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HomeMy WebLinkAboutBuilding Permit #72 - 88 DUNCAN DRIVE 7/24/2009BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 72 Date Received Date Issued: ZI—A y o IMPORTANT: Applicant must complete all items on this page LOCATION FS % DUMC -AQ Dk Print PROPERTY OWNER GASJ W tE MAN&i Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village ves Vi$ TYPE OF IMPROVEMENT °t o n1. 41I LOCATION FS % DUMC -AQ Dk Print PROPERTY OWNER GASJ W tE MAN&i Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village ves Vi$ TYPE OF IMPROVEMENT PROPOSED USE ResidRe Non- Residential New Building tamily Addition Two or more family Industrial Alteration No. of units: Commercial e air, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: Identification Please Type or Print Clearly) OWNER: Name: GA2q bolp-r.-gNr.j Phone:9'7�•z�s-�tSa` Address: R!E DjPJ CONTRACTOR Name: 7 1,14/4 w news `c.�,lf..� ,J.�I�t S Phone: C Z-21�5.7Js'S' Address: ►-LS Rswo!t- 2o 04.2 2 -- Supervisor's Construction License: /9 f(5 k-5 3 Exp. Date: /O 7-4 `10 Home Improvement Licenser ARCHITECT/ENGINEER Address: Phone: Reg. No. ll -Od FEE SCHEDULE: BULDING PE /T: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $-N,600 — FEE: $ k-0 -" Check No.: �Ld� Receipt No.: 22-2- NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner M=,,-----A.,/,------Signature of contractor I Location No. 7.2 Date 7 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame /Frame Permit Fee $ sAcwust 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # �Eo-- BAiIdind Inspector I 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 COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS DATE REJECTED DATE APPROVED Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes c Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osaood 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 MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine NOTES and DATA — For department use ❑ Notified for pickup - Date i Doc.Building Permit Revised 2008 No 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 ❑ 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 Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 c O U O u v U a Cc: p O ^C C ww CIOw m p q GG w � � cn -co G iw � E-� :3 c4 co ii w Qtr w a] z cn GAJ o O cn H � � uj z am c � W c� O (A i.+ C O v V :'alp R ev A CD c .� s o (/) CD_ Ec Z � J' O :gym z c� O � o C$ u Co42 �O `i um ate. c E H � m y m3 l� m Ca C3 o w O mo cm e` ace m C/) cacooW 4 _ �J acz m (� m � C3 Ho o c V � Q c Q ti C O = m m=m o N o E- m CO3 W CO � �v te... rcO 21m r.. N C=U= = C Z oc E -o v ."C O C** a m- O� _ ` y O �- r sa*.m :IN as 0 O v Z CD B. O H 0 C � c CM O•� CA �E m m CD = O .O 3� O a o�Q c o c ca �ev .o C Z CD V y O C C c CO2 0 LLI 0 U) LLI U) oe W W cc W N The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations kv 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information1 I Please Print Legibly Name (Business/Organization/Individual): pe t lek W`i V_,C4 _-.) W S ctot4 Dto rS I A� • Address: q S, ppv\4% U City/State/Zip: kyperki l/ NIA c w 32 ° t�Pfiibi$���k:,: � i�r,�2-�s• 7 � SS Are you an employer? Check the appropriate box: 1. DA I am a employer with Jr• 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the'attached sheet t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing the 'Wb&'efs1 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 their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: __twe� C. C Vry1 Policy # or Self -ins. Lic. #: D OoW S JV L- 5 N2. Expiration D: -T-61 — Z , I Job Site Address: City/State/Zip: 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 finis 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 infornkdon provided above is true and correct. Signature: Date: -7 " LY -0? Phone #• Official use only. Do not write in this area, to be completed by city or town offklal 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 #• ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE 20091 :20 06/30/2009 16:20 PRODUCER (800) 225-1865 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Fred C. Church, Inc. 41 Wellman Street Lowell, MA 01851 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 800-225-1865 POLICYEFFECTIVE POLICY EXPIRATION INSURERS AFFORDING COVERAGE NAIC # INSURED INSURERA: Citizens Insurance Company of America New England Window & Door LLC 45 Fondi Road Haverhill, MA 01832-1302 INSURER B: Hanover Insurance Company INSURER C: Massachusetts Bay Insurance INSURER D: Wausau Underwriters Insurance Company 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. INSR ADO'L REPRESENTATIVES. POLICYEFFECTIVE POLICY EXPIRATION Is TYPE OF INSURANCE POLICY NUMBER DATE IMMIODNYI DATE IMMIDDIMLIMITS - GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIABILITY DAMAr�X RENTED PREMISES Ea occurence $ 100,000 CLAIMS MADE M OCCUR MED EXP (Any one person) $ 10,000 &ADV INJURY $ 1,000,000 A ZBN8161407 7/1/2009 7/1/2010 -PERSONAL GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 POLICY M PRO- LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 X ANYAUTO (Ea accident) BODILY INJURY $ ALL OWNED AUTOS C SCHEDULED AUTOS ADN8162169 7/1/2009 7/1/2010 (Per person) BODILY INJURY $ HIRED AUTOS NON -OWNED AUTOS (Per accident) PROPERTYDAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO AUTO ONLY: AGG $ EXCESSIUMBRELLALIABILITY EACH OCCURRENCE $ 9,000,000 X OCCUR FICLAIMS MADE AGGREGATE $ 9,000,000 $ B UHN8167305 7/1/2009 7/1/2010 $ DEDUCTIBLE $ X RETENTION $ COMPENSATION AND ){ WC STATU- OH - _LIMIJEWORKERS D EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE BINDWC 7/1/2009 7/1/2010 E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 OFFICER/MEMBER EXCLUDED? If yes, describe under 500,000 SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION New England Window & Door LLC 45 Fondi Road SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN Haverhill, MA 01830 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. AUTHORIZED REPRESENTATIVE P ACORD 25 (2001108) Client # 7Qrn Mst # 09-10 GL, WC, Auto, Cert # © ACORD CORPORATION 1988 Umb . § C - 14 • _ .e«- « e. 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