HomeMy WebLinkAboutBuilding Permit #308-15 - 89 LOST POND LANE 9/25/2014 BUILDING PERMIT o*"°RT b qti
TOWN OF NORTH ANDOVER 00�,
APPLICATION FOR PLAN EXAMINATION
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Date ey
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Permit No#: �g17E0'`PP �y
Dat �SSACH�15��
e Issued: �i�
I PO TANT:++Applicant must complete all items on this page
LOCATION I.ns� D�id1 iL�
Print
PROPERTY OWNER Chl`i.s
Print 100 Year Structure yes no
MAP PARCEL:arlo7 ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building VfDne family
❑Addition ❑ Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
klRepair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District
❑Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Repair 0A /drr rrcel-Acd &, ; Jor An-/in anj Stdm
Identification- Please Type or Print Clearly
OWNER: Name: r pis Phone:
Address: osA- PO
Contractor Name:,'��eueMj Phone: -4/43
r
Address: t/ 4en� 94 • -50/mn 70
Supervisor's Construction License: ` - 103C) 1E Exp. Date:1�/d�/a?d/5�
Home Improvement License: Exp. Date:--7��,6zq/1—
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: $ ,ODO. D0 FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner S` --•^ Signature of contractor ' - '
Plans Submitted ❑ Plans Waived 0 Certified Plot Plan ❑ Stamped Plans ❑
TYPE"OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/Massage/Body Art ❑ Swirmning Pools ❑
Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑
Private(septic tank,etc. ❑ permanent Dumpster on Site ❑
I
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
1COMMENTS
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
ti
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)
❑ Notified for pickup Call Email
Date Time Contact Name
Doc.Building Permit Revised 2014
J
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
o 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
o Workers Comp Affidavit
a 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 ConstructionSin le
( g and Two Family)
o Building Permit Application
o 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:Building Permit Revised 2014
Location D
No. Date
• - TOWN OF NORTH ANDOVER'F
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check#
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J v
Building Inspector
IAORTH
Town of t E 1,, ndover
O - 0
No. ro
T Z
o Ah ver, Mass,
COGNIc Mt Wlcu 1-
Pay TEO ^p
S U
BOARD OF HEALTH
Food/Kitchen
PERMIT L D Septic System
THIS CERTIFIES THAT Ckus ..........9.0,1%........................................... BUILDING INSPECTOR
.................. ...... .. ... .
.. .. Foundation
has permission to erect ....... ................. buildings on .......�.......L&:kYw.1.*4*A� j..0w4,L..
Rough
to be occupied as ............. ...... ...��i............'... 4spect
.....�.... ........ �.......................... Chimney
provided that the person accepting this permit shall in eve conform to the terms of the application Final
on file in this office, and to the provisions of the Codes anti FY--,L s r ating-tgile. In�ction,Alteration and
Construction of Buildings in the Town of North Andover. 1" l �/ (/�+ • PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
q& UNLESS CONSTRUCTIO M T Rough
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.
The commoniveaRk offfassaehasetfs
office o, fAvexsfigaflons
d#O Washineon�S'iteei
asiog, 02111
-t i mussgo-PId rz
Affidavit:
g 1du 1 -
.�7a�.e(Business/dr auiaation/l'ndz`u' ^al} .S'tG1lL
Address: denrY YJ. c ♦� 2
City/ tate,!.�Jl.�. \ L�'�M f• Iw O 1 1-7V � V1Rv .^ -z
.6xeyont an empleyer?cheekthia appxopxlatelaox: Typo of'project(re%*ed):
1,Q am a ex�aployer-with_. 4- El S am.a general contxactax and 1 6, []New censfmc-U0n
playees(�avd(ox�a�tune}T 71ave�iredthe sub-cox�ractoxs
2. S am a sole proprietor orpaztnex
fisted onthe attached shoot° `7. R emacleliug
BMP and`havono•employees Thesemb-contractowhave 8. ZFemolition
woriing .foxma in.any capacity. workers'comp,insurance, 9. []Buildhig addiflon
PTO w031-exs' comm.�nsmauce 5. ❑we axe a corporation and it's 101]Eleetricalle'.V&s ox additions
xecluixed.� ofzcers have exercised.their
3.El Z am a homeowner doing all work right of exemption per MOL Il,.�P umbingxepaixs or additions
mys err.U owoxkers°comp. c.152,§1(4),and.wohavon.o 12,PR_oofxepairs
insnraxzcere Zixed.�i employees.L'aworkexs' uEl Oaer
comp,kBwancexequked.]
