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HomeMy WebLinkAboutMiscellaneous - 11 SECOND STREET 4/30/2018 (2) 11 SECOND STREET J 210/o30-0-0003-0000.0 i i I c Location �� S C U'`J No. d Date i NORTq TOWN OF NORTH ANDOVER ? • • 0 ` Certificate of Occupancy $ Building/Frame Permit Fee $ ncNus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ i Check # �i 6446 ./ Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING NE BUILDING PERMIT NUMBER. O DATE ISSUED: X 3 SIGNATURE: AR0 --I Building Commissioner/I for of Buildings Date Z SECTION 1-SITE INFORMATION O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 030 004 Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Fronts e ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide R red Provided Required Provided 0 1.7 Water Supply M.G.L.C.40. 34) I.S. Flood Zone Information: 1.8 Sewerage Disposal System: Publio ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of Record e,)l yml,q fr�C' f( Seccnv d s�- Name(Print) Address for Service: Signature Telephone 2.2 Owner of Record: Name Print Address for Service: O Z m Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licesed Construction Su rvisor: Not Applicable ❑ Licensed Construction Supervisor: C License Number AddressN V �j � y I �y� E iration Date (/ ic xP a_ Signature Telephone 3.2 Regis ed Home Improvement Contractor Not Applicable ❑ v ��� / Company Name Registration Number r Addressa� "l r d� Z Expiration Date ^ Signature Tele hone Y SECTION 4-WORKERS COMPENSATION(M.G.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result, in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......❑ No.......0 SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Descri tion of Pr posed Work: do .40 t 9— *et Mf Yr ' J v',(Ottcel(c Pv& SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant 1. Building 0�'60. Com�,)/s" (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5) Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ' I, ,as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date , SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 5 I, 1 C(,U t J Ie zjv / as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name Signature of Owner/A Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR T ,4BERS 1 ST 2 ND 30 J SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS [[EIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE " North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is-that.the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S.150 A._ The debris will be disposed of in: _ (Location of Facility) Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through.the Office of the Building Inspector ACORDCERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD 05/02/2003. PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATI N INTERNET ,INSURANCE AGENCY, INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 522 CHICKERING ROAD NORTH ANDOVER, MA 01845 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA:ARBELLA PROTECTION David Gulezian INSURERB:NORFOLK & DEDHAM D.G. Contracting, Inc. INSURERc:ARBELLA PROTECTION 428 Pleasant Street INSURERD:AIG INSURANCE North Andover, MA 01845 INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE(MMIDDIYY) DATE(MMIDDIYY) LIMITS I GENERAL LIABILITY 8500013549 07/01/2002 07/01/2003 EACH OCCURRENCE $1f000,000 A X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurence) $ CLAIMS MADE OCCUR MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 Y GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,O O O,O O O POLICY 1Ea LOC B AUTOMOBILE LIABILITY 90151692 06/12/2002 06/12/2003 COMBINED SINGLE LIMIT $1,000,000 ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ X SCHEDULEDAUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ C EXCESSIUMBRELLA LIABILITY 4600020399 12/10/2002 12/10/2003 EACH OCCURRENCE $ 1,000,000 X OCCUR FICLAIMS MADE AGGREGATE $1,000,000 DEDUCTIBLE RETENTION $ $ D WORKERS COMPENSATION AND WC 333-27-74 03/31/2003 03/31/2004TOR'i LIMITS ER EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? E.L.DISEASE•EA EMPLOYEE $ 100,OOO If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION Ruth Doyle SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 010 DAYS WRITTEN Andover, MA 01810 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRE ATI ACORD 25(2001/08) ` ORD CORPORATION 1988 NORTH Own of over O No. '�' 05, ��AoC�; �� dover, Mass., DRATED PpP 5 BOARD OF HEALTH Food/Kitchen Septic System PERMIT T BUILDING INSPECTOR THIS CERTIFIES THAT �L �� , ....................y....... .............................................. ..........Y....................................................... Foundation • / G�N C� has permission to ere �........................ buildings on 11 ...... !...: Rough to be occupied as..... !.P/ActoM to b 0w Chimney .......................................................... ........ provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws . lating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. 3,73 PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRUCTION STARF ELECTRICAL INSPECTOR Rough (� Service ............. ......... ..................................................................................... BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry. Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. Date....../..�d 1..."...J Z/ NORTH °•,"`°:•�"� TOWN OF NORTH ANDOVER A PERMIT FOR WIRING �sS^csW This certifies that .........S.......'j/. .. ............%./..'`Cr/�•.�.:......w.:... has permission to perform ..............� d ' ...................... I p ...: .................................. wiring in the building of........C.�`.(�G .�� ` �� S ........ .................................................... C L 5 �cdoj Sl . ate......... . . ....... ............. . orth Andover ass. U �...... Fee..3. ...�........ Lic.No. 5 rte- ..1l,.. .. ............... LECTRICAL IWS'PECfOR Check # �` 4L fir ;s `'t 7 7C Department of Fire Sef-I/ICeS Permit No. a Occupancy and Fee cc Checked ••�` _'� BOARD OF FIRE PREVENTION'' EGULATIONS [Rev. 11/9 (leave blanks _ APPLICATION FOR ER IT TO PERFORM ELECTRICAL WORK All work to lie pertixmed in ac tt jil with the Mass,ichusetts l7lC 601 Code WE('l,S27 C' t 12.00 (F'LE:9SE T'PLVT IN INK OR T)'PE.9L L 1 0 HATIONj Darc; d� D City or Town of: Q To the Irlshc. nal �/ IhWes: By this applicatlllll tile. LIMICI-Signe gives notice ► lis or her intentioll to perfbrnn the electrical wort: described below. Location (Street& Number) S G )C) ST- Owner -'Olvncr ur'fcnttnt I J�t��o�l6g/�ol� 7 'V _ f�>P/��Q pU L ds Telephone No. Owner's Address /q7 A461AI ST. I-JD . OOOOA, w elaq_;7 Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate [lox) Purpose o1 Building Utility Authorirafion No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No. of Meters New Service Amps / Volts Overhead❑ Und'tb"rd ElNo. ot'Meters Number of Feeders and Ampacity Location and Nature(it Proposed Electrical Work: Ov Z4CK5 Coal Action of the dlorr* !able num I)e livived hr elle!ns>ec•lor of I I'irc.s. No. of Recessecl 1,ixfures No.of Ceil.-Susp.(Paddle)Fans No. of Total Transformers KVA No, of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting FixturesSwimmin 6 J Pool Above ❑ In- ❑ o. o n►ergency Ig► Ing grnd. grnd. Batte�nits No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No.of Detection and Initiatin• Devices r No. of Ranges No. of Air Cond' Tons, No. of Alerting Devices / No. of Waste Disposers Heat Pump Number Tons KW No. of Self Contained Totals: Del ection/Alertin , Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems: No.of'Devices or Ec uivalent No, of y',later No. of No.of Heaters KW Signs Ballasts Data Wiring: No.of Devices or Equivalent No. Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiling: No.of Devices or Ec uivalent OTHER: Allac'h additional derail y desired,or as required br the ho.pecrru of ll'ir INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work play iSSuc unlcsS the licensee provides proof of liability insurance including"completed operation"coverage or its Substantial equivalent. "hllc undcrSigned certifies that Such coverage is in force, and has exhibited proof of Same to the permit issuing office. CHECK ONE: INSURANCE VrBOND ElO"f HER [I (Specify:) I-/)q 41'r �©O Estimated Valuc ol'Electrical Work d � P�1, A('�f2lrs � � l tratic►1 ate) �Q (When required by mtmictpal policy) pOCIk-y SM-607/3ffQ Work to Start: Q� Inspections to be requested in accordancc with MEC Rule 10, and upon completion. /cc:rlr/j, rnrrler I tour /IS lr/t/l�)L'l1/rI/l CS al'perjurt, that the l/lf///•inat//1/1 on this applic(!ho/r is true and c-omplef:. FIRM NAME: jr LIC. NO.: e760A 3r� Licensee: �' yl1'�/-}5 S�/��G �(� Signature LIC. NO. 6063E tl/'applic abl, 'plat "uren�l,l"in llre license ntanbe�r 1h Address: .