HomeMy WebLinkAboutBuilding Permit #904-15 - 97 SAW MILL ROAD 5/11/2015Permit NO:5 L —
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
Date Issued: J I Lt 15
IMPORTANT: Applicant must complete all items on this pane
LOCATION' 1� 7 _-_1'I-t✓ 4_1 / /_ L R �)
Print
PROPERTY OWNER 1-"-4 Aiz y 1-1-o ^r*A/- e TT' ,LU�r13��ZD
Print 100 Year Old Structure yesno
MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
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
DESCRIPTION OF WORK TO BE PERFORMED:
/�B0ntV_65 �N/� o�/y� ��T 7 -
Identification
Identification Please Type or Print Clearly)
OWNER: Name: ✓ 419-2c/ ,-7,-o N,,,'-./, cA �c c �-r T Phone:
Address:
CONTRACTOR Name: de Y --,c/' Q i •�2. Phone:
Address:
oS / 6
Supervisor's Construction License: Exp. Date: /Q ` )J
Home Improvement License: /U 17wl 6A Exp. Date:
ARCHITECT/ENGINEER Phone:
d�
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: $ 9 7e - o --o FEE: $ -Z6 —
Check No.: r t I; Receipt No.: 7
NOTE: __Persons contracting with unregistered contractors do not have access to the guarantyfund
Signature of Agent/Owner Signature, of—
contra-Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
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
DATE REJECTED DATE APPROVED
CONSERVATION Reviewed on S ,0 %
Signature/'-
COMMENTWa IL ,►gyp,,.` �� X -O6" ��b1V\WAAIP-wj
HEALTH
COMMENTS
Reviewed onJ ►111
Oy
r
OL
Zonlrg Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comme
<-r"Conservation Decision: Comments
Wgter & Sewer Connection/Signature & Date Driveway Permit
I
DPW Tow Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Departinent 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)
I� 2� A
�7 S
El Notified for pickup - Date
i
F
Doc.Building Permit Revised 2010
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 submAted with the building application
Doc: Doc.Building Permit Revised 2012
Location
No. q0 -I c5— Date
Check #,a
2-3 7 6 �
TOWN OF NORTH ANDOVVR
Certificate of Occupancy $
Building/Frame Permit Fee $ C)4 -
Foundation Permit Fee
Other Permit Fee
TOTAL $
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1
COTE nnow F.OSTERz-
.
(:l!S'VOM Iil.111-DING + REMODELING
This agreement made this 9h day of April, year Two thousand and Fifteen by and
between Cote and Foster Contracting, Inc. hereinafter called the Contractor and Mary. _
Honan & Matt Lombard, hereinafter called the Owners, witnesses that the Owners intend
to add onto the existing deck and remove old at the address of 97 Saw Mill Rd., North
. Andover, MA.
Now, therefore, the Contractor and the Owner, for consideration hereinafter
named, agree as follows:..
ARTICLE 1
The Contractor agrees to provide all the labor and materials to do all things
necessary for the proper construction and completion of the work shown and described
on drawings. The drawings and specifications are the basis of the contract.
Wpmt" f v ARTICLE 2
In consideration of the performance of the contract, the Owner agrees to pay the
Contractor, in current funds as compensation for his services hereunder $16,980.00 to be
paid as follows:
Payment 1- $6,000.00 at start of decking removal
Payment 2 - $6,000.00 at start of composite decking to be installed
Payment 3 - $4,980.00 at completion of project
ARTICLE 3
. Final payment on contract amount as agreed, above to be paid within ten (10) days
of project completion or occupancy. If final payment has not been made within this time
a 10% charge per month on the balance due will be charged. All minor punchlist items
will be complete as part of the one year warranty on the finish product. Failure to pay
balance within ninety (90) days may result in legal action.
Initials: S g
n
20 Aegean Drive - Unit 15 - Methuen, MA 01844
Tel: 978-682-6518 - Fax: 978-682-1221
www.coteandfoster.com
k,
ARTICLE 4
Additional work above and beyond the contract agreement:
All additional work done to be quoted at the time the client requests the work. The work
will be done and billable at its completion. The client has ten (10) days to pay the
additional cost after he or she has-been billed for it. =
Initials:
Sign]
Here
In witness whereof they have executed this agreement the day and year first above
written.
all
William T. Foster
DBA Cote & Foster
t�^ Sign
Here
4MaatoPmqbVaW)9Owner
li�j�i i ii�
7P/
1-7i�
6Vlq,�S
PT -T PLAA'
Lot # 45 Sawmill Ro}d
North Andover, Mae4chusetts
SOSU: 1" = 50, Buyer: Steven Leone
Augukt 191980
,Peflr Lb NEP
D 30ot /423, Page 1-f.
.rte
and Plan 0 M8. :` _ole„ � f Lo• r�; •c-
�9 Z�'
c OT 4 o
000
4 ; r. ✓ J, O
60
r • Ua . �� • 7 L r. (�dJ
CDT 46- �
41-Pa
r
r
��- LOT V6
/= N'OTE: '"his is not a survey and is to be
,F used for mortgage purposes only.
. 3.- Do not use offsets for establishing
lot lines for the erection of fences,
walls, hedges, etc.
= hereby certify that the building on this
property is located as shown on plan and complies with
the zoning set back requirements of the Town of North
� Andover.
C `�•, Rf: `� 7-CABLE T= rLCOL :' ,AIN ZONING.
c w C YR %I NEER- NG SERVICES, INC.
