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HomeMy WebLinkAboutBuilding Permit #386 - 95 JOHNSON STREET 11/2/2011 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION permit NO:� Date Received Date Issued: Y.I RORTANT:AppEcant must complete all items on this page LOCATION - n'lJa JZ� riot _ PROPERTY OWNER Print MAP NO:� PCEL: ZONING DISTRICT: Historic Distr7,, ye n o Machine Shop y no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building PIDne family ❑Addition ❑Two or more family ❑Industrial jAiteration No. of units: ❑Commercial 'Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑Other _ N'~ a _ — § � ��`®T�IOodpla f; �0;Wetlands o l`} r,p �Watershecl District ` D Septic, ,❑Well DES Cc 11 111 ON Obi WOR i�TO BE PERtaO_RI�UD: oaf" S © z)o� {� Identif"ic tion Plea Type or Print Clearl OWNER: Name: t (SS l CLt f i c-i ca. Vi8-r Phone: ; Address: Q,5.. k hSa n CONTRACTOR Name: �Q a S l�n S �Uc� Phone: t{7 r CENTRA Y Y9 ,Z Address: Supervisor's Construction License: C 5 5 5 Exp. Date: 1 o`Z X01 Z Home Improvement License: �J 0 Exp. Date: to ARCHITECT/ENGINEER Phone: Address: Reg, No. FEE SCHED ULE:B ULDING PERMIT.•$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASEED ON$925.00 PER S.F. Total Project Cost: $ D 0 . y FEE: Check No.: i ��� Receipt No.: NOTE: Persons contracting with unregistered contractors do Hot have ac ss to the guaranty fund -:c'- ___—_', rat: -r::_^,.rT:c.:"- -- - _ - _�ss_•_;`_....�c..2r_9:�_�Z>�-'1=> -r'j-y:-..--_-T§:4:_.__.h_ - ofA Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public ❑ Tanning/Massage/BodyArt ❑ SwhnmingPools ❑ 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 CONSERVAT 10 Reviewed on Signature COMMENTS HEALTH Reviewed on Signature $COMMENTS r y Zoning Board of Appeals:Variance, Petition No: Zoning Decision/recelptsubmitted yes Planning Board'Decision: Comments Conservation Decision: Comments !Nater & 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 i Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. i.: 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 U Notified for pickup - Date 1� I DocOuilding Permit Revised 2008mi Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Inferior Rehabilitation Permits ❑ Building Permit Application ❑ klV-Iners Comb 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 Colitl-ac ❑ 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 i 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 En ineeredirroducts NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg .Permit 11n 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.BuildiagPermit Revised 2008mi Location c� No. Date NORTH TOWN OF NORTH ANDOVER OL � F � 9 Certificate of Occupancy $ SACMU S t� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # ' 24779 Building Inspector NORTH i To"- of , . No. o o , over, Mass., LAKE COCHICHEWICK y1. %S RATEO PP"? 5 BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT................kA . .......... .......V vs.. Foundation so has permission to erect........................................ buildings on .......... ....... ... ..... .. ................ Rough to be occupied as...........s. . . Chimney ".'r....... ..........1/�i i� provided that the person accepting this permit shall in every re ect conform to the sof the application on file in Final 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 MON S ELECTRICAL INSPECTOR UNLESS CONSTRUC T Rough - ............. ........... .. ................. ............................................................. Service BUILDING INSPECTOR 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. Ng FD 8199 Date 0 TOWN OF NORTH ANDOVER RECEIPT SsgCHU This certifies that.. /51 Ir 0 ......................................T.`....................... haspaid....X ........................................................................ fu.2. /7-,-G.... .. ......., Received by......