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HomeMy WebLinkAboutMiscellaneous - 15 MERRIMACK STREET 4/30/2018 i 15 MERRIMACK STREET 210/041.0-0017-0000.0 r a Location� roe Pox C No. 6 ,3 Date y I' ^TM TOWN OF NORTH ANDOVER 3? i • O F R 9 Certificate of Occupancy $ S Building/Frame/Frame Permit Fee $ 5110+cHu sa 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ a ` Check # a a IG360 � Building Inspector K TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT!EtAM RENOVATF, OR DEMOLISH A ONE OR TWO FAMILY DWELLINGso BUILDING PERMIT NUMBER. 0-3 DATE ISSUED: SIGNATURE: Buildin Co ssioner/I for of BuildingsDate SECTION 1-SITE INFORMATION O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Y I i Map Number Parcel Number 1.3 Zoning Information: 1.4 Properly Dimensions: Zoning District Proposed Use Lot Area Fronto ft 1.6 WELDING SETBACKS ft Front Yard Side Yard Rear Yard Regaired. Provide Rapired. Provided Rzcpired Provided v 1.7 Water Supply M.G.L.C.40. 34) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zane ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSEEIP/AUTHORIZED AGENT (Strict: 'ye;, P,(D m 2.1 Owner of Record &e-6agp. n /-6 Name(Print) Address for Service: I Signature Telephone 2.2 Owner of Record: A 0 Name Print Address for Service: z M Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ _ o T Fw,-11 a O (� Licensed Construction Supervisor: 0 9, 1 k� ��MP License umber r� Expiration Dat D ic Signature Telephone y 3.2 Registered Home Improvement Contractor Not Applicable ❑ I�d6-r Company Name �� a� �Rr Registration Number Address / p � �✓ 06 � 6oj a i' 0�0 Expiration Date z Si nature Telephone G) SECTION 4-WORKERS COMPENSATION(MG.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 Workcheclr aH■ bk New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OMCIAL USE ONLY Completed b ermit applicant 1. Building ":K �13 (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 bel►alt;in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, ,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 Si tune of Owner/Agent Date NO. OF STORIES SIZE BASEIVIENT OR SLAB SIZE OF FLOOR TIMBERS I' Z. 3 SPAN DIMENSIONS OF SILLS DMIENSIONS OF POSTS DUvfENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING -- X MATERIAL OF CHUANEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE _ PFpDUCER THIS CERTIFICATE!S ISSUED AS A MATTER OF INFQMAMON AM-CONFERS:NO RIGaM UPON THE CEanFIC►TE Pollack Insurare Agency HdLDER.THIS 10ERT16ICATE 00E9 NOT AMEND,EXTEND on 12 Parmenter Road ALTER THE COVERAGE AFFORDED 8Y THE POLICIES BELOW. Londonderry NH 03053 Phone: 603•-432-2011 Pau:603--432-6096 INSURERS AFFORDING COVERAGE NAIC IP INSURED RWRERA: woet=world znsuranoa Co. INSURER B: The Travelers Cca 'es Robert J. Farrell UISURERC: w. 29 Cortland Road INSURER n. - Hampstead NX 03826 MSURR2 E COVERAGES -nu-M,uwn nr n,nl Innrnr i u m nn ruu rI nIr nrru Inrumr.m'n n-uualnr o u„qo"oUC ron m r-tmuou naaloo vissa-imc taMam,I ftumu,a ANY KWUN M A 1•I tKM UK WNUI I IUN VP ANY WN I KAI:I U1L:U I MbX UUWM6N I VY11 N H6'P%(:1 I U WHIIiH I Hly CtK I a•u;A1 E MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES OES CRIRED HERRN IS SUBJECT TO ALL THE TERM%EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY NAVE BEEN REDUCED BY PAID CLAIMS. INSK WITC LTR NSK TYPE OF INSURANCE PDXY NUMBER DATE DATE LIMITS GENERAL LIANLITY EACH OCCURRENCE S 500 000 YJAMA61c I O KtN I to .