Avyapplicanethai checksbox ZmasEa�so llonithesectionbelo�rsho�ingtiieirvrorkers'eompmswonpolioyinformafion.
7 omeov�ners vTha mtMi6hkawdavitmdicatingifiey redpingalZworkandtbeobit°oufsidecantracforsmns�submi anewaf�davi indica�iugsuch
xCon-�aofarstha�cbeokthisbo�mUs4atEached�zadditionalshee�shov�zngtfienameofthesuF�-contra°forsand#teirvtorkexs'eomp.policyinformaiian,
�'t��a72ernp�oy��t�itr�i�,��avir�i�tgt�os7�e��'cornpe.�asr�tiorxinsr�ra�cefa�.�rzye��loyee� .�eiot�a���e�alicyt�r2ti,�o�,�iz'c
infon"Iffaon.
hsnxauce cmpanyName:.
kolicy#or Selin.s..Bic.#: Expiration Date:
rob bite A ddxess: CityiState/71p:
ttaelxaCOPY ca tXlowoxkexs'co�mtpensationjiolzcytleclaxatzoupage(silowing-Me,policynwaherand e�ixatiorcdate.
Failure to secure:coverage as xequirecTuuder Sectzon.25.A-ofl GE c.152 can.leadto the impositian of exh9Aalisenal as oz a
:iue up to$1,500.00 and/ox onu-year imprisozvnenE�as wep as czPitpenaltzes in ih e foxrn of a STOP WORY,ORDER.and a fine,
op-UPto$250.00a.dayagainsttheviolator: Ba advised that a copy ofthissiatementmaybofoxwaxdedtothe Ofaoeof
investigations of ffio.DfA for i4lxance coverage verification.
tto XZeeby cep#�fy zrricie #iieiains�a�tctperZartieg a�pejFry#Xicrt#rZe iz2o �rrziax�p�oviec�aroYe is due ancicat�ee#,
S`tanature �
Data,: q •? bl
i'ho�e# -7V—4' 13- 46.21
Qfciax Use 0rtry. Do not write in trim area,to be coftwrefed by City or toren ofeiaf
City or 'own: Permit/License#
SssuingAuthority(okefe(ne):
Z.Maid ogoealth 2.BUffding)[)epartment 3.CityROWt clexk 4.Eleetxleall''nslrector S.RInmbing Inspector
€,Outer.
Information and Instruction
Massachusefts GenexalLaws chapter152xequires all employers topxovidewoxkexscompensationfor their employees.
-PUTS faxitto Ibis staf ite,an ervPfoyee is dofmod as"..,evexgpexson irilelie sexvzce ofaaaothm imder any c ikaot oi•bixe,.
epxess oim�alned,oral oa`wxitfen."
An efmfoye is dofmod as"anzndivzdual,pt inexsh ,association,corporation ox otherlogal eAtitya or anytwo flrmoxe' .
of thofoxegoingengaged inajointentexpxise,and includingthelegalxepxesenfagvesofa'deceasedemplp ex,.oxthe
receiver Or. p,associations,or eLher legal mfity,employing employees. Sov,�evexihe
ownerofad�ellingltousehwhignotmoxethmtht'eeapathrtentsand�vhaxeszdostbexein,ortheoccupaz otthe
dwelling li ouse of another who employs persons to do maintenance,comtraction orxepair wo*on such dwelling house
or axrthegxounds orbuilding appuxienanttherefo shallnot because of such exnploymentbe deemedto be an employe "
MGL chapter 152,§25C(6)also states that"every state or local JZcensing agency sltaTl tzth7Zold the issuance or
renewal of a license or permit to op exate a Tomiaess or to constmet buildings k the:coanrmaawealth for any
aVOcank who has not produced-acceptable evideRee of coampliaaace with the iarsuraaice coverage regnzred;'
.additionally,MUL chapafex 152,§25C(7)states Voither the commonweafh nor any ofits political subdivisions shall
enter into any confract fox the p exfoxmance of publicoxuntil acceptable evidence of compliance with the insurance
-requirements ozthis chapterhavebeextpxesentedto.thb coufxactingauthority2'
.r ppucants
PleasP,dtl o at the woxSrexs'compensanZon affidavit completely,by cbecliing ttre boxes that apply to your situation and,if
iieceagary,supply sub-confraotox(s)name(sj,addxess(es)ardhonenumbex(s)alongwiththeir cex€iftcate(s)of
insiixance; LimifedLiabilityCompaMes(LLC)or mifedLiahilitj•partnexships(LLP)Withno employees otherManthe
membersoxpaztuers,arenotxequixecfocaxryworlers'campensatzoxtinsuxance. anT�LCorLL?�doeshave
employees,a polncyzsxegaxed. Be advhodthatfliisafdavltmaybombn:&tedtothe Departmentof indusfd
.Acoident fox conffi:tnatzon ofinsurance covexage. Also ba sure to sign•and date fhe affidavit The af%vitshould
b e xetumedto the city or town fhatthe application fox thepermiE or license is being requested,nod the i7earim ens of