300 CANAL STREET
LAWRE_ E
.4ASSACHUSETTS
624-
3e�-j uutf r• '4�
IrN
The Commonwealth of Massachusetts -
Department oflndustrialAccidents
Office of Investigations
600 Washington. Street
Boston, MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/ContractorslElectricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/fndividual): (— °� ' U 7--,f /Z
Address: D (off q
City/State/Zip,� 7W,1 Phone
Are you an employer? Check the appropriate
Typo of project (required):
`
1. ❑ I am a employer with
4. I am a general contractor and I
6. ❑ New construction
employees (full and/or part-time).*
2. El am a sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet.
�• ❑Remodeling
ship and'have no employees
These sub -contractors have
8. ❑ Demolition
working for me in any capacity
workers' comp. insurance.
g, ❑ Building addition
[No workers' comp. insurance
5. El We are a corporation and its
10.❑ Electrical repairs or additions
required.]
3. ❑ I am a homeowner, doing all work
officers have exercised their
right of exemption per MGL
11.[] Plumbing repairs or additions
myself. [No workers' comp.
c.152, §1(4), and we have no
12.QRoofrepairs
insurance required.]
q �
employees. [No workers'
1311 other
comp. insurance required.]
'Any applicant that checks box #1 must also fdI out the section below showing their workers' compensation policy information.
Homeowners who submit this affidavit indicating they Lire 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 workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:. 177,0 1 tee* Ccc V_ u 5 Tie y
Policy # or Self -ins. Lie. #:ZAI C o a y 9( a 9 3rI Expiration Date: " o?U /`.5
Job Site Address: �� ��-lcJ �! L -L City/State/Zip: /Y',O 477 %ry' O r
Attach a copy of the workers' compensation -policy declaration page(showing the policynumber and expiration date).
Failure to secure coverage as requiredunder Section 25A ofMGL c.152 can lead to the imposition of criminal penalties of a
fine up to $1,50 0.00 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 AIA for insurance coverage verification.
I do hereby certify un der the pains and penalties ofperjury that the information pro vide�cd shove is true and correct.
Sienature: �A) � /�t►r.. V C5 Date: L ` ) + f .l
Phone#• -q 97-
yO7� - rya
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. PIumbing Inspector
6. Other - -
('nn4arf Percnn� Phone#:
Information and Instruction -8
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 ofhire,
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 to construct 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 ofits political subdivisions shall
enter into any contract for the performance ofpublic 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 -contractors) 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 anLL C or LLP does have
employees, a policy is required. Be advised that this affidavit maybe 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 retumed 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. Anew 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 bum 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 Commoan�wealth of 1\4 chusetts
Department oaffndustxial Accidents
Office of IaVesfigAtions.
600 Washington Street
Bostont M. A 021 X 1
Tel, # 61.7,727,4900 ext 406 ox 1.-87T MASSA F,
Revised 5-26-05 Fay ,# 617-727;7749
ACORUr CERTIFICATE OF LIABILITY INSURANCE
/m6/ M/DDIYYYY)
5/6/2015
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 certificate holder is an ADDITIONAL INSURED, the policy(ies) 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 endomement(s).
PRODUCER
MTM Insurance Associates
1320 Osgood Street
North Andover MA 01845
CONTACT
NAME:Victoria Lowes, CISR
PHONE(978) 681-5700 FAX
No•(978)681-5777
E DRE :vickiel@mtminsure.com
INSURERS AFFORDING COVERAGE NAIC #
INSURERA:State Auto Insurance
INSURED
Cote & Foster Contracting, Inc
20 Aegean Drive
Unit 15
Methuen MA 01844
INSURER B AIG Casualty Company
INSURER C:
INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:14-15 master List RFVISIDN NIIMRPR-
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.
INSR
LTR
TYPE OF INSURANCE
ADDLSUBR
POLICY NUMBER
POLICY EFF
MM/DD/YYYY
POLICY EXP
MM/DD/YYYY
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,000
A
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE ❑X OCCUR
BOP2722545
2/31/2014
2/31/2015
PREMISES Ea occurrence $ 300,000
MED EXP (Any one person) $ 10,000
PERSONAL & ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
X I POLICY PRO LOC
PRODUCTS -COMP/OP AGG $ 2,000,000
$
AUTOMOBILE
LIABILITY
Ea BIKED SINGLE LIMIT 1,000,000
BODILY INJURY (Per person) $
A
ANY AUTO
ALL OWNED FX71 SCHEDULED
AUTOS AUTOS
BAP2370166 02
2/31/2014
2/31/2015
gODILYINJURY(Pereccident ) $
X
HIRED AUTOS X NON -OWNED
AUTOS
PROP
PROPERTY DAMAGE
$
Medical payments $ 5 000
UMBRELLA LIAR
OCCUR
EACH OCCURRENCE $
EXCESS LIAB
CLAIMS MADE
AGGREGATE $
DED I I RETENTION $
$
B
WORKERS COMPENSATIONX
AND EMPLOYERS' LIABILITY Y / N
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
If yes, describe under
N / A
004962937
/20/2014
6/20/2015
WC STATU- OTH-
E.L. EACH ACCIDENT $ rj00 000
E.L. DISEASE - EA EMPLOYE $ 500,000
E.L. DISEASE - POLICY LIMIT $ 500 000
DESCRIPTION OF OPERATIONS below
A
Property Coverage
BOP2722545
2/31/2014
2/31/2015
Business Personal Property $40,491
Scheduled Equipment
2/31/2014[L2/31/2015
ContrctorsEquipment $169,928
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
Certificate holder as listed below
This certificate of insurance represents coverage currently in effect and may or may not be in compliance
with any written contract.
Town of North Andover
384 Osgood Street
North Andover, MA 01845
nrnon 1%e I'M 9%1ne%
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
MacDonald CPCU, CIC 10tW9"4____
- - - -- A-- - -I v l V65-ZU1U AcUKD cvKPORATION. All rights reserved.
INSn25i7mnnsim Tho annRr1 nama nnrl Innn ora raniciawA m2rlra of annRfl