par person) $ ALL OWNED SCHEDULED - AUTOS AUTOS BODILY INJURY(Peraccldent) $ HIREOAUTOSNON-0en WNEO PROPER DAMAGE $ AUTOS Per accidt $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ 1 $ WORKERS COMPENSATION W C STATU- OTH- AND EMPLOYERS'LIABILITY YIN X I TORY LIMITS FR A ANY PROPRIEIORlPARTNERIEXECUTNE POWC550065 IM/2014 1/1/2015 E.L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? N N I A (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 1,000,0 Rs,describe under DESCRIPTION OF OPERATIONS below I I i E.L.DISEASE-POLICY LIMIT $ 1,000,00 DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES(Attach ACORO 101,Additional RernarW Schedule,if mon space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE GLCAC$Columbia Gas Co. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 350 Essex Street Lawrence,MA 01840- AUTHORIZED REPRESENTATIVE ©1986-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD � � �ba i i �A � / 1 ' f r ' } i � i • �'k�'J 5 �7 �, y�y ... ,.�, M .,..'r 4�i��s.$Y " �r�'� M.,�„�.,/r� ..�'���'�i::r<��1°'.,w � i � � ,� ., �' . _ j The Commonwealth of Massachusetts Department of Industrial Accidents - - �� Office of Investigations 600 Washington Street 4� Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information L Please Print Legibly Name (Business/Organization/Individual): ? Q`/�.4 &-7VL ��I.CV L4-hen (p. ,:t—N . Address: 3bp , 4Nd&UrK, 6/9/P City/State/Zip: Phone#: 42 9 69E0u Are you an employer?Check the appropriate box: T f (required): 1. I am a employer with 4. ❑ I am a general contractor and I Type oproject( q ) -b * have hired the sub-contractors 6. ❑New construction employees(full and/or part-time). 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5 We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13 Other 4N911Wt i AJ comp.insurance required.] *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. 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 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: /U012•�U�4 Policy#or Self-ins.Lie.#: POWC 55-00(06 Expiration Date: D//,Oj ZAus— Job Site Address: RS kMed&f�)L U W• Il xA0tio+- Ci ip: M.` B $ks^ 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. I do hereby certify under the pains and penalties of perjury that the information provided above..is true and correct Si nature: Date: 7 Phone#: V9 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#: G)Imunblof�a as.a�dtusc2cs An6a•iprew�{,e,r Gas Account# Audit R acct PRELIMINARY AGREEMENT READ TINS AGREEMENT AND MAKE SURE YOU UNDERSTAND IT BEFORE SIGNING. MAKE SURF:ALL BLANKS ARE COMPLETED AND ALL PROYISIONs TUAIDO NOT APPLY ARE CROSSED OUT.THIS AGREEMENT HAS LEGAL FORCE. AND EFFECTAND BINDSTHOS 3 EWHO SIGN. This Agreement is made an ` ILS //Yl. ' between Honevl ell of 65 Sbawmut Rd,Suite 4,2"Door,Canton, Mayrs�misenS WWI,(8110-247.4112)hereafla called"Administrative Contractor"or"Honeywell"•and /J�4v11�l�Cty1L Ylrllrr 1)of tf'J (Custnmcr) (Address) . lled"Cust m � (Tdcplame) Hereinafter called"Customer."The Customer is t Otm enant of the above-mentioned Premises. DESCRIPTION OF WORK TO BE PERFORMED In consideration of the Administrative Contrada's agreement to select a qualified Installation Contractor to pert ml in a grad N•orkmanlike manner all wink("the Work")set forth in the attached Work Order(s),the Customer agrees to the terms and conditions of this Agreement.No Work