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HomeMy WebLinkAboutBuilding Permit #434 - 92 BRIDGES LANE 10/17/2002 BUILDING PERMIT °f "°pTH qti TOWN OF NORTH ANDOVER F APPLICATION FOR PLAN EXAMINATION Permit NO: � � �{ Date Received �� � � op •�°� � p°q^reo SPP 4h �SSACHU`��� Date Issued: IMPORTANT:Applicant must complete all items on thispage LOCATION —i's ==Pnnt = - PROP_ERTY,OWNER -c ��a2 ►_th�.� .. S�1S,A..I :SRS A mPri-t ` MAP NO:I t_-D; _P,.ARCEL' '7� ZONING IDISTR-CT: Mistoric Districtyes ; �llach�ine Sho Villa e - p� . g yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non-.Residential N lding a fami ddition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: De olition Other Septicl1/ell' -load plain Wetlan s .WatershedjDistnct 'Water/Sewer , DESCRIPTION OF WORK TO BE PREFORMED: Zc a4---4 --� rCQ i Identification Please Type or Print Clearly) CoS8 -SC1'19 OWNER: Name: ari ��.�.,�S Phone: 78 - suo -c.ot4 Address: CONTRACTOR Name. P.horie tp a 3> 4,z5 Fss r-> ak�. �ctii t " , ^ 4 ;? dress -3 Sc `-r47. Su:pervisor's=Construction4'License Exp Date W 'h � s _ Ho:mearm.provement'Licer!se Exp 'Dae ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BAS D ON$125.00 PER S.F. Total Project Cost: $ k7- E o o a — FEE: $ �I l r Check No.: lSRecei t N .: L .7 N • � j NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Si nature of A qwn 5 ner nature of contractor 9_ _ ___9 �,,,.�,.,,rs.�s�,.•a��"��s.t+r+�.,`.�i•-•—.r..w.,.re"iy.•.s.�.-4..,+N'Fe'.f`�"....aE...i(y�.>—�V:�.v�+L..Yn.+.+•,..%iwY'?�f1^°yr.`r't'-+I�' Location Date / No. 7 t NOR7M , TOWN OF NORTH ANDOVER 3 °t w F p • certificate of Occupancy Building/Frame Permit Fee $ �SswcMusE� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ �- Check # _--- 2 i 1 I Building Inspector 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 & DEVELOPMEN COMMENTS CONSERVATION Reviewed on , Signature COMMENTS i�/L2 v l'1 i 1 y /cam: t U-c rr HEALTH Reviewed on Si nature COMMENTS 'f-/'r :zz' k i 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 F]RE DEPARTMENT Temp-Durnpster on site,. yes sno Located7at !24�NtamStreet = Fire Departmentas:ignature/dates 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 - Date i Doc.Building Pernut 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 ❑ 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 0 Certified Surveyed Plot Plan ❑ Photo Copy of H.I.C. And C.S.L. Licenses ,,u- 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 et this recorded at the Registry of P PP Deeds. One co and roof of recording g g Y PY P g must be submitted with the building application lication Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 CERTIFIED PLOT PLAN LOCATED /N NORTH ANDOVER, MASS. SCALE:1"= 40' DA TE:911212008 Scott L. Giles R.P.L.S. Frank. S. Giles R.P.L.S. 50 Deer Meadow Road North Andover, Mass. W 38. N _s O w / � 0 c) O �o LOT#7 43,898 S.F. a 1 1 CERTIFY THAT P`tN 0f THE OFFSETS OFFSETS SHOWN ARE FOR THE USE yah 0 OF THE BUILDING INSPECTOR ONLY o Sc SHOWN COMPLY AND SUCH USE iS FOR THE S y WITH THE ZONING .13972 DETERMINATION OF 20N/NG Fs�'�ECIS BY LAWS TER NORTHANDOVER CONFORMITY OR NON-CONFORMITY '�qL LAKO WHEN BUILT WHEN CONSTRUCTED. NORTH c To"%vn of over , to No. �=_ LAKE O` dover, Mass.,-/-% I� COCMICKEWICK �A 7�S RATED PS BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System • BUILDING INSPECTOR THIS CERTIFIES THAT............ .. �,".1.L Foundation has permission to t..... ............................ buildings on ...... �.............. Rough to be occupied as... ..... ......A............ .....