- A X COMMERCIA Q6NXHALLIABILITY NPP916821 10/17/04 10/17/05 PREMISES oecurenc�> 650,000 CLAM MADE n OCCUR MED 9W(AM one Person) S5,000 PERSONAL&ADVIKNRY $500 000 GENMMLAGGREGATE $1,000,000 GENLAGGREGATE LIMIT APPLIES PER PRODUCTS-COMPTOPAGG 61,000 000 POLICY LOG AummoBILE LIABILITY (En aaCCd� 1t31NGLE uMl t i ANY Aero ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per Person) i HIRED AUTOS BODILYINJURY t NonaowND sums (Per accident) PROPERTY DAMAGE (Perao6cenq GARAGE uA81LtlY !UTO ONLY.EA AC_CMT S ANY AUTO OTHER THM EA ACC S AUTO ONLY; AeO S EXCESSIUMRRg"LIADILLTY EACH OtxURRENCE S OCCUR CLAIMS MADE AGGREGATE E S DEDUCTIBLE _ RETENTION 6 6 TY WYO1fal f Amumtnnnm nun �.�.��,.n $ ANY= 6ZZUB384OD95004 11/04/04 11/04/05 EL EACH ACCIDENT S100000 OFFICEWnfEMT3E]iEXCLIlDED4 EL DISEASE-R►GWL0 s 100000 Iryes� "MM& E.I_DIMME-POLICYL.UT 15000( 0 SPECwI PROVISIONS below OTHER DMRWnON OF OPERATIONS I LOCATLQNS I VEHICUES l EXCLUSIONS ADDED BY ENDORGSWENT I SPECIAL PROVISIONS Roofing - Residential CERTIFICATE HOLDER CANCELLATION HAIpPRT SHOUL,b ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE 10MRATION DATE THEREOF.THE ISSUINd INSURER VALL ENDEAVOR TO MAIL 10 DAYS VVRIT 13N NOTICE TO CERTIFICATE HOLDER NAMED TO THE LEN.BUT Fen A mo TO OO 30 SHALL Hampstead Print a Copy IMFosE TION ILTIY of ANY taND UPON THE tNSUwEts,1TB AGENTS OR attn.- Rob 3 Commerce Park Drive E. Hampstead NH 03826 S .. lack ACORD ACORD 2512004!08) ®ACORD CORPORATION 1988 A..r� %,V"&r1&U"Weut{n UJ iriassacnitsens Department of Industrial Accidents Office of Investigations • 600 Washington Street Boston,MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Busin orp&atiowwividual): �0b FRye n PAJL,�) Address: 021 Cc j�t r! Mtl 6 City/State/Zip: F., 14A005_1Q�� I+ �' � Phone#: LCL3 - _ q.4 6 Are you an employer?Check the appropriate box: Type of project(required): 1.[ I am a employer with 4. ❑ I am a general contractor and I employee's(full and/or part-time).* have hired the sub-contractors 6. ElNew construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. t ?• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9• ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.13 Plumbing repairs or additions myself. [No workers' comp. C. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' comp. insurance required.] 13.E] Other i{co �elCr�ccM«r� *Any applicant that checks box#1 must also fill 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 a new affidavit indicating such. tContractona that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. �( Insurance Company Name: ale T�aJL� (�2S �w� R�,Je S Policy#or Self-ins.Lie. #: 6 zzu Ig ©Pq4©�c{ . ExpirationDater I- COQ(-O 5 Job Site Address:_ MGM t_nx Si' City/State/Zip: ANV V& 0M- D m<, 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. Ido hereby cert' under the pains and penalties of perjury that the information provided above is true and correct Si ature: ` 0 Date: — — Phone#: 0 3 — oC — OrIcial use only. Do not write in this area,to be completed by city or town o icid 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 M Information and Instructions ers comp ns ti their Massachusetts General Laws chapter 152 requires all employers service of another under any contrac t in Provide oe et of hire ;¢ Pursuant to this statute, an employee is defined as ...every pe 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 three ma���encdonswctionresides ortherein, work on such occupant dwelling house dwelling house of another who employs p 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 chapter have been presented to the contracting authority." requirements of this Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)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 estions regarding the law or if you are required to obtain a workers' Industrial Accidents. Should you have any qu 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia 