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HomeMy WebLinkAboutBuilding Permit #865-13 - 990 FOREST STREET 6/12/2013TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: � l� ho Date Received Date Issued: �� IMPORTANT: Applicant must complete all items on this nate LOCATION f d -_OfvS_" �' . Print PROPERTY OWNER f 6 rQSk, MAP NO: �PARCELA2ZONN.PrDin,tSTR1CT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 11 New Building One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial 'IQepair, replacement ❑ Assessory Bldg ❑ Others: Demolition ❑ Other 0 Septic 0 Well' ❑ Floodplain 0 Wetlands El Watershed District 0 Water/Sewer DESCRIPTION OF WORK TO IRF. RFR%nPA/f-r-n- OWNER: N gal un/,�_hpli Please Type or Print Clearly) Address: q iD I-6ryyE- 4A- - CONTRACTOR Name: { Dmo (,yeen4 Phone: 07-55f,2 6y Address: 16 5 Bots 34- Flagg 44, M 0 2,11 f Supervisor's Construction License: i 171 q Exp. Date: /C5/27//,3 Home Improvement License: Iy :2? 5-7 Exp. Date: 713 ARCHITECT/ENGINEER K //} Phon Address: Reg. No. FEE SCHEDULE. BULDING PERMIT: $92.00 PER $9000.00 OF THE TOTAL ESTIMATED' {COST BASED ON $125.00 PER S.F. Total Project Cost: $ ` 11060FEE: $ `��b — Check No.: c9ecZ d 4 I ( b 5 0 Receipt No.: GL Ce NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Sgnature_of contracto — - — Location C No. bu Date TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee TOTAL $ Check# Building Inspe'ctor 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 Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS R Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board'Decision: mments Conservation Decision: Comments Water & 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 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 Notified for pickup - Date Doc:.Building 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, Interior Rehabilitation Permits o 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 ❑ Flo or/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) o 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: Doc.Building Permit Revised 2008mi n >rA>� V/ I O Z LL O m L Y \ O LOL E > N U C. 'N GWcc N Z Z m C ° 'O 7 LL -C 3 K ? C U LL p N Z Z co d t : 11 O 4A Z `= ~ W W L to 7 R' V fn LL 0 LLJ d y C7 t bD 3 K LL H z Q d W 0 LU 5 LL N i [O O a+ U N �+ o Y O N _ O cc .C. L C. as ma 0 y t) Q L y 4) 4) 0 �. cc o cn O � a.: 3 ` m > _ Cc CD L C O t/1 .--o 0 O Q: "- o - (A 0 0 An C coo L • Q C. F, O O = C a L LL 0 C C. d F- � d E m W_ _ 'a +�+ O O tl. •� ujCc N C *Z ' 'C_ t O H C �•• ~ w0 0 L am, yM 4) =o t04. C. 0 v O V CL Z Z 0 CO CI)j: Q E Z O 0 W Cl)a. o LJJ O U Cl) W c W J W L Q _ .O N O t O Z O a � J 0 40 twn V ti H � cc CD 00 O CL� a� Q C � J O Z 0 CLN c H y 19W W OC W U) Fax Server 5/9/2013 9:40:45 AM PAGE 2/002 Fax Server GREEINS-01 BSULLIVAN CERTIFICATE OF LIABILITY INSURANCE[---�ATE5/9/2 DlYYYY) CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 5/9/2013 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(les) 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 Salem Five Insurance Services, LLC 445 Main Street Woburn, MA 01801 CO TACT NAME: PHONE (781)933-3100 5595 F"X {781) 933-9048 A1C No Ext : A C, No E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIL tf INSURERA:Safety Insurance Company 39454 INSURED INSURERB:Safety Indemnity Ills. Co. 33618 Greene Installation Co. Inc. 165 BOW .Street INSURER C :AIM Mutual Insurance Co. 0913 165 Bow Street Everett, MA 02149 INSURERD : INSURER E INSURER F: _ EAC:H OCCURRENCE $ 1,000,00 �LYIJIv1\ 1\VIYIGGR: 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 ..._ ADDLSUB .._. ...-._-..._-.—.--_ .. __.