may bre performed Nithout the written consent of Owner.Customer understands that calculated enerff sasings arc estimates ally and am not guaranteed. PRICE For field fmin tc'an use only;. For the Work described in the Work Order(s),and shovv n on COMMENTS: the accepted Oiler Sheet,attached hereto, O SEE HEALTH AND SAFETY FORM the Total Estimated Cost is S �1 �l. O OTHER 67_.:✓Ci The Total Do at the time of Installation from S the Customer for the Work to be performed is: Ijthe Installation Contractor determines'that the Work cannot beprovided for the Price quoted above,all paHiev Rill!rave the riglu to terodnate this Agr nuenf.Price quoted is valid for 90 daps • Owmer of the Premises agrees to pay,prior to the commencement of the Work-and Administrative Contractor aaxpts, in full satisfaction for the Work the Price sa fath above. • Tenant agrees to pay,prior to the commencement of the Work,and Administmtivc Contractor accepts,in full satisfaction for the Work the Price set farlh above. RIGHT TO CANCEL, 'THE:('USIOMER MA)•CANCEL THIS AGREEMUNI IF IT IIAS BEEN SIGNED AT A PLACE.OTIIF.R THAN AN ADDRESN OF TIF: ADMINISIRATH'F.CONIRACITHL NH ICH MAY BE ITS MAIN OF'F'ICE:OR mNNCII THEREOF'PRO\'IDFJI THAI"Il1E CUSIWIER NOTIFIFS IDE ADMLNLS"1'RA'I"T CONTNACIoR IN WRITING A]VISMAIN OFFICE OR BRANC.II 111'IIRmNARY'MAIL.POSTED,BY 1'FLEGRA.M SENT OR RV DEIJ'ERV,NO IA'FER'HIAN MIDNIGIIT OF TUU.THIRD BUSINESS DAY FIIIJJININC'n1E SIGNING OF'11115 AC,RF.EM{:\T.SEE NOTCt.OF CANCF.I.I.ATION(IN DUPLICATE-)ANNEXED FOR AN E\PLANATON OF'NILS RImIT. IMPORTANT:ADDITIONAL,TERMS AND CONDITIONS ARE ON THE REVERSE SIDE Hy signing below)vu,the Customer,represents that(i)You read and understood both sides of this Agreement before you signed (2)y'ou agree I c bound by the Hants and conditions set tomb on the front and back of this Agreement-,(3)The Administmtiv t ctor(directly or'di—fly)has made no representations or mm nlies regarding the Work,other than those containe thi.Ag mnenl;(4) The time you signed the Agreement,it has been signed by the Administrative Contractor or its• minis-t tiv rcpres E(. t re were no blanks that had not been completed and that the Work you requested was p dy de. Ibe above. � � Hone •ell Sigh c Date - Owncl_ Si_amre Date Tenant's Signature Date MAIL THE SIGNED AGREEMENT TO: HONEYWELL 65 SHAWMUT RD,SUITE 4,2'FLOOR CANTON,MA 02021 Honeywelf-White Installation Contmeter-Yellow Customer-Pink Revised 1012010 �= Office of Consumer Affairs Business Reg License or registration v N _ itHOME IMPROVEMENT CONTRACTOR valid for individul use only ~� �`' before the expiration date. If found return to: -�Registration . 102726 p 'a Expiration 7/2/2018 Type Office of Consumer Affairs and Business Regulation DBA 10 Park Plaza-Suite 5170 g POLAR BEAR INSUIlA.—T CO:.: . Boston,MA 02116 Vincent LeBlanc .. 51 SO.CANAL ST #5A LAWRENCE MA 01844- Undersecretary -------- _y Not valid without signature --- Massachusetts --Department of Public Safety Board of Building Regulations and standards Construction Super,isor SpecialtN License: CSSL-105924 VINCENT E LEBtANC 24 LANDING DRCQ METHUEN MA 61844 Y ' ,.4 �• Expiration"" Commissioner 01/30/2016' DRIVER'S LICENSE ga END 4d NUMBER $; 03 20-2013 NONE •S09063933 �4b - 3 DOB . 01=30104-1 1- }•t Ma sD -� NONE �s SEX M 16;Ro7 m M _ VINCENT E a 24 LANDING,DR g13�iga1 METHUEN,MA 01844-5825 5 DO 03.21.2013 Rev 07.1,,nag. d ! 1