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 at: I� mp& z7-r is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section I OA. The debris will be disposed of in: (Location of Facility) S gnature of Permit Applicant Fire Department Sign off: 9z Dumpster Permit Date V40RTH Town oft over No. 03 ton over, mass., 0 cLAKE o CHICHEWICK 7,es RATED 0k'?G C7 BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System 306% 640^0 044ficrl BUILDING INSPECTOR THISCERTIFIES THAT.........................................................................6-*....... .......-*.... Foundation s4 it, P has permission to erect........................................ buildings on.....Zr........ ..........Is...46........ Rough to be occupied as.......?w W^00 W&I CAP A) C%4. 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 relating ? t)e Inspection, Alteration and Construction of Buildings in the Town of North Andover. Y 11 1 PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS CAL INSPECTOR UNLESS CONSTRUCTION STTS Rough � S ELECTRICAL ......... ........... .......................... ............14.0k!..................BUILD. BUILDING..INSPECTOR Service Final Occupancy Permit Required to occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough 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. MA Construction Supervisor#082056 Home Improvement Contractor# 135385 ROB FARRELL ROOFING, SIDING & REPLACEMENT WINDOWS FREE FULLY ESTIMATES 978-682-9449 No.Andover 603-378-0515 Hampstead 603-247-4668 Ceil INSURED 29 Cortland Rd, E. Hampstead,NH 03826 I/we,the owner(s)of the below mentioned premises,hereby contract with and authorize you as a contractor to supply all materials, labor,and perform all workmanship in accordance with the following specifications,terms,and conditions on premises below. Owner's Name ( k QA KL :5 Phone Job Address l 5� r lA c- ST' City _State_ SPECIFICATIONS + Acs W-ATea n2,,k&Q 4(1 Lr Tori.► l_� P�►,, Vie.I r (JA�lejl AlmtAll- ()0 kQ CA.0�QrC I`� �/�fl• �r` �1 Q TCS + r,.lAr-e k Nwp) c �-- ,` VAIl�Y� L)S:a,5 30 �� j (ccs sr�(� Ykt��tle.. Materials and labor to cost$ D �� Payments to be made e as follows 0. Coq 1cr,0j Options: Additional cost.$ � D CL-Vo 6Q- )` a, T � - � X75., The above costs,specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Owner has 3 days from date signed to withdraw without any consequences. Respectfully Submitted: Signature 7 Owner This proposal may be withdrawn by us if Signature Date not accepted within days. Owner l` 15 MERRIMACK STREET / 210/041.0-0017-0000.0 i i i i r F f Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws,Ch. 139, Sec. 313 l To: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectmen addresses � 1 Re: Insured: Property address:__Z.T A/ e,k A� Policy No. l/ Loss of / y 19 File or Claim No. Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, ,Chapter 143, Section 6 to be applicable. If any notice under Mass Gen. Laws, Ch. 139 Sec. 313 is appropriate please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Title: On this date, I caused copies of this notice to ent to the pers ns In d`above at the addresses indicated above by first class mail. S' nature',,7- MASSACHUSETTS aMASSACHUSETTS CONNECTICUT NEW HAMPSHIRE VERMONT MAINE RHODE ISLAND Boston Lawrence Bridgeport Claremont Brattleboro Augusta Pawtucket JASSMIATION Barnstable Pittsfield New London Gorham Burlington Lewiston CLAIMR/SRV14:1 OF Brockton Salem No.Haven Laconia Montpelier Skowhegan NEW YORK149 RXGLAMD,IMC. Fall River Springfield Stamford Manchester White River Jct. S.Portland Utica Fitchburg Worcester Waterbury Portsmouth W.Hartford