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Home My WebLink AboutBuilding Permit #527 - 91 WAVERLY ROAD 3/1/2010TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: ✓ D` Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION t.11 61 V e y t Print PROPERTY OWNER 1,1) /1- e S e EtJe- t E Print MAP 'NO: PARCEL: ZONING DISTRICT: Historic District yes o` Machine Shop Village yes c TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District. Water/Sewer f3 UESCRIPTION OF WORK -TO BE PERFORMED: a"I, Identification Please Type or Print Clearly) _ OWNER: Name: �r� m B 5 (f rppt''i✓y e � i G Phone: q �� 2 - �s /v Address: {, r K iy 12 CONTRACTOR Name: -ffcc 6 C < Pho Address; -7 ? ��:n � T dto 6'7N -cb, a i fO' Supervisor's Construction License: Exp. Date: Home Improvement -License: % r 1? Exp. mate: 6A�/,� 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: $ i 3 0 a - 0 FEE: $ r Check No.: '21,a:�r q Receipt No.: 22C 25- NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund T 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION- Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments 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 924 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories: Total land area, sq. ft.: Total square feet of floor area, based on Exterior dimensions. 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 - Date Doc:.Building Permit Revised 2008 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/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: Doc.Building Permit Revised 2008 Location �& A& No. Date't/U TN TOWN OF NORTH ANDOVER � 9 • i „ ; Certificate of Occupancy $ �M�s Building/Frame Permit Fee $ • Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 22,25 az Buifding Inspector m m m //m VI m mm Cl y .0 � d CO) C'7 Com! Z CO) 06C) r C � � C CL y a.CO CD o p . CD o rF CLQ CD CD CD C CD y� av � CD C2 y O CD CD Z� o CD 0 C CD f w�� cn .H V J O s fA O Q N Soy• 1 y ��®0 o ci m c� c. � m o = Z N m .+ C �. =r -c N •�I — m N *a c CL y W �an d o o CO) N Oo IE �m: m = = CD 'O O O, O % O Zy 0 � 00 c m . C N a �Om�J �a o y A O m to c CIL y v a y O p� N t' N d d T Q � a CL C= .�► CA O N vj N ! m 02 CO) O m C, cc ao . 'C O G N w w � O O cd ® N d so a.o c� an, O =CA. =o c o O �• O C 0 C.i Deo 1' ti of Yil D = 0 m nD 1 ' -A i ! im r v Cn n CA Cc n cn011 O ce O O aQ O 7 c�^n al CL x Q. B -J d ndards rT -eon/,p 'Illations of } Board of BaildingEME ST COHTRCcT�F`` 1 E IMpRpVEN►. HpM 126398 -f r# 266302 Reg-Jstratlon I �[at�on 51261,2010 1 E p r Nldua► �m�� Type, ► �a `L G Joceryne S►rois '�'-",,A, Jocelyne Sirois , 1 Admire's ratol J 77 Elm St v Methuen IJIA01844 tmcn 01 Ptrktlic S.tkot� t .111.6s rSt<<nd' t, pcpa iort� `►ntk ► Raij itt license �1 �ts�ac ery isor guildin . ► go�uconstruction Sup CS 6'857 �icen5e' Restricted to 00 l! SIRp1S -' go BO�k 2461 NIA p1844 1?J2912p10 MEIN Expiration• 1329 Insert Fine Print Here Insert Farewell Statement Here J. Sirois Woodworking and Construction PO Box 246 Methuen, MA 01844 Tel. 978-6854504/Cel/ 978-360-8448 Invoice No. JINVOICE _ Customer Misc Name Mr & Mrs James Cheverie Date 2/27/2010 Address 91 Waverly Rd Order No. City No Andover State Ma 01845 Rep Phone 978-725-8510 FOB Qty Description Unit Price TOTAL 1 Remove old plaster and fix plywood on floor. 1 Replace with new drywall,tile in shower and floor. 1 Repaint bathroom,fix ceiling in kitchen where open to fix tub. 1 Install new fan in bathroom and lights. 1 New fan above stove. 1 Carpentry and wiring permit include. 1 Material and labor $7,300.00 $ 7,300.00 1 Down payment. 1 Balance to be paid when job complete. 1 Tub and toilet supply by plumber. Jt4 vJ SubTotal $ 7,300.00 Shipping Payment Select One... Tax Rate(s) Comments TOTAL $ 7,300.00 Name CC # Office Use Only Expires Insert Fine Print Here Insert Farewell Statement Here The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations . 600 Washington Street Boston, MA 02111 www.massgov/dia Workers" Compensation Insurance Affidavit: Builders/Contractors/Electridans/Plunatlbers Applicant Information Please Print Le-Obly Name (Businms/Organization/Individual): v a�� Address: `7 If/P-1 0 City/State/Zip: j)i e -T Phone #: �'/ �� ' Vsay Are you an .employer? Check the•appropriate box: I-[] I am a employer with 4- ❑ 1 am a general contractor and I employees (fullaxrd/or part-time). have hired the sub -contractors 2.9I am a sole proprietor or partner- listed on the attached sheet 1 ship and have no employees These sub -contractors have working for mein any capacity. workers' comp. insurance. 5. ❑ We are a corporation and its - [No workers'. comp. insurance required.] officers have. exercised their 3. ❑ I am a homeowner doing allwork 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): 5. ❑ New contraction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition I0.❑ Electrical repairs oT additions I L❑ Plumbing repairs or additions 1211 Roof repairs 13.0 Other - *Any applicant that checks box #I -mils[ 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 their workers' comp. policy information. I am an employer that is providing )0orkers' compknsation insurance for my employees. Below is the policy and job site information - Insurance Company Name: 64��. Policy # or Self -ins. Lic: #: C d 1 X0 �� St " Expiration Date: Sob Site Address:_ _ (it� �, ! City/Statelzip: -h Attach a copy of the workers' compensatyn 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 $250.00 a day againstlhe violator,- Be advised that a copy of this statement may be forwarded to the Office of lnvestigations of the DIA-fdr Mau-= -coverage verification. I do hereby .certcry under the pains annd penalises of perjury that the information provide�dj7 acorrect - J, is true and correc / r i // w .._,�, tint[•• d / Z. Phone #: V Oficial use only. Do not write in this area, to be completed by city or town vfficiaL City or Town: PermitlLicense # Issuing Authority (circle one): 1.,_$oard of Health. _2_ Building Department 3- Citylrown.Clerk 4. Electrical Inspector 5- Plumbing Inspector 6. Other Contact Person. Phone #- w �j7 p�0 CERTIFICATE OF LIABILITY INSURANCE OP ID DATE (MMIDD/YYYY) 3 02/16/10 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION TYPE OF INSURANCE ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Michaud, Rowe And Ruscak Ins. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P.O. Box 188 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. North Andover MA 01845 GENERAL LIABILITY Phone: 978 688 8829 Fax: 978 557 2130 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Preferred Mutual Insurance Co. 15024 INSURER B: Sirois Woodworking Jean Guy DBA INSURER C: 77 Elm Street PO Box 246 Methuen MA 01844 INSURER D: INSURER E: UAMAUE'UEly- PREMISES (E.occurence) $ 50000 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. MH LTR AUUM SR TYPE OF INSURANCE POLICY NUMBER CTIVE DATE MNWD TION DATE AAM/DD LIMITS REPRESENTATIVES. AUTF10REPRESENTA GENERAL LIABILITY EACH OCCURRENCE $ 1000000 COMMERCIALGENERALLIABILITY CLAIMS MADE F—I OCCUR CPP0120526510 UAMAUE'UEly- PREMISES (E.occurence) $ 50000 MED EXP (Any one person) $ A X Business Owners 03/12/09 03/12/10 PERSONAL &ADV INJURY $ 1000000 GENERAL AGGREGATE $ 2000000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2000000 POLICY JECT LOC AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT $ (Ea accident) BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO AUTO ONLY: AGG $ EXCESS / UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR O CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION WC STATU-7-7'J'H- AND EMPLOYERS' LIABILITY y / N TORY LIMITS I I ER E.L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE[D OFFICERIMEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ (Mandatory In NH) If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT 1 $ OTHER DESCRIPTION OF OPERATION / LOCATION / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Woodworking CERTIFICATE HOLDER CANCELLATION ACORD 25 (2009/01) 0198EP2909 ACORQCQRPORPTION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION NORTAN2 DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN 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 Town of North Andover Sutton Street REPRESENTATIVES. AUTF10REPRESENTA North Andover MA 01845 ACORD 25 (2009/01) 0198EP2909 ACORQCQRPORPTION. All rights reserved. The ACORD name and logo are registered marks of ACORD