*... .. ...........I......... Department....... ..................................................................................... WHITE: Applicant CANARY:Department PINK:Treasurer The -( ®o.mmonwealth of Massachusetts Department•of Fire Services Office of the State Fire Marshal P.0.Box 1025 State Roacl,.Stow,MA 01M : . . PERMIT Date: North Andover permit No Dig Safe Num er (Cityof Town) (If Applicable) In accordance with the provisions of MG-L-1 4 8 Chapter1(Z as provided in section 5 7 7 ('MR 34 Start Date This Peraut is granted to:. Gy�� l Full name of person,Fig or Corporation Petmissionto locate dumpster for construction/renovation/demolition of building. Comments: dumpster. must be • 25 t from structure if unable to place with required Rcstnctt°°S: clearance //dumps-ter must be covered with plywood or tarp end of 'work -day at (Give location by street an no.,ordescnbgA7uch manner as to rovied adequate idcntification.of location) • +gar �._ FeePaids 50.00 Fire Chief This Permit will expire- S i n ature o tc 1 granting permit) O<f cal granting permit (Tide) The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl � v Name (Business/Organization/Individual): vsr, LSC Address: /O C V l eh -j 6,y S i� City/State/Zip:1 w 01-9t/3 Phone#: 1-179- y 9 ?02 Areyouan employer?Check the appropriate box: Type of project(required): 1. [9 11 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. t 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 [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3. F] I am a homeowner doing all work right of exemption per MGL 11.[1 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.ER froof repairs insurance required.] I employees. [No workers' 13.0 Other 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. $Contractors 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 workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: A-r lyl m aTV 4 L :7&ys u 2 r4�� Policy#or Self-ins.Lic.#: p L p w a .7 y' 7-3 3 Expiration Date: Job Site Address: '7 r �(�t�1A/ 90j•1 S°r— City/State/Zip: jqJ(). j+n,>7o✓csti Attach Att 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certiryunder the pains andpenalties ofperjury that the information provided above is true and correct. Sign re: e Date: Phone#: / �!f' 7 9" V 9 79- Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: A CORD tM. I N S U RAN GE 11MID- ...: :. 10/26!11 THIS BINDER IS A TEMPORARY INSURANCE CONTRACT UB-j7=Df T COND'ITI.0W'SHOWNOk THE REVERSE SIDE OF Ti _ PRODUCER t,�,N,,�y_ �^ C9MPANY • x I BINDER fl - FAX Z% MUTUAL INSURANCE .� 3593 om.7$� -270-559 OA`m EFFECTIVE TIME miE EXPIRATION TIME MM Mutual Insurance AM AM -� x 12,01 AM 11/204',@ 1x1 54.Th1rd Avenue 1z:o1 -�PM 11/20NOON _ Burlington,Ma 0!`•83`0 X THIS SINDER IS ISSUED TD EXTEND COVERAGE IN THE ABOVE NAMED COMPANY 31!0088 _ sue CODE PER EXPIRING POLICY 0! PLPWO79733 CouE CODEX 837 DESCRIPTION OF OPERATIONSNEHICLES/PROPE (Indud(np Location) wsuRED - Workers compensation policy VQfas Cons-tructlons, LLC 10k9 St Lawrm-ce-Na 01843 - COVERAGES LIMITS TYPE OF INSURANCE COVERAGFJFORMS DEDUCTIBLE _ -COINS% i AMOUNT - PROPERTY CAUSES DF LOSS^ BASIC ❑BROAD ❑SPEC. GENERAL UZBIUTY EACH OCCURRENCE' - COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES^ S MED W(Any ate penin) 3 CLAIMS M � OCCUR, :.: } PERSONAL&ADV INJURY S GENERAL AGGREGATE j S __.._. —.—_. ••--•--- RETRO DATE FOR CLAIMS MADE; PRODUCTS-COMPIOP AGO 15 _-_-- ODNIBINED SINGLE LIMIT . 5 AUTOMDB:LE LIABILITY ANY AUTO BODILY INJURY(Per penorl) S ALL OWNED AUTOS BODILY INJURY(Par accident) S SCHMULED AUTOS PROPERTY DAMAGE S 141RED AUTOS ( MEDICAL PAYMENTS NON-OV.NED ALTOS PERSONAL INJURY. ROT S - UNINSURED MOTORIST S AUTO PWM— DAMAGE DEDUCTIBLE ALL VEHICLES I I SCHEDULED VEHICLES ACTUAL CASH VALUE COLLISION; - STATEO AMOUNT _ 5 OTHER THAN COLL OTHER GARAGE LnUILITY AUTO ONLY-EA ACCIDENT 5 ANYAUTO OTHER THAN AUTO ONLY; EACH ACCIDENT j AGGREGATE EXCESS LIAB!LITY i EACH OCCUttRENCE UMBRELLA FORM i AGGREGATE. — S - OTHER THAN UMBRELLA FORM RETRO DATE FOR CLAIMS MADE: I SELF-INSURED RETENTION S . WC STATUTORY LIMITS Q - X "ORIFnS COMPENSATION WW --•—__-•-_•-•- t- AND Workers Comp E.L. EACH ACCIDENT —_ -.1 _-_ r X -'-:`•PLOYcR'S LIABILITY El, DISEASE-EA EMPLOYEE 5 r E.L DISEASE-POLICY LIMIT 5 SPECIAL TOTAL ANNUAL PREMIUM FOR THE POLICY TERM 10/2/07 TO 10/2/08 1 S181,00 PEES s - OONER mOtdsl OTHER OF WHICH$135.75 REMAINS UNPAID;REPL COST CONTENTS;510000 LOSS TAXES s _ COVERAGES ASSESSMENT:NON-SMOKER&SMOKE DETEC-fOR CREDITS ESTIMATED TOTAL PREMIUM 15 -! CAME rJ,ADDRESS , i �--`-� •�"""'I�DITfDtJ4t-iNSURtD- I Russell &Patricia Karl Lo—A' ----- -_•.