#. .... ....... . ...........1�i,)( �10)(14.............. Chimney provided that the person a pting this per lt shall in ev respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-La s 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 CONSTT'U SS Rough ............................. Service BUILD CTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. SEE REVERSE SIDE Smoke Det. CERTIFIED PLOT PLAN LOCATED IN NORTH ANDOVER, MASS. SCALE:1"= 40' DATE:919212008 Scott L. Giles R.P.L.S. Frank. S. Giles R.P.L.S. 50 Deer Meadow Road North Andover, Mass. `OV � Q� w w N 381 0^ W co 0 0 0 LOT#7 43,898 S.F. 1 CERTIFY THAT OFFSETS SHOWN ARE FOR THE USE �a`tN OF I THE OFFSETS OF THE BUILDING INSPECTOR ONLY o SC , SHOWN COMPLY AND SUCH USE IS FOR THE WITH THE ZONING 72 DETERMINATION OF ZONING i39 ' psi CISTER �� BYLAWS OF CONFORMITY OR NON-CONFORMITY �C LAHb „ NORTH ANDOVER WHEN CONSTRUCTED. WHEN BUILT f poHTp TOWN OF NORTH ANDOVER o `"_•D ''1"° OFFICE OF w BUILDING DEPARTMENT 1600 Osgood Street Building 20, Suite 2-36 North Andover Massachusetts 01845 1sswCHustt ' Gerald A.Brown Telephone(978)688-9545 . Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION lease ' t DATE: zoo JOB LOCATION: C(Z ^3•-,iia, lr.,� o r Number Street Address MAp/t,ot HOMEOWNER Name Home Phone Work phone PRESENT MAILING ADDRESS Sq City Town State Zip Code The current exemption for"homeowners»was extended to include owner-occupied dwellings to two units or less and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned"homeowner"assumes responsibility for compliances with the State Building Code and other Applicable codes,by-laws,rules and regulations. The undersigned-homeowner"certifies that he(she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNERS SIGNATURE APPROVAL OF BURDING OFFICIAL Ind 10.2005 I Foma HomwMm Exemption RO:\ID(.)F \PPE:V.S6RF')54.1 CU.NSERV.MON6188-9530 ITEAL111698-9540 PL.L\',-I\C,688-9535 i .: . k ` f+ - r I i 7-7 na i; + ' Fes, t�5 Hovs� 4-. v � ! r. I \� i ❑ � r FL2i - 5 f4sb PT j C j io o.Z. P t,0 R,FDN - 1 t � L lA,. ! � . } | r ! | | / | / . ] j t � 170 i t c' t H ":.a J Timis t a Eb T The Commonwealth of Massachusetts • 4 Department of Industrial Accidents Office of Investigations i ii iti i - 'i 600 Washington Street Boston, MA 02111 www.m ass.gov/dca Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): —Tyv-8.m�act„� Address: "kz :3 e.A b C hS L� ill 8-(0 8 8 •S`t't`� City/State/Zip: &p . A-.')2b) Qk' 0 AAf*- 0',%47 Phone#: ��� �'<� •�•tc,� �,o z� Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 1 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. [Building addition o workers' 5. We are a comp. insurance co ance ❑ oration and its P corporation required.] officers have exercised. 10.❑ Electrical repairs or additions 3 1 am a homeowner doing all work right of exemption per MGL l I.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no insurance required.] t employees. [No workers' 12.[] Roof repairs comp. 13 ❑ Other insurance required.]gwred.] +Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they arc uoii-ig all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: 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 this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct Signature: Date: to Phone#: '7!b TZ.4 ' 4-b Z.1 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 M 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 hire, 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 local licensing agency shall withhold the issuance or renewal of a license;or'permit to operate a business or Wconstruct 