HomeMy WebLinkAboutBuilding Permit #436-2016 - 99 COACHMANS LANE 10/6/2015 Sc�evN�D �%C3/is
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BUILDING PERMIT t NORkoRTH �o
TOWN OF NORTH ANDOVER o
APPLICATION FOR PLAN EXAMINATION
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Permit No#: Date Received �,gssgcHus���5
Date Issued: I ��
IMPORTANT:Applicant must complete all items on this page
LOCATION S°� C°��� ��s /Owe
Print
PROPERTY OWNER 7XeA e.S.S- /Yv,/»/'yA1e
�l Print 100 Year Structure yes no
MAP 637 PARCEL: UV ZONING DISTRICT: Historic District ye no
Machine Shop Village ye no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building A One family
❑Addition El Two or more family 11 Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition 0-Other
p Septic 01Nell �'FEloodplain, Wetlantls. 0 '1Natersl:ied�Distnct
_❑_1NaterlSewer
DESCRIPTION OF WORK TO BE PERFORMED:
/zE.Sr'cs/� /�</1ff' :.car�-�i /`��ri7r�e -s'j�•:'��°
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Identification- Please Type or Print Clearly
OWNER: Name: 7-6,ell�ss� ,Qy���i'gr Phone:
Address: f9 coq c����� /qr�e �/�/� -�������•e
Contractor Name: X9 Phone:
Email:
Address: Z 9
Supervisor's Construction License: ®9��!�� Exp. Date: 9-�- �6
Home Improvement License: //99 Y4 Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT:$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ .3-;:� y,F7 FEE: $
Check No.: (do `f Receipt No.: Z�`f
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
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Location
No. 4 1 Date U'
• - TOWN OF NORTH ANDOVER
T .
Certificate of Occupancy $
Building/Frame Permit Fee
Foundation Permit Fee $
Other Permit Fee $
f' xt,vx'�` TOTAL $
Check#
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 m U FORM
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
ti
HEALTH Reviewed on Signature
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
]DPW Town Engineer: Signature:
� Located x3,84 Osgood Street
�
FIRE DEPWRMMENT� -�T;ernp Dumpsteraon safe es > ono
Lo
ADM at 124 Main Street ' �- '-°a ,{ * .x 3 :71 ",' .' _ ..�
<Fir�e Depa meat»sgnatur�e/.date ,
g'F�te r::,�s-v's.=.' S•
COMMENT�S� Z k
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Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICALS Movement of Deter: 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 i
NOTES and DATA— (For department use) f
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® Notified for pickup Call Email
Date Time Contact Name
Doc.Building Permit Revised 2014
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
OTE: 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/Cross Section/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
OTE: 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
2012 IECC Energy code
Engineering Affidavits for Engineered products
OTE: 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:Building Permit Revised 2014
NORTH
own of E 1, Andover
No. %_ 20( * _ - P\
ver, Mass
, 64
A- COC NIC Kl WICK
7d ADR�TED /.Pa�,�9
lS V --
BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
THIS CERTIFIES THAT .....�e'2:e: .....�.U.9^��Q'�''.� BUILDING INSPECTOR
.... ....... ..........................................................
.. 1,�i1 J ................. Foundation
has permission to erect .......................... buildings on ... .. ..... .. d..C1� . . .�M�....��'�!'!Q-
Rough
to be occupied as .... - !' .. ��. ...... !�r�!.`. .....:..f �:rgr +.... As%%L..... ...e...`.`: ......... Chimney
provided that the person accepting this permit shall in every respect conform to the terms of the application Final
on file in 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 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION TARTS Rough
............ Service
............ ... . �L��,iI�iOJ �T..ieti.rn.....................
Final
d BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy.Buildinz Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT C
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
Ali-Tech Window & Siding, Inc. SIDING
20 Aegean Drive Unit 4 F °°sa'e°
C.