•_ I 95 Johnson St. Aunt I PRC; xV N. Andover, Ma 01810 � i Degas Constructi®n,LL C 10 Carleton St Lawrence, Ma 01843 P(978)479-0390 F(978)454-3051 (Owner)Gratien Michaud *Contract Date: 10/26/11 To: Russell & Patricia Karl 95 Johnson St. N. Andover, Ma Scope of work: Strip approx. 9 squares of(3) tab shingles and replace with new shingles Include. *Ice water shield *Drip Edge *#15 Felt paper *New ridge vent TOTAL COST:$3,200.00 *please upon agreement X X C � � "Thank you for your business" Lic#CS081755 #IM064144 #IH151707 i i Massachusctts ©e,rirtment of Public Sa#'cr}: Board of Building Re,-ulations and Standards Construction Supervisor `License License: CS 81755 Restricted to: 00 j GRATIEN D MICHAUD . 5 1!C.,A. THORTON ST '- LAWRENCE, MA 01841 Jam- �y f Expiration: 4/23/2012 0)IM) issiuner Tr#: 20412 I I 92. Office of Consumer ffa-A o�nes�v R gulatio uae�a i HOME IMPROVEMENT CONTRACTOR i Registration: °151707 > Expiration: .Ei/.22%2012 Type: Individual GRA IENHAUD22 MIC � 4$- --- GRATIEN MICHA 104 THORTON ST -" MA ,CE LAWREN = 4�— 01841,,....__:. - Undersecretary- y i 'M DATE(MMIDDI'MY) A�o CERTIFICATE OF LIABILITY INSURANCE 10/26/2011 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 cartlflcate holder is an ADDITIONAL INSURED,the P011CY0e8)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 endorsement(s). CONTACT J09ephiae QgBrlri PRODUCER NAM DeAngelis Insurance PHONE (978)692-3397 AIC,No1. 97A)GOS_0773 tc•MA1L..ExO: 283 Merrimack Street ADDRESS.: �AZSeuceR cu9tD.M.ERIp�00005693 __ __•_ _ 14et huen MA 01844 INSURER(S)AMORDING COVERAGE „• NAIC _ INSURED INSURERn:National, Grange Mutual. dna CO 42 _ INSURERS;. . Gratien Michaud, DBA: Vegas Construction LLC INSURCRC: - 10 Carleton Street: INSURER D: INSURER 6: ._. _-. ...... ....--- Lawrence MA 01843 INSURER I-; COVERAGES CERTIFICATE NUMBER:2010 term 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. tN •-- TYPE OP INSURANCE �••' AI L PODGY NUMBER --- MILIDD EFF PUUC fp LIMITS . LTRIN Q:WVQ GENERALUABILITY EACH OCCURRENCE $ 300,000 •DA � X COMMERCIAL GENERAL LIABILITY PREMIB.ES11+w +rronee, $- 500000 A I CLAIMS-MADE FX-1 OCCUR Ta567R 1/5/2010 1/5/2011 MEDEXP(Anyeneperaon) S 50,000 —....... PERSONALdADVINJURY S 300,000 R I GENERAL AOGREGATE $ - 600,000 GFN'L AGGREGATE LIMIT APPLIES PER; PRODUCTS-COMPIOP AGG $ 600,000 X POLICY I I PRO- LOC Is AUTOMOBILE LIABILITY I COMBINED SINGLE LIMIT $ (Es accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) 8 SCHEDULED AUTOS I PROPERTY DAMAGE 9 HIRED AUTOS (Peraeeldenl) _..... NON.OWNEDAUTOS -. S -• - $ UMBRELLA LIAB OCCUR I EACH OCCURRENCE EXCESS LIAR CLAIMS-MADE AGGREGATE DEDUCTIBLE RETENTION $ S WORKERS COMPENSATION I..._ WC STATU• I DTH- AND EMPLOYERS'UABIUTY YIN T.ORILLIMJJ_S -ER' -- _ ANY PROPRIETORIPARTNERIEXECUTIVE❑ NIA ..G.L EACH ACCIDENT OFFICERIMEMBER EXCLUDED? (Mandatary In NH) E.L DISEASE-EA EMPLOYEE S. II yea describe undgr DE3GIRIPTION OF OPERATIONS 0" E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS f LOCATIONS)VEHICLES (Arnch ACORD 101,Additional RBnqffirF Schedule,K mere space Is required► Certificate is issued in the intoreet of the named insured and holder listed below, subject to company Conditions and exc lua dons. CERTIFICATE HOLDER CANCELLATION (9 7 B)4 54-3 051 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Russell Se Patricia Karl ACCORDANCE WITH THE POLICY PROVISIONS. 95 Johnson Street North Andover, MA 01810 ALITHORIZEDREPRE9ENTA7)VE David Segal/JLL ACORD 25(2009109) m 19882009 ACORD CORPORATION. All rights reserved. INS025(20oso9) The ACORD name and logo are registered marks of ACORD