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-contractor(s)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 submitted to the Department of Industrial Accidents for 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 Office of Investigations would like to.thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia 09103/2008 08:46 ttAx) r.UU IrUU I DATE(MMIDDlYYYY} ACORD- CERTIFICATE OF LIABILITY INSURANCE PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION STETMtFiRT I.TD/INSURANCE ° ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER_ THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ----_—.----.—I—ALTER_THE_..COVERAGE_AFFORDF.D--BY-THE-.P-OLICIES-BELOW.- Raymond, NE 03077 6031895-2200 INSURERS AFFORDING COVERAGE MAIC* INSURED Shelter Enterprises, Inc INSURER Travelers Insurance Crowning Glory Cupolas I INSURER B: Liberty Mutual � I 335 Route 135 rr:SURER C: I Brentwood, NH 03833 ..SURER D: 603-679-8555 INSURER E. COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING ANY REQUIRE5;ENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR J! 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 11001 _ POLICY EFFECTNE POLICY EXPIRATION LIMITS LTR TNOBD TYPE OF I RAN POLICY NUMBER I DATE MMIDO DATE Nvu00NY I cuceni rno Iry EACH OCCURRENCE s 1.000.000 DAMAGE I. 1 8 COMMERCIALGENERALLIAMLITY PREMISES EaRonce = 300,0001 'CLAIMSMADE Fx�OCCUR MED EXP(Any one person) S 5.000 6809193C503COE'07 01-01-08 101-01-09 PERSONAL&ADV INJURY s 1.000-00 0 000 000 GENERAL AGGREGATE 3 2,000,000 GEJ7.AGGREGATE LIMIT APPLES PER- PRODUCTS-COMPIOPAGG Is 2,000,00 POLICY JECTT LOC AUTOMOBILELIABILTTY 'COMBINED SINGLE LIMIT fANYAUTO lEa accidenq ALLOWNEDAUTOS BODILY INJURY S Per parson) SCHEDULED AUTOS I(Per — HIRED AUTOS BODILYINJURY 5 HOWOWNEDAUTOS IPol"C64e1 11 } I(Perraccident)vwwE $ i GARAGE LIABILITY IAUTO ONLY-EAACCIDENT 3 ANYAUTO I OTHER THAN EA ACC S ElAUTOONLY: AGG S EXCESSIUMBRELL{ALIABILITY EACH OCCURRENCE S — I OCCUR i I CLAWSMADE AGGREGATE S ' neoucrlBLE I � s RETENTION S s STATU- OTH= WORKERS COMPENSATIONAND ITORYLIMITS I ER I WOAKE SCOMPENSY RC531S360456016 10-27—O7 10-27-08 1 E.L.EACH ACCIDENT -S 100,000 1111111M` MIARTNERIEI.CVn4E B OFFICEMMEMEER L7tCLIJ0E07 E.L.DISEASE-EA EMPLOYE S 100,000 'bounder n w A S'PFCiA'LPRVviSiOfrobtiow I s.L aLSEA$E_POLiCYLim�i a 5011 1Or� OTHER I DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS f i CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE-DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Ted Lewis DATE THEREOF,THE ISSUING INSURER WILL ENDFAVOR TO MAIL3D_ UAYS WRITTEN 92 Bridges Rd NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL No Andover MA 01845 IMPOSE NO OBLIGATION OR LIABILITY OF ANY IOND UPON THE INSURER,ITS AGENTS OR fax 9978-451-2660 R£:'.'ESENTATRES. AUTHORIZED REPRESENTATIVE ACOR025(2001108) ©ACORD CORPORATION 1988 c��aM2FE ORDER DAVID L. ROBERTS CO. Division of Shelter Enterprises, Inc. 335 Route 125 • Brentwood, New Hampshire 03833 (603) 679-8555 Fax (603) 679-8066 U 6 011 A Design/Build Corporation CHANGE ORDER NO. g ADDRESS DATE MA7 , � PHON JOB NMACAND LO., ,,..,. OD".,.:"EER DATE OF EXISTING CONTRACT s TL� 4- >E - ...... .... . . .... . .. .. .. -S N te: Is revision becomes part of,and in conformance with,t e existing //K€ WE AGREE hereby to make changes as specified above, at this price $ L(�i PREVIOUS ��� CON�nACT Date_ti.���!= U,4��0�1 AMOU4-1t'�Aad- REVISED CONTRACT $ ;P.-..erized Signa 're; L TOTAL ACCEPTED: The above prices and specifications of this Change Order are satisfactory and are hereby accepted. All work to be performed under same terms and conditions as