MA Reg. # 118836 Methuen, MA 01844 �
MA Lic# CS - 106508 1-800-851-0900 a— e
www.hitechcorp.biz MEMBER
Date: l i �� Consultant:
Job Name: Telephone:
Job Address: Town:
Contractor agrees to start described work on or about weeks after final fittings,and complete described work in about working
days,Contractor shall not be held liable for delays due to cause beyond our control.Hi-Tech shall not be held liable for any damage to lawns or
plants.Contractor shall not be liable for any damage to paintingor stain during installation of windows or doors.Hi-Tech does not do any paint-
ing or staining.In the event that a punch list should accrue at the end of the job,a maximum of 2%is the allowable amount to be held back.
The following work includes all labor and materials needed to complete your job in a workmanlike manner.
Job Includes Trim
Combination Job-Siding With Other WorkP.V.C.Coated Alum Aluminum
Building and Elec.Permit Fasaa Trim Fascia Treatment
Siding Removal Sofrrt Trim Fascia Color t
i
*Preparation Package 'Window&Door Trim Fuii Custom None
IET
ssory Package Shutters Location Z;UeCLrlayment insulation Gutters -
Soffit Treatment
Siding Downspouts
Soffit Color /- 7
Remove Debris Lock.Elec,Meter
Center Vent F1Fully Vented ❑ Non-Vented
Preparation Includes ' Location
a RtwlVanted as Needed
Window And Door Casing treatment
❑Energy Savings 1 Bug Guard Starter
Window And Door Casing Color
❑ Full Custom Formed J-Less Full Custom Famed
Accessory Package includes ❑ Blind stop capping ❑None
COl. Location
c+
inyl Light Stocks V nyi Dryer Blocks _
Cutter&Downspouts
Vinyl Electric Outlet Blocks Vinyl Exhaust Vents .r
Gutter Calor .. f3wmspouls Color
VnN Faucets Blocks Vinyl Gable Vents T Location r 's 1
G1
ill Underlayment Insulation To Be Used Special Nates
❑Hi-Tech 318 ❑ Other s
L
Location
Area jo Be Sided
Compiete House ❑ Garage
g
Sldin To Be Used Payment Policy
Color ,
Bank Financing ❑Owner To Arrange ❑ Hi-Tech To Arrange
Brand 1 Profile
Cash Or Check E] master Card
Comer Post To Be Used Total Investment
Comer Post Color:
❑Wide Insulated ❑Wide Non-Insulated 113 Deposit 060
❑Regular insulated. ❑Regular Non-insuiated 113 Payment
1/3 Balance of Day Substantial Completion LJ 531s
You may cancel this agreement if it has been signed by a party thereto at a place other than the address of the seller,which may
be his main office or branch thereto,provided you notify the seller in writing at his main office or branch by ordinary mail posted,
by telegram sent,or by delivery,not later than midnight of the third business day following the signin. of this agreement.See
the attached notice of cancellation form for an explanation of this right.
An interest charge of 1.5%per month(18%per year)will be Date of Akceptance
added to any amount unpaid after 30 days from invoice date.
to the event of defauh of payment of this order w any part thereof and tare account is referred Signatur
to an attorney for cdfedn ft purdeser agrees to pay reaswaWe attomaY lees.
I!We give H Tech permission to obtain all necessary permits.
Signature
Signature ..!:- LLlL�I�✓"L--. tnFradl
The Commonwealth of Massachusetts
Department of IndustrialAccidents
I Congress Street,Suite 100
` Boston,MA 02114-2017
s� www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
NaMe(Business/Organization/Individual): %e [✓
Address:
City/State/Zip: Phone#: f7v�'-
A.re you an employer?Check the appropriate box:
Type of project(required):
1.F, ,I am.a employer with employees(full and/or part-time).* 7, 0 New construction
2.Q I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling
any capacity.[No workers'comp.insurance required.]
3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
9. ❑Demolition
10 Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.[]Electrical repairs or additions
proprietors with no employees.
12.E]Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs
These sub-contractors have employees and have workers'comp.insurance.$
•
6.FJ We are a corporation and its ofCceIrs� �have exercised their right of exemption per MGL c. 14.,E1]Other
152,§1(4),and we have no.employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
i 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 state whether or not those entities have
employees. If the sub-confractors have employees,they must provide their workers'comp.policy number.
lam an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site
information.
