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HomeMy WebLinkAboutBuilding Permit #358 - 88 Kingston Street 11/2/2006 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION O NORTH N m A Permit NO: � O Date Received i Date Issued: SACHUSE� IMPORTANT: Applicant must complete all items on this page LOCATIONPrirtt CY PROPERTY OWNER e rtey Print MAP NO.: PARCEL: ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building ❑ One family ❑ Addition ❑Two or more family ❑ Industrial Alteration No. of units: repair, replacement ❑ Assessory Bldg ❑ Commercial Demolition ❑ Moving(relocation) ❑Other ❑ Others: ❑ Foundation only DESCRIPT OFORK TO BE PREFORMED Identification Please Type or Print Clearly) OWNER: Name: �rr'1 f.✓r, L <<<°�S Phone: r Address: ell— CONTRACTOR Name: 1`� �0 i (4'r e(v Phone: Address: wOac� 0C Supervisor's Construction License: ®�/�1�� Exp. Date: 9XSE/ 7 Home Improvement License: /-2 5 0 Vf Exp. Date:/0 4/6 6 7 ARCHITECT/ENGINEER Name: Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERM T:$12.00 PER$I000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost :$_� � '� FEE:$ jo .� Check No.: S2v Receipt No.: Page W4 TYPE OF SEWERAGE DISPOSAL Swimming Pools C Tanning/Massage/Body Art E, Public Sewer Well Tobacco Sales —J Food Packaging/Sales E.'—! I ter on Site t Permanent Dum s �— �, P Di. Electric Meter location to Private(septic tank,etc. _� � project NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund Signature of Agent/Owner Signature of contracto ' Plans Submitted ❑ Plans Waived El Certified Plot Plan ❑ Stamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF- U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ I COMMENTS I DATE REJECTED DATE APPROVED HEALTH ❑ ❑ i z COMMENTS FIRE DEPARTMENT - Temp Dumpster on site yes Ono Fire Department signature/date 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 Building Setback (ft.) Front Yard Side Yard Rear Yard Required Provided Required Provides Required Provided Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: NOTES and DATA— For department use Doe:INSPECTIONAL SERVICES DEPARTMEN' :BPFORM05 Created JMC.Jan-'006 i 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 Addition Or Decks ❑ Building Permit Application ❑ 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) 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) ❑ CPY o of Contract ❑ Mass check Energy Compliance Report 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:INSPECTIONAL SERVICES DEPAUNIEN'r:8PFORN105 Page 4 of 4 t%ORT#1 Town of : � _ 4Andover No. A dover, Mass.,/, ' COCMICKE WICK y�. S RATED P'V BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System .0 BUILDING INSPECTOR THIS CERTIFIES THAT.......1. ................ ............................................................................................................. Foundation has permission to erect........................................ buildings on.... ....Xtov. rAn...... �....... Rough to be occupied as .............................................. ....�..�.......�,i.t . .... ............W..I�.. . ...�.i�� Chimney provided that the person accepting this ermit 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 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 O� PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUST S Rough 111 Service .. ... .. . ........................... ............ BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFina, No Lathing or Dry Wall To Be Done RE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. The Commonwealth of Massachusetts 1 I Department of Industrial Accidents Office of Investigations a ; 600 Washington Street Boston, MA 02111 « ' www.mass.g ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ++ Please Print Legibly Name (Business/Organization/Individual): J, (0 ( er Co W s-t, Address: 3 &,4r(CCA-021JAve City/State/Zip: �e7W, M. 0 /J yy Phone 2 9`/6 r Are you an employer?Check the appropriate box: Type of project(required): 1.❑ 1 am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2 I am a sole proprietor or partner- listed on the attached sheet. + 2 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.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §](4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' comp. insurance required.] 13.F_1 Other *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. *Contractors 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: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: City/State/Zip: 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. /do hereby certify uder the ains and penalties of perjury that the information provided above is true and correct. Signature: 04Date: Phone#: 7 7A- S SZ ?