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HomeMy WebLinkAboutBuilding Permit #686 - 99 BEAR HILL ROAD 4/24/2007BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Y- ye -e ut5k;K1F HUN OF WORK TO BE PREFORMED: Identification Please Type or Print Clearly) OWNER: Name: Phone: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PE/R/MIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BA ED ON $125.00 PER S.F. Total Project Cost: $ `! Z ©O FEE: $ Check No.: ' l -2 �- y Receipt No.. D y� NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature ofAgen#lCwner Signature: of contractor Location No. Date SORT►, TOWN OF NORTH ANDOVER � 9 " Certificate of Occupancy $ s'"^° • E<� Building/Frame Permit Fee $ (-- ACMUS Foundation Permit Fee $ r Other Permit Fee $ TOTAL $ Check # Z0'E 43 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 & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION COMMENTS DATE REJECTED DATE APPROVED ❑ ❑ DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS 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 Located at 384 Osgood Street 'EIRE. bEPARTMENT-=l`emoJEutps ite c� sits yes nb :- Located'at,124 Winn ireet ' Flre Department rgnatureldat®° 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 Doc.Building Permit Revised 2007 r 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 submitted with the building application Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 E *� u a2 S w° � � o 9 c b w° VL d �o F•- x �' a- _ O 6 a w Z F u Q p� o QQ a� u a2 S w° � � o 9 c b w° pGo v G 0 U w x �' a- poo w 6 a w c 40 w J a°' w ca ° z cn o cn } Q o f� o� o c E fA TV � m O 'm3 r m y y O Em 'COL 0 _ m� am�c O RS A Ima o m A y O10 0 ca O Z � m �a H O C •Cp = m d C3:, N H S OS~ O WOui w V1 at E Z ..• W E C3 0 CM O 0 CL = W a ` m O tiL4 CL t S C—L � 9L—,'.' To 2 O Z O I y CIO co O c O CD Q cc ic CA 0 C3 h c O V c CL COD C3 1= Z CD 3 .o C L O d' CL. cmQ c cc � c 'v O Z CD C. CA c 0 LLI W W 19 W U) • C O : O C ;;C O C �1 O ` H O C •a.cc J CL c ev cc c CDo y Ea r S C Z ti It S d H !E c } Q o f� o� o c E fA TV � m O 'm3 r m y y O Em 'COL 0 _ m� am�c O RS A Ima o m A y O10 0 ca O Z � m �a H O C •Cp = m d C3:, N H S OS~ O WOui w V1 at E Z ..• W E C3 0 CM O 0 CL = W a ` m O tiL4 CL t S C—L � 9L—,'.' To 2 O Z O I y CIO co O c O CD Q cc ic CA 0 C3 h c O V c CL COD C3 1= Z CD 3 .o C L O d' CL. cmQ c cc � c 'v O Z CD C. CA c 0 LLI W W 19 W U) J 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 Legibly Name (Business/Organization/Individual): 2 S - C Address: JD Z j mS 4.6;- City/State/Zip:/4 .6;-City/State/Zip:/o 4,4a&,c %-?A, dafts Phone #: Are you an employer? Check the appropriate box: I . ff I am a employer with _Z. 4. ❑ 1 am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors t. ❑ I am a sole proprietor or partner- listed on the attached sheet. I ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5• ❑ We are a corporation and its required.] officers have exercised their S. ❑ I am a homeowner doing all work 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): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.[fRoof repairs 13.❑ Other -nny appucan[ mai cnecKs oox s I must also till 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 anew affidavit indicating such. ;Contractors that check this box must attached an additional sheet showing the name of the sub -contactors 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:__4 Policy # or Self -ins. Lic. #: W C -Z //ZZ_ yep Expiration Date: /I - Z I ` a7 Job Site Address: Z?e4;,1_ �KL OAU/City/State/Zip: /fto &&--, A34 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. 