— POLICY EFF POLICY EXP - -'--"-""--"-`------"" LTR TYPE OF INSURANCE INSR MQ POLICY NUMBER MMIDDIYYYY MMfDD(YYYY LIMITS GENERAL LIABILITY— EAC:H OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL. LIABILITY BMA0008519 5/8/2013 5/812014 DAMAGEI PREMISES(6a occurrence $ EXP(An y One peI sou) $ 10,000 CLAIMS -MADE OCCUR PERSONAL RADV INJURY $ 1,000,00 - GENERAL AGGREGATE $ 2,000,00 GEML AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG $ 2,000,00 POLICY PEG LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea el-Aent 1,000,00 B BODILY INJURY (Per person) $ " ANY AUTO 6208932 113012013 1130/2014 ALL OWNED SCI IEDULED X ----- AUTOS AUTOS BODILY INJURY (Per aceidcnt) $ X HIREDAUTOS X NON -OWNED AUTOS PROPER YDAMAGE $ _ PFR ACCIDENT $ UMBRELLA LIAB OCCUR _ EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED RETENTION $ $ - WORKERS COMPENSATION AND WC STATLI_ OTH- X C EMPLOYERS' LIABILITY Y f N TORY LIMITS ER 500,00 ANY PROPRIMBERlEXCLU RIEXECIJTIVE AWC-400-7025594-2013A 314/2013 31412014 i)FFICER/MEMBER EXCLUDED? n NIA E.L. EACH ACCIUEN 1 g (Mandatory in NH) Ifyes, describe under 6. L. UISEABE _ EA EMPLOYE $ 5500,00 DFSC'RIFITION OI- OPERATIONS below EL. DISEASE -PCN ICYI"IMIT $ 500,00 DESCRIPTION OF OPERATIONS I LOCATIONS f VEHICLES (Attach ACORD 101, Addldonal Remarks Schedule, H more space Is required) 10 day cancellation clause for non payment, 30 days for all other regarding General Liability. Lowe's Companies Inc. and any and all subsidiaries are named as additional insured per written contract for Auto Liability purposes only. L`FRTICI!`ATC unl nen 10012 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Lowe's Companies Inc. IS Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P.O. Box 1111 ACCORDANCE WITH THE POLICY PROVISIONS. North Wilkesboro, NC 28656 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts 7Print Form Department of Industrial Accidents Office of Investigations s 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information %� Please Print Legibly Name (Business/Organization/Individual): il0i�a,� �?fZQt�Q Address: 165 'ow e4re.04 City/State/Zip: L-yyf /yl/-� Phone #: 6/7-5Y7'$7/3 Are you an employer? Check the appropriate box: l.I � I am a employer with._ 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t C. 152, §1(4), and we have no 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 I L ❑ Plumbing repairs or additions 1.2. ❑ Roof repairs 13. ❑ Other *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. #Contractors 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 -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: &T /H /" luivad TnsurmtP Com Policy # or Self -ins. Lic. #: A WC 7D2.;Sff + 1013/q Expiration Date: 3 � Job Site Address:_ q to s ` City/State/Zip: 1104AA Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration ate). 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 cern _ under the pains and penalties of penury that the in orntation provided above is true and correct. Phone #: b 17- M 7rV13 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 Phone VL - R A 1'.6, Office (fConsuvrier Aff;zin & Buquicso Regulation ME IMPROVEMENT CONTRACTOR ®gistratign: '10295i Type, bon: 7/'Q014 PfWatO QOrPQFatif)�- GR.' -ENG NS-1AL LA 1101\1 C0., i N C, Rf,raha 55 Fj aw streo EvereiI, 02149 Lllndrrsecrctary ITEMIZED INSTALLED SALES CONTRACT CONTRACT # NUMBERCUSTOMER STREET ADDRESS STAT_ ZP- i C'TY -- — STATE ZIP i TELE?HONE .NE'S CONTRACTOR CASH sgtvtc SCC REG I CARD CHARGE SE NUMBER MA, NAP — State License Number; All O'hc! States—1-mme's Em io ( u p yee Number. AL C-. - ',,;A:: D, NV 445-:-50 unlimited, TN #16066, only. This is a. car -ac;. 