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HomeMy WebLinkAboutBuilding Permit #721-13 - 99 HAY MEADOW ROAD 5/1/2013TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDI PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: FEE: $ Check No.: l Receipt No.: DOTE: Persons contracting with unregistered contractors do not have acce , to a guars fund 'Si nature of contrac or 'Signature of Adent/Owner..:.. 9_._.__.:.._.... _:..._ ..: _.-.... Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OFSEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ .. Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/SaIes ❑ 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 Reviewed on Signature COMMENTS 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 Connecttion/signature Date Driveway Permit DPW Tower Engineer: 9ignatu're* Located 384 Osgood Street FIRE DEPARTI�i NT -Temp Dumpstef on site yes no Located at -124 MainStreet Fire Depaifine signafureldate COMMENTS Dimension Number of Stories: Total land area, sq. ft.: Total square feet of floor area, based on Exterior dimensions. 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 Building Department The folowing 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 COTE: 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 COTE: 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 10TEo 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 appal 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 Doe: Doc.Building Permit Revised 2012 Location / 2 y /` 7C�4G�° 1 No. -'7,2, / — / Z-1 Date • - TOWN OF NORTH ANDOVER • Certificate of Occupancy $ y Building/Frame Permit Fee ' Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 3 Check # �j'29z3/ 26343 %�Liilding Inspector Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 19,759.00 m $ - $ 237.11 Plumbing Fee $ 29.64 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 29.64 Total fees collected $ 396.39 99 Ha meadow Road 721-13 on 5/1/2013 Bath Remodel Ao s � a H J Wd `Z LL O O m C a) L Y Y 'd O LL E N N In Y Q N 0 o CJuiW Z C7 z �_ D m C O Y C 7 LL Op = W i N O E U LL 0 O y�•j z z J d. OD O d' — C LL O V !aA z0 U u W W pp O d' N v •� {n _ C LL O (~J a Ln z H a pp O d' C LL z W ac Q W D LLJ w V" O 7 m O z O N �+ a Q N Y 0 N C C) Cc y.r c6 p 2 J . 4a 0 ECL d o E� O y : �� 0 L v N s� CLM • 0 J °` (D ,0: 0 •_ d c 0 —�0 U) N Q .0 E O +: C: CL G O •� c 0 0 CL O : L CD (D m 1- v O O p Q L L c CL m ++ ea O.2 co p O O uj ALL R N 0 'O : 5 mw y:.. V Q. O 'a . d N 2 cc o LO C O 1- �t w Q0U z G co z Cl) w CLx LLJ LLI CL O W CL U) Z 0 m i a � U) O V U ' O CO W z �1 .�V N 0 CD E 0 �O O z N CD CD _ a �o-- .E m m C i o� V i C. Q c Q O _ V J � 0-0 C 0 CL V c CL U) 0 uj uj U) W W w W 2013-03-13 13:07 I V. Lowes #2;;O? ISO 6036814226 >> .16033297026 P 1/1 1� t�rnnc �f 0,1 was O c r) . 1� q� / IW. Y 2- �I TOI LET- UIGt(� — 60-SHWR 36" 60 All d1mcnMons -xize devlgnotlotls glvcn are vublcct to verlticution on Jpb ;ill* and ndjuvlmcnt to 11t Job condltlon+: L TMS h: un original design and must not be I Dcslgncd: 3/9/2013 relcused or coplcd unless applleuble fee has Printed: 3/13/2013 been paid or,,ob order placed. tm•Movcrrnan.klt All Druwinp A; 1 AC40 D® `SVR CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYYY) 4/25/2013 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 endorsement(s). PRODUCER FIAI/Cross Insurance 1100 Elm Street Manchester NH 03101 CONTACT Lynn Blanchard NAME: y PNONE0. (603) 669-3218I FAX. No: (603)645-4331 ADDRE EMAIL .lblanchard@crossagenc com y' INSURERS AFFORDING COVERAGE NAIC # INSURERA:Union Insurance Company INSURED Thomas A. Dube Construction -Plus, Inc., Dube Plus & Dirt Pro; Watertown Village, LLC 10 Bricketts Mill Rd, Suite C Hampstead NH 03841 INSURER B :Acadia Ins Co. INSURERC: INSURER D: INSURER E: [INSURER F : COVERAGES CERTIFICATE NUMBER:Dube Construction 2013 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. I LTR LTR TYPE OF INSURANCE AD L UBR POLICY NUMBER EFF /Y MM/DDYYY MY LICY EXP M /DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGERENTED 100 000 PREMISES Ea occurrence $ r A CLAIMS -MADE FxI OCCUR PA -5028190 /26/2013 /26/2014 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 $ X POLICYFX PRO LOC AUTOMOBILE LIABILITY A COMBINED SINGLE LIMIT Ea accident 1,000,000 BODILY INJURY (Per person) $ B X ANY AUTO ALL OWNED SCHEDULED AUTOSAUTOS CAA5028191 /26/2013 /26/2014 BODILY INJURY (Per accident) $ Per accidenPROPERTY t $ DAMAGE NON -OWNED HIRED AUTOS AUTOS Auto Extension Endorsement $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 B EXCESS LIAB CLAIMS -MADE DED X RETENTION$ 10,000 $ UA5028192 /26/2013 /26/2014 B WORKERS COMPENSATION X WC STATU- OTH- Y LIMITS AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE �N OFFICER/MEMBER EXCLUDED? (Mandatory in NH) / A CA5028193 (3a.) NH & MA /26/2013 /26/2014 E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEd $ 500,000 If yes, describe under DESCRIPTION OF OPERATIONS below homas Dube excluded E.L. DISEASE -POLICY LIMIT $ 500 000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) RE: McGetrick Residence - 89 Duncan Drive, North Andover, MA. Covering work performed by the Named Insured during the policy period. O� J4 N � CERTIFICATE HOLDER _ CANCELLATION (978) 688-9557 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Andover 120 Main Street AUTHORIZED REPRESENTATIVE North Andover, MA' 01845 Judith George/LM5 ACORD 25 (2010/05) INS025 (201005).01 ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AID® CCPR v CERTIFICATE OF LIABILITY INSURANCE D IDD/Y 4/25//25/ 20133 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 endorsement(s). PRODUCER FIAI/Cross Insurance 1100 Elm Street Manchester NH 03101 CONAME: NTACTYn Lynn Blanchard PHONE (603) 669-3218 FAA/C No: (603)645-4331 AUDARIESS:lblanchard@crossagency.com INSURERS AFFORDING COVERAGE NAIC # INSURERA:Union Insurance Company INSURED Thomas A. Dube Construction -Plus, Inc., Dube Plus & Dirt Pro; Watertown Village, LLC 10 Bricketts Mill Rd, Suite C Hampstead NH 03841 INSURER B -Acadia Iris Co. INSURERC: INSURER D: INSURERE: 1 INSURER F: rnvcoer_cc rFRTIFICATF NIIMRFR•Dube Construction 2U13 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. INSR LTR TYPE OF INSURANCE ADDL UBR POLICY NUMBER POLICY EFF MM/DD POLICY EXP MM/DD LIMITS GENERAL LIABILITY Judith George/LM5 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $ 100,000 MED EXP (Any one person) $ 5,000 A CLAIMS -MADE ❑X_ OCCUR X CPA5028190 /26/2013 4/26/2014 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIESPER: PRODUCTS -COMP/OPAGG $ 2,000,000 $ PRO LOC X POLICY X JFCIT AUTOMOBILE LIABILITY EOacccl dentSINGLE LIMIT 1,000,000 BODILY INJURY (Per person) $ B X ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS X 028191 /26/2013 /26/2014 BODILY INJURY (Per accident) $ PeOPERT ntDAMAGE $ Auto Extension Endorsement $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 B EXCESS LIAB CLAIMS -MADE DED I X I RETENTION$ 10,00C $ CUA5028192 /26/2013 /26/2014 B WORKERS COMPENSATION X WC S`UMT[ OTR - AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OFFICER/MEMBER EXCLUDED? (Mandatory in Ni N/A CA5028193 ( 3a.) NH & MA /26/2013 /26/2014 E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYE $ 500,000 E.L. DISEASE -POLICY LIMIT $ 500 000 If yes, describe under DESCRIPTION OF OPERATIONS below homas Dube excluded DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Covering work performed by the Named Insured during the policy period. Lowe's Companies, Inc. and any and all subsidiaries are Additional Insured under General Liability and Auto Liability policies as required by written contract. CFRTIFICOTF HOLDER CANCELLATION ACORD 25 (2010/05) INS025 r5,mnnm m ©1988-2010 ACORD CORPORATION. All rights reserved. Tha AnnRr1 nama and Innn ars. ranieforarl mnrike of ArnRr1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Lowe's Companies, Inc. Attn: Installed Sales Insurance AUTHORIZED REPRESENTATIVE PO BOX 111 N. Wilkesboro, NC 28656 Judith George/LM5 ACORD 25 (2010/05) INS025 r5,mnnm m ©1988-2010 ACORD CORPORATION. All rights reserved. Tha AnnRr1 nama and Innn ars. ranieforarl mnrike of ArnRr1 0 ,.._ Massachusetts - DeP:Irt'�'ent of Puhlie Safet} tf et Mations and Standards Board of Buiidin. R 'ervisor License Construction Sup T` License: CS 94372 i_ 1 LORIANN J LANGAN 1 7 CREST ROAD KINGSTON, NH 03848 4 y Expiration: 7/31/2013 Tr#: 1297 ('unuttissitute7• -. --- ... __._ _ _... -. • I ' ��e �partzan.antaeaCL�a�P/%�aeeae�eat Mee of Consumer Affairs & Business Regulation ME IMPROVEMENT CONTRACTOR egistration: 119623 T: 1 Expiration;- 816/2013 Supplem Dube Construction - Plus, Inc. LORIANN LANGAN 10 Bricketts Mill Road, Suite "G" Hampstead, NH 03841 Undersecretary 2013-04-29 09:39 w r • O dl Z F8 y w2CC- co q�M n C O m r cn z z 0 0 m o � C a aN � � o m z Lowes #2382 ISO 6036814226 >> 16033297026 P 1/7 I r • VI dl �j' F8 y q�M a n r a x N m C A m N n C N r. m m A a D 0 f 2013-N -29 w co N N O v 09:40 I Lowes #2382 ISO 6036814226 >> 16033297026 P 2/7 z M o�(a� 0.79i O F4 -9 0 ) q cj) ° r mr rm r Q a A c M. o c y 5 O O Q o a ' oa8 w O. H O D M fC• �. 3 g C Q) Woro y ayr co w tL Wcx lb 0 r � M �� CD 0 3 ~ c y W O0 (G' 06� 5 y? b Cl) m x y S f g y H /0 •/ c $ c, m = r, z CL tip go O 0 O. D o ,., o w -• cs � c� g O y :5. c o � 4. ,0 .0 a m 69 69 Q,6 Co N 5.0 �. 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