�6( Official use only. Do not write in this area,to be completed by city or town gfficial. 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 you 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 pen-nit/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 Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia 77 a. 3 PART W. 7= - z 9Y�/ hs� ����syS���• PROIPtyo CO(N DATE $ALSUBMITTED TO WORK TO BE PERFORMED Al F A44 1� �8 YFa - AD!pRE$S s f E DA10 TE QF ALAN$ a ARCHITECT PHONE NO." :cbt of r � CE6�✓ � d rfo eeeky pi to fc�rrsh the matefaisd pVlw e rm th �ebor pees ry for 7.11777171 1 then, 1 A v i i �.V!» C.. b a'� V(.t�I Uv3'�,s. A, �a S dU777 r %� 7777 4 yt © l /tif� �}Yrr. lulu, riAll v 6 � T1 f LIM Vii' ot'1S • C.,�11��'�r ?!3 L�1 /l/1®{v All material as guaranteed, to, be as specified, and the above work to be performed in accordance with the drawings and speeifi- ations submitted for:aboveW'.ork and completed,in a substantial workmanlike manner for the sum of e (412iq I grL bolla ($ /•� � - ) t � w,�rfth payments to be-made as follows: 9 Z �, P Respectfully submitted Any afteraU�on or deviation from above specifications involving extra:costs will be uecxited only upon written order, and will become an extra charge Per GVer arid,above'the estimate. All agreements contingent:upon strikes, ac- rts,ordetaystieyondour control. Note—This proposal may be withdrawn' , by us if not accepted within 3 a days. { r=T7777777=-7 77 ;4CC�pTANbF PAOt'bSAt_ a WJI.. Th'SISbetta� specifcatfora atdonidlt�bns ate satistctory andae hereby accepted. You are, authorize fro Bio the,k rs°gi�fedaf an rii� emade -as outliedabove F �-" •. t ate a• ACORDDATE(MWDD/YYYY) TM. CERTIFICATE OF LIABILITY INSURANCE 0912612006 PRODUCER Phone: (978)475-0400 Fax: (978)475-2171 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION THE HOWE INSURANCE AGENCY ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 4 PUNCHARD AVE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ANDOVER MA 01810 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELQW. INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: National Grange Mutual KEITH J CORMIER INSURER B: DBA K J C CONSTRUCTION INSURER C: 35 MAPLEWOOD AVENUE METHUEN MA 01844 INSURER D: 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. /NSR AD01 TYPE OF INSURANCE POLICY NUMBER POLICYEFFECTIVE POLICY EXPIRATION LIMITS LTR INSR DATE MWDDIYY DATE MMIDD/YY GENERAL LIABILITY MPK46220 07/31106 07131/07 EACH OCCURRENCE $ 500,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 'SES aren. $ 500,000 PREMEe oc CLAIMS MADE FX� OCCUR MED.EXP(Any one person) $ 5,000 A PERSONAL&ADV INJURY $ 500,000 GENERAL AGGREGATE $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG. $ 1,000,000 RO- POLICY JPECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY (Per person) $ SCHEDULED AUTOS 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 $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE Is OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION$ $ WC-ATU- OTHER WORKERS COMPENSATION AND TORY LIM TS EMPLOYERS LIABILITY E.L.EACH ACCIDENT $ ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ If yea,dexribe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER: DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS RE:TERRY WILKINS 88 KINGSTON STREET,NORTH ANDOVER MA 01845 CERTIFICATE HOLDER CANCELLATION VILLAGE GREEN WEST SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS CROWINSHIELD MANAGEMENT WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 18 CROWINSHIELD STREET DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,IT'S PEABODY MA 01960 AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE J/� Attention: ACh nstlne J. range ACORD 25(2001108) Certificate# 2316 ©ACORD CORPORATION 1988 - TIONS. zu� - ,--t �� � ,BUILDING-REGUL�ISOR BObR �CTION'Sl1PER .' CONSTR ; 1 Ucen5e � 051948 Number OS te-08i9811956 no: 623.0 1181207 Jr. l `' rcted' 00 ADEN p O g4 CommniS'sioner METH. ✓fes 6� / .��1 Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: ._ . 125049 h Expiration 1011/2007 ' I Type DBAI K.J. Cormier Construction Keith Cormier 35 Maplewood Aver Methuen,MA 01844 Administrator I Location= No. . Date HQRTFTOWN OF NORTH ANDOVER F 9 Certificate of Occupancy $ . o -_• s . s'•••°''<�' Building/Frame Permit Fee $ � JA�NUSE Foundation Permit Fee $ x Other Permit Fee $ TOTAL $ Check # 19760 Building Inspector