<` ��[0 r S'r", A16Atl- ODy�R uS.Tel. No.: 6 a3 �y --t 'Did Alt.'fel. No.: 7 ' 6 OWNER'S INSURANCE WAIVER: I am aware That the Licensee(toes!7("11 h(11'e the liability insurance coverage nurnl;tlly t required by law. By Illy Signature below, I hereby waive this requircnle"t. I and the(check one)❑ owner ❑ owner's aLcnl. Owner/Agent Si-nature Telephone No. PERA9IT rEEE: $ Date.... TOWN OF NORTH ANDOVER PERMIT FOR WIRING '2SACH This certifies that .... ....... Z'�.....zz:......... ........................ has permission to perform .............. ................... Z �I ..;......... ..................... wiring in the building of.... ........./' ............................................... at.........1Y1...... ....... ............. ,North Andover,Mass. Fee.... .............. Lic.No. /,�. ........ (ELECTRICAL INSPECTOR Check # 457 Official Use Only Permit No. -71, ?�f�Cd712n2d�ri�,g1'�f d� .S.S�f�?�ZlS�7'7S Dt o�pudGc Say Occupancy&Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00 (Please Print in ink or type all information) Date 6` /!�> d UGC� To the Inspector of Wires: Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location(Street&Num.)ber /L /! C'(-CC, Owner or Tenant l/ i,W Re i4 r Y/tel '"�,/•� Owner's Address / l�� �� /f Is this permit in conjunction with a building permit Yes El No t� (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service ZU C) Amps I/'? adv Voits Overhead ij/ Undgmd ❑ No.of Meters New Service '900 Amps /ala r�yv wits Overhead Er Undgmd ❑ No.of Meters Number bf Feeders and Ampacity Location and Nature of Proposed Electrical Work r r Total No.of Lighting Outlets No.of Hot fuse No.of Transformers KVA Above ❑ In ❑ No.of Lighting Fixtures Swimming Pool gmd ❑ gmd ❑ Generators KVA No.of Emergency Lighting No.of Receptacles Outlets No.of Oil Burners Battery Units No.of Switch Outlets No of Gas Burners FIRE ALARMS No.of Zone Total No.of Detection and No.of Ranges No of Air Cond Tons Initiating Devices Heat Total Total No.of Diposal No. Pumps Tons KW No.of Sounding Devices NoJ of Self Contained No.of Dishwashers Area Heating KW Detection/Sounding Devices ❑ Municipal ❑ Other No.of Dryers Healing Devices KW Local Connection No.of No.of Low Voltage No.of Water Heaters KW Signs Bailases Wiring No.Hydro Massage Tuds No.of Motors Total HP OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES= NO = ' have submitted valid proof of same to the Office YES= NO = If you have checked YES please indicate the type of coverage by checking the appropriate box INSURANCE = BOND = OTHER = (Please Specify) (Expiration Date) Estimated Value of Electrical Work$ Work to Start Inspection Date Resquested Rough Final Signed under th enakies gf FIRM NAME /i ! J '/ I( r -f CAI `t L° -t,n LIC.NO. 411,!If Licensee , eI,T �/n�//r Signature / LIC.NO 6 //�� `� Bus.Tel No. �2 25 Address'alAClc 5"-tdI^C lSf �� OU^+.� Alt Tel.No. OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws.And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) Telephone No. PERMITfEE $ (Signature of Owner or Agent) Z , The Commonwealth of Massachusetts a d Department of Industrial Accidents , Office of Investigations Boston, Mass. 02911 Workers'Compensation Insurance Affidavit Name Please Print Name: Location: City Phone # I am a homeowner performing all work myself. 0 I am a sole proprietor and have no one working in any capacity I am an employer providing workers'compensation for my employees working on this job. Company name: Address City: Phone#- 1 Insurance.Co. Policv# Company name: Address City: Phone* Insurance Co. Policy# Failure to secure coverage as required.under Section 25A or MGL 152 can lead to the irr4meition of aiminal penalties of,a fine up to$1,' OD and/or one years'imprisonaKs t-as rim as_ciW pxenaties-o-theSacm-faSTDPYNDRKDRDR and ahneWj(,311)0.OD)-ajdW.-gaintmd: I understand that a copy of this statement may be forwarded to the office of Investkjations of the DIA for couetageverification. I do hereby cerfily under Bre pains and penalties of perjury that the Inforrnatiarr provrded above is five and correct Signature Date Print name PbmQ# Official use only do not write in this area to be completed by city or town officiar City or Town Perr�t/Licensi El Check if immediate response is required El Building Dept ❑ LfcensinQ Board ❑ Selectman's Office Contact person_ Phone# ❑ Health Department ❑ Other