'is"Wecn ',Owe's (as defined in ii e Terms and Conditions) ("Lodge's" ), and the above-namad Customer for the instai!ation of goods at the Customa:'s . ssicantial pre pises (the "Premises") at the following installation address: RECTADDPESS CITY STATE ZIP -------------- 'c`icrar'.vr aicatiarts: The Environmental Protection Agency (EPA) has requested that M�at'!s 1 I.ty;: e•',n rig:,+Py installation customers that a lead based paint hazard may exist in dwellings builtTax prior to 1978. See pamphlet EPA 747-K-99-001 for details. Labor JLC-,:, ' (.,r 11 4, J *Tax Total 'here applicable labor is taxabte; Teck local tax restrictions Work is to commence upon reasonable availability of Contractor which is anticipated to be� % r ri [fill in date]. Estimated completion slate is [fill in date]. NOTICE TO CUSTOMER All items listed in this contract and specification sheet(s) are to be installed under conditions agreed upon at time of purchase and at the price appearing on this contract fc-rn. This assumes sound existing substructures, superstructure and points of attachments. Extra labor or material incident to installation necessitated by dsfeciive substructures, superstructure, points of attachment, or the moving of fixtures or appliances to be billed at extra cost to customer. DO I CT SIGN s HIS CONTRACT UNTIL COMPLETE AND YOU HAVE READ THE TERMS AND CONDITIONS CONTAINED ON THE i REVERSE SIDE OF THIS CONTRACT. BY SIGNING BELOW, YOU ARE ACKNOWLEDGING THAT YOU HAVE READ, UNDER - I Si.A'1I� ,�NF�l AGREE TO THE TERMS AND CONDITIONS SET FORTH ON THE REVERSE SIDE OF THIS CONTRACT. YOU ARE Epee -..i 11i_D TO A COPY OF THIS CONTRACT AT THE TIME OF SIGNATURE. i UfTN=SS OUP. HAND(S) AND SEAL(S) BELOW THIS `) DAY OF ,F L ' Owner (Seal) Specialist or Abeve (Seal) (Seal) Spouse -lw1 --1 --radru a E�vu9-�* reseipi or a true copy of this contract which was completely filled in prior to Customer's execution hereof. If credit is extended to yov, you the buyer may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction. See ihe ardached notice of canceliation form for an explanation of this right. — - - - —------je— a ee%®i reL t=,.r vji .+��'e_r ;l ,r ` �6P n "'wV,M^cSteu fil3t j -t-, ns, s'Zha a Ivdd barex l3aiot ha-zard gray exist 1n dy,sil1ngs buiIt ase Par-hphfet ZPA 747-K-99-001 Tor details. f Niai Is *Tax Labor *Tax Total * Where applicable labor is.taxable; check local tax restrictions I , "c as o co;Am ec : upon reasonabia,availability of Contractor which is anticipated to be EaVir_t?d cow ; {ion dafe is [fill in date]. [fill in date]. NOTICE TO C.ISTf3MEC, '=til ii:efinS 118t ., ea in. t',isc contract and specification sheet(s) are to be installed under conditions agreed upon at time of purchase and at the price appearing on this coniraci form- This a•ssu nes sound existing substructures, superstructure and points of attachments. Extra labor or material incident to installation necessitated Fy efecti` s s ;vs ru:;t;;ras, superstructure, points of attachment, or the moving of fixtures or appliances to be billed at extra cost to customer. � �� O NOT S1G N i � a' eIS -r,CNTRAC I UNTIL COMPLETE AND YOU HAVE READ THE TERMS AND CONDITIONS CONTAINED ON THE REVERSE Sj[;E OF THIS CONTRACT. BY SIGNING BELOW, YOU ARE ACKNOWLEDGING THAT YOU HAVE READ, UNDER- STAT )D A'`ND AGREE TO THE TERMS AND CONDITIONS SET FORTH ON THE REVERSE SIDE OF THIS CONTRACT. YOU ARE ENTITLED TO A COPY OF THIS CONTRACT AT THE TIME OF SIGNATURE. WITNESS OUR HAND(S) AND SEAL(S) BELOW THIS, DAY OF r , i Specialist or Bove ` ,f:•, Owner _. (Seal) r' e (Seal) (Seal) ` Spouse Customer acknowledaes receipt of a true copy of this contract which was completely filled in prior to Customer's execution hereof. If credit is ext pried Qo you, you the buyer may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction. See ,hs a:?ached n ice of cancellation for an explanation of this right.