1 do hereby cern y-rtt er the ains d penalties of perjury that the information provided above is true and correct. Si nature: Date: Phone #: a ao rJ Official use only. Do not write in this area, to be completed by city or town ofrciaL City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 6. Other 4. Electrical Inspector 5. Plumbing Inspector Contact Person: Phone #: Mar 13 07 03:36p Matthews Insurance Agency 8788853855 p.1 ACC?RAA, CERT1F➢CATE OF LIABILITY INSURANCE ! 03/13/2007 Matthews insurance Agency 182 Parker Street, Lawrence, PSA 01843 976-681-1112 INSURED �Kebert,------- Hebert Building& Remolding 102 Adams Ave North Andover, MA 01845 I THIS CERTIFICATE IS ISSUED AS A (NATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC# i4wRER A: LlOYD `S---- INsuRER B: AIG -~ INSURER C:--�-- (NSURER 0: -- INSURER E: E: THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ADOVE FOR THE POLICY PERIOD INDICATED. NO- NITHSTANDING 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 SIPPM RF,')t IrFn RV PA In rl a lmcz �m INSRD I POLICY EFF TIVE T P RATION TYPE OF INSLazcMCE POLICY NUMBER; LIMITS �GENERAL LIABILITY -- I ��I X� COMMERCIAL GENERAL LIABILITY � EA -4 OCCURREVC[ X CLAIMSM.ADE OCCUR PRE1.1lSES 4Earen��Y 1�` M�ED`EXP(AnImeperson) $ rJ, GOQ : !rLac02959/05 08/09/06 08/09/07 o «aDVlN,uFY - $500,000 GENERAL AGGREGATE ($1,000 1, 0 0 GEN L AGGREGATE LTAT APPLIES PER: i O PRODUCTS. COMP/OPAGG $500,00— POUCY F-1JC-RCOT I 7 LOC I AUTOMMLEUABILTY ANYAU10 COMWNEDSINGLE LIMIT (F.a accident) $ ALLOWNEDAUTO:S SCHEDULED AUTOS f BOD LYINJURY $ (Per pf wrin L HIRED AUTOSI --------- BC J I fJO1WNEn.AUTf1S 1 BQOlLYINJURY $ lPerBCcidB'A) r—� -- ------- PROPERTY f 1 I I j f DAMAGE S (PC: DC:.IaBnt) 1 i ! GARA;GELlABILJTY ,— AUTO ONLY- FAACCIDEN7' I S OTHERTHAN EAACs ^ ANYAUTO I - i j i I AUTOONLY. AGG $, MESSWISRELLAUABIUTY OCCUR CLAIMSMA.DE EACHr $ -� AGGREG4ic j S DEIX;CTIBLE 1 $ 1 wcsTPTU- I JOTH- ER _ WWORKEWCOMPENSATIONAND RETENTION S FWLOYEW IUASILIITY IWC 2922401 '—i EF: L.JaE�77 I r� j 11 / 21 / 0 6 11 21 / 07 / E.L. EACH ACC DENT $1 v v r U V li 0 0,0()0 (0%EFi'.IHdDE1 H I E.L. Djl_ ISE • EA E5AP:0�-9 tsaibeun4er S C'AL PROVISIONS be,ow - T 1 F L 7lSEASE. POUC'f UM T g ij 0, 000 OTHER - -- -.-_..._.._. ___...,_,._.. .�w....�.,�.,�..,c..nruwwsoamcry l a arC61AL rKGYFNJNS CERTIFICATE HOLDER CANCELLATION —� Town Of North Andover North Andover, MA 0184.5 SHOULD ANY 7F THE ABOVE DESCRIBED POLICIES BE CANCZLLED BEFORE THE EXPIRA'rCN DATE THEREOF, THE ISSU'.NG INSURER MILL ENDEAVOR TO MAIL DAYS VhPJTTP-N NOTICE TO THE CERTIFICATE HOLDER NAMED TO TH.r-. LEFT. BUT FAILURE TO CD SO SHALL. R.IPOSE NO OBLIGA?ION OR UABIUTY OF ANY YJ,10 UPON THE INSURER, ITS AGENTS OR 1958 § 8, § 2 z / / \ . R 2 0 7 >< w ■ § ' � > § q § m 2 ■ \ v i m Kk 7 ° \ \ \ \ \ \ m 7�&&■ § 0\%MZk ESQ-1r, \ 9° 0 > 0 3 ; � M R � 10m m E E m } $ \ K ) Z8 ;u y > 2 \k, - {� m(co =mGO > m z...n |� A J § § o ° sr CD o e e n q§ .i 0 7 § \ 7CA §� cq OD cn \ n § �k§�. ■ /� §m \ q § !' A �r 1. ra R.S. HEBERT construction & Remodeling Inc. 102 Adams Ave No. Andover Mass. 01845 978-686-0786 phone/fax LIC #:058241 reg. # : 153811 DATE :4/24/07 OWNER'S NAME:James Miragliotta PROJECT ADDRESS:99 Bear Hill Rd. No. Andover Ma.01845 I. PARTIES This contract (hereinafter referred to as "Agreement") is made and entered into on this _24_ day of _April , 2007 , by and between James Miragliotta(hereinafter referred to as ""Owner"); and R.S. Hebert Construction & Remodeling Inc., (hereinafter referred to as "Contractor"). In consideration of the mutual promises contained herein, Contractor agrees to perform the following work, subject to the terms and conditions below: II. GENERAL SCOPE OF WORK DESCRIPTION Supply all labor required to complete the following. Strip and install 28 sq.roofing on house and garage. A. LUMP SUM PRICE FOR ALL WORK ABOVE* $ 5450.00 * This Agreement will expire 15 days after the date at the top of page one of this Agreement if not accepted in writing by Owner and returned to Contractor within that time. t Owner Contractor 4 Contractor Owner Owner