Insurance Company Name: SV/Q/Ay ✓ / �f'���e %res ysQ q r c e
Policy#or Self-ins.Lie.#: 4d4s' d 0 781 y Expiration Date: /e
Job Site Address: 91 eo f cW air wX e City/State/Zip: 4, .41-41v
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.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 and penalties ofperjury that the information provided above is true and correct.
Signature: Date:
Phone#: 9 7F' 7,F /?W,F
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#:
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 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 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 be 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 yoix'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 Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-727-4900 ext.7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 wwwmass.gov/dia
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CERTIFIC F LIABILITY INSURANCE ' DATE(MiWDOfYYVY)
THIS CERTIFICATE IS ISSUED ASA MATTER OF 1N I R A IO ONLY AND CONFER NO RIGHTS UPON THE CERTIFICATE HOLDER!THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NE El! A. END, EXTEND OR A TER THE COVERAGE AFFORDED BY THE POLICIES
BELOW_ THIS CERTIFICATE OF INSURANCE DOE .I TI ON 3TITUTE A CONTRAC BETWEEN THE ISSUING INSURE
REPRESENTATIVE OR PRODUCER,AND THE CERTIF Ai OL ER. R{S}, AUTHORISED
IMPORTANT: If the certificate holder is an ADDTCIO I L 1 SI` RE ,the policy(ies) must a WANEQ,subject to
endorsed. If SUBROGATION IS
the terms and conditions of the policy,certain policiI i ' ui an endorsement. A atement on this Certificate does not confer rishts Ito the
certificate holder in lieu of such endomsemen . !
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PRODUCER BARRY J KITTREDGE INSURANCE i coNrAcr I
81 S MAIN ST NAME.
BRADFORD, MA 0183,5 PHQiE
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INSURED I MSURERA: LM In uranCe Corporation
HI-TECH�W„hN�DlO�W&SIDING INSTALLATION INC
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29 ARROWWOOD ST NSURERB:
METHUEN MA 01644 NSURER0` I
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COVERAGES7<ISURER R
CERTIFICATE NUM 'fi: 15250 REVISION NUMBER- I
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE ? T Ol EL HAVE BEEN IS JED THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,:TE O ND ION OF ANY CONTRACT OF,OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY 9E ISSUED OR MAY PERTAIN,THE IN R' AF ORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS•
EXCLUSIONS AND CONDITIONS OF SUCH POUGIES.LIMNS I O AY HAVE BEEN REDUCED 8 PAID CLAIMS.
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DESCRIPTION OF OPERATIONS/LOCATIONS r VEHICLES(ACORD 101,Adan' 01 anS medule,maybe attached Itmor apace le squired)
Workers compensation insurance coverage applies only to th � (
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This certificate cancels and supersedes all previously Issued :if ,Only as they relate to work rsGom
pensatipn coverage.
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CERTIFICATE HOLDER CANCELLATION
!� SHOULD ANY OF T 1E ABOVE DESCRIBED POLICIES BE CANCELLED BEFO
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVEtiED I
ACCORDANCE W11 THE POLICY PROVISIONS. I
AUTHORIZED RFPRFSFN�TATNE
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ACORD 25(2014101 II I (D 1983-2014 ACORD CORP ION. All rlghts rssory
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CERT N0.! e:315250 [KENT CQ,D, 19,3130 Oidx Oenpea 11!10/Z 1111:5�3 57 1
(C8r1 eagv 1 of L
Massachusetts -Department of Public Safety
iBoard of Building Regulations and Standards
Construction Supen-isor
License: CS-096516
4.
TIMOTHY W'WICS
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Methuen MA 01$744 ]
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Expiration
Commissioner 09109/2016
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TIM WICKS
29 ARR ': � `—
OWWOOD STS ,== �_c:;•.���'�.r,<:-= °—
METHUE'N,MA 01844 Undersecretary