kdusfrialA.eeidenfs. Shouldyouliaveanygaesiionsxegaxdirg&elawerziyorsal'oxecpzitedtoobfaiva*oxkexs'
comp ensaffoupolicy,please call the Department at f n amber listed below: Self-h=ed companies should enfa melt
seli^imurance Incense mn&r on the appropriate lice. I
City or Tom MOOS
f'Ieasebesuxefhat'�heazc�dav%fiscompleteandpxinfeclZegibly. TheDepaxim.entl?aspxavzdedaspaceattlxebottonz
ox"the afxclavitfoxyoutofill Out ktho event the Office,ofTnvestigationshasto coma-ciyotxxegardingthe applicant:
).Tease be-sure to nllin',bepexmxt/lzcensenumbex wh7eb will ire used as a xeiexencenumber, Tn addition,an app9cant
thatmust subzoifxnultiple pexmit/license applications in any givenyear,need only suhmnt one aifdavif indicating curtest
P olicy iMormafion(h,necessary)and under .Tela Site.Address"tfte applicant shouldwrite"all IOCatgD:M iaz .(city or
towir)"A copyoi tTie aftidaviGthat has s OR offtciallyssiamped ormarlsedbyme city Ortowumaybepxovided tome
applicant aspr9of�,atavalidafitdavit•ison�le�ar�tureperrnifsorlieenses, ,A.new�itr�davifmust7ae�11edouzeaclx
year'V&exe ahome owner or citizenh obtaining aliemse oxpennitnotxelafed to anybusiness ox commercial venture
(i.e.a doglieense orpexmittoTutu leaves eta)sazdpexsonisI�IOTxecluirectto ca nlaletethis of Zdavif,
The Office OInve3694ti0ns wWdMoto thak you inadvance fox youx coopexaflon and should yo-a have any guest'tons,
please do not hesitafe to give us a Gay.
The Depaxtln.ent's address,telephone aiad faxnumber,
T7�Oxb1�Gaf I ofM=a IAIWP
DQ-Pa teat QfW-9*W Acus iAa
6b W4qhh.WQn fteet
Revised 5 26-05 FRS E
STEVEBUILT
CONSTRUCTION
Construction Contract
STEVEBUILT, henceforth known as "Builder,"and Chris Johnson (89 Lost Pond
Rd), henceforth known as "Client,"are entering into this contract this 12th day of
September, 2014, for the purposes of establishing the provisions of the
construction of exterior repairs as described in the proposal located at 89 Lost
Pond Rd., North Andover Ma. 01845
• Client agrees to the estimate provided by the Builder on August 29, 2014,
with the following changes (to which the Builder has agreed):
NA
• Pursuant to the estimate, and the changes listed above, the Builder
agrees that he will be repairing/replacing exterior trim and siding at 89
Lost Pond Rd., North Andover Ma.
• Client agrees to pay Builder according to the following plan:
Total of$4000.00 of which $2000.00 (50%) is due in advance. The
remainder, $2000.00 is due upon completion of the work. Final payment is
due within 14 days of completion.
• Client agrees that if payment is not made according to the above plan,
Builder has the right to stop all work until such time as payments have
been brought current.
• Client understands that if changes are necessary during the course of
construction, the Builder will provide the Client with a change order, and
the Client will be responsible for the additional incurred costs of the
agreed upon changes.
• Builder will be responsible for all materials and equipment necessary for
the completion of the job, which the Builder agrees were included in the
estimate, or were added with the changes listed above.
• Builder agrees that construction will begin on September 18, 2014, with an
estimated date of completion on September 30, 2014.
• Builder agrees that any delays and/or changes not agreed to in this
document must be discussed with Client before work is to continue.
• Builder agrees to hold an insurance policy worth 2 Million dollars, which
will cover equipment, materials and all employees and/or subcontractors.
• Builder agrees to obtain all necessary permits for the construction, the
costs of which will be the builder's responsibility.
• Builder agrees that he will remove all debris, equipment, materials, etc.
from the location upon completion of the construction.
• Builder agrees that all employees and/or subcontractors will be legally
permitted to work in the United States.
Invalidity or unenforceability of one or more provisions of this agreement shall not
affect any other provision of this agreement.
This contract is subject to the laws and regulations of the state of Massachusetts.
Stephen J. Driver
Builder Name ature
Chris Johnson n� 0��
Client Name Client Signature
I
9-24-2014 11:52 PAGE1
MTE(NMmoYYYV)
OR& CERTIFICATE OF LIABILITY INSURANCE 9/24/14
THIS
THS CERTIFICATE 15 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER
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), AUTHOM7-ED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate hdder is an ADDITIONAL INSURED.the policy(es)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 endorsemen
c
tOOUCER NAME: _ •
2obert M. DeGregorio Insurance I'lp N . 161? 646-3313 X N�; (8171 846-3317
34 Woodside Avenue �ss:
Ninthrop, MA 02152 INSUMRS AF�QRDINGcowRAOE_ NAICA
INSLIRERA:EBBex Insurance Company
SURM - .. .. INSURER 9: _.. ... •-•
Steven Driver INRIRERC:
4 Henry Street IN"ER,o:
Salem, MA 01970 INSUROkE:_
INSURER F
:OVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS iOs TCERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOWHAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT W(TH 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.
r AML -' EFF � LIMTS
TTR I TYPE OF INSURANCE POLICY NBER !Y LY
4ENERALUA24LITY 3DW0007 9/22/14 9/22/15 EACH OCCURRENCE S, 300,000
DAMAGETO RENTED
X COMMERCIAL GENERALLIARILITY ( lA.(Ea awmnc9) i 50,000.
CIAIMSMADE OCCUR MED W(Anyone person) i 1,000
PERSONALb ADV INJURY S _ _
—' GENERAL AGGREGATE $ GOO.000'
PROD
U=_UCTS•ODw/QPAGO 600_,000
3 _
-17
pOI,ICY PRO,JECT LOC s
AUTOMOBILE LIABILITY _Ea accldert S
BODILY INJURY(Pat parson) S
ANY AUTO -.. .. -
AUTOS N=_D AUTOS SCHEDULED
BODILY INJURY(Per maidenq $
NON-OWNED PRO�RIV DAMAGE S
HIREDAUT05 AUTOS arocclfhrlt_„ __ _
- - b
UMBREUA LIAROCCVR EACH OCCURRENCE1P S ..
EXrESSUAB CLAIMS-MALE AGGI;r=GATE S
' S
DED RETENTION WC STATIM OTM-
WDRKER6 COMPENSATION TOSYLI-MMS,
AND EMPLOYERS'LIABILITY
YIN
AN(p(tOpRIETOIbPARTNER4;XECUTNE E.L.EACN,ACaCENT --. --
OFFICERMENQER EXCLUDED? NIA
(Mandatory in NN) E.L.DISEASE-EA EMPLOYEE S
DGdaIPOlbNe UOdOERATIONS below E.L.DSASE- ICY LIMIT
CESCRIPTION OF OPERATIONS!LOCATIONS IV04CLES (AMa0f1 ACORD 101,Additional Remarks Sclmdule,If more space Is requred)
Carpnetrv, paintinC and masonry\
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED IN
Town of North Andover AOCORDANCE WITH THE POLICY PROVISIONS-
Building Dept
North Andover, Ma AUTHo REPFircSEldTA
i
/�.
A.,fx'i'.
®1888 ORD CORPORATION. All rights reserved.
ACORD 25(2010105) The AC ORD name and logo are registered marks of ACOD
Fax: E-Mail:
Massachusetts -
Department p meet of Public Safe
ty
Board of Building Regulations and Standards
C'omtruction Supervisor
License: CS-103018
STEPHEN J DRIV,IR rr7wr
4 HENRY STREET �'.� x lip �'
�'
Salem MA 01970= +
✓ 4 }t 9N t
Expiration
Comm!{ss}oner 06/29/2415•
f., .._.-+a�_�.r.w+.--.a.x......w+........,,�G.._s........._-..-.�...._--..�..«r....._.e...»....e....,wa...`.a..n....,..n+r-?.
. �lc tft�s�tfrrrzncr�tr�/�r�n.?ft'�rs.;rr�r<se/l,° ,
_ office of Gossamer Alfiirs&Business Regulation
= ME IMPROVEMENT CONTRACTOR
egistration: 176148 Type-
iration: 7/22/2015 Individual
STEPHEN J.DRIVER
STEPHEN DRIVER
4 HENRY St
SALEM,MA 01970 Undersecretary
�_ ArA