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HomeMy WebLinkAboutBuilding Permit #769-2016 - Exception 1/4/2016NORry BUILDING PERMIT LF 11 `r TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#. " !'�D Date Received • / 74p�H.1TEo �SSgcHuS Date Issued: IMPORTANT: Applicant must complete all items on this pane LOCATION Po,),x ej, Print PROPERTY OWNER -a- V—tl-AgiA�L.4 10A MAP6C�Print 100 Year Structure yes l PARCEL: 1W7 ZONING DISTRICT: Historic District no Machine Shop Village yes . no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial R -Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other I Septic: ❑ UUell ! ❑FSI©©tl r lama O Wetlantlsd ❑' `Watershed Dl tncti ® rW.5, /Sewer DESCRIPTION OF WORK TO BE PERFORMED: PA -In 11� - Please Type or Print Clearly OWNER: Name: Address: Contractor Name:T_ bXr, horeo, Phone: 60,? ,3dt i -6,0 5 Email: Address: 2) Euera rP-ev. rr'vc ©�R `J Supervisor's Construction License: GS -oyi 9,'9 Exp. Date: 3Ld-21� Home Improvement License: ARCHITECT/ENGINEER Address: Date: 6/361 Phone: Reg. No. A G o3J, Y.S FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ 6 &Z2 FEE: $ gz Check No.: �' Receipt No.:� NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 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 i6 Workers Comp Affidavit 4. Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract 4. Floor Plan Or Proposed Interior Work 4. Engineering Affidavits for Engineered products TOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks 4. Building Permit Application Certified Surveyed Plot Plan 4. Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract Floor/Cross Section/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 TOTE: 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 46 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: 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: Building Permit Revised 2014 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL r Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools 0 wen ❑ 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 PLANNING & DEVELOPMENT Reviewed On COMMENTS Signature_ CONSERVATION-- _ -Reviewed on ____Signature COMMENTS C HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments r ' Water & Sewer Connectionlsianature & Date Driveway Permit DPW Town Engineer: Located 384 Osgood Street 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.$10041000 fine NOTES and DATA, -- (For department use ® Notified for pickup Call Ema Date Doc.Building Permit Revised 2014 Time Contact Name Location e -e,-4 f" --v cO No. Date 1 W, rA n r L J W D Q m Nm L U Y O .LL L 4J N N Q Ln ® d ? 0 C O 7 LC L 7 W O U (6 LL O H Z z m J C =1c6 K LL O N z U j W K U In f° LL O aCA zCA Q t . 7 w LL z W C G a W LLQ LL N " CO O Z a� w Ln N O O N O O V W 'Q L a E n CD m Y � �' c d d ^ v` I E - H C J m a _ cl) W Q cZ +mss O W 0 E o o U N o 0 4)� u �w 3 c W J o mo~ aZ a) O as o �U) c) cr c _ F- _ Q .o H o en � v m m f�cc s W = 70+_-� O O : j LL uj 2 'Vl = O F- .0 -0 :E.2 OZ W ci CL co N'O %-C0 L) 0 m 45 CL L. John Koran Construction, L. L. C. . BuiOng and W modeCing 21 Evergreen Drive Hampstead, NH 03841 December 22, 2015 Stephen J. Kohr General Manager North Andover Country Club 500 Great Pond Road North Andover, MA 01845 Dear Mr. Kohr.: phone 603-329-6209 fax 603-329-6209 This is a contract for the small pavilion on the golf course at the North Andover Country Club. Construct a 9' x 9' pavilion as follows: 1. Remove existing structure. 2. Install 6"x6" pressure treated posts on existing piers. 3. Install 6"x6" pressure treated beams above the posts with 4"x4" angle braces. 4. Frame roof with 2"x6"rafters and board sheathing. 5. Cover the roof with architectural shingles. 6. Install 2"xl0" pressure treated seat on two sides. 7. Painting not included. 8. Disposal of debris included. 9. I will apply for permit. Payment schedule: First payment due upon signing contract. $2,275.00 Second payment due after old pavilion demolished. 2,275.00 Third payment due upon completion. 2,275.00 Total cost: Signature of Auttforized Agent Dat $6,825.00 Signof Contractor Date / ,' Page 1 State of Massachusetts Home Improvement Contractor License #102071 State of Massachusetts Construction Supervisor License #47989 NAT -24839.4 � J a ' gso AL - 1 4, ' . N`.. s� 1 -�Qi� s U 6 � 4- h c" 2 x C-� U Yk��'bPF 1 L Le h 1 .tea The Commonwealth of Massachusetts z. Department oflndustriulAceldents Y 1 Congress Street, Suite 100 — << Boston, MA 02114-2017 www.mass gov/dia 9 C sation Insurance Affidavit: Duiiders/Contractors/EIectricians/Piumbers. 3301 s ompen TO BE MED WITH TEE PERM'TTING AUTEOPJTY. A hcant Information Please Print LeaitblY Name (Business/Organization/individnal): :Zb6, Address. 1 CC— City/State/Zip: r City/State/Zip: HU -M Are you an employe;?_&_=k!& box: Phone #: lam® 3 .3 L t &PAO -1 1. yfam a employer with L employees (full and/or pari time) * 2. ❑ I am a sole proprietor or partnership and have no employees working for meill any capacity. [No workers' comp. insurance required.] 3.[] I am a homeowner doing all work myself- [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole 5.FJ I am a general contractor and I have hired the sub-cointractors listed on the attached sheet. These sub -contractors bade employees and have workers' comp. insurance., 6. Q We are a corporation and ifs offigers have exercised their right of exemption per MGL c. 152, § 1(4), and we have M4 oyees. [No workers' comp. insurance required.] Type of project (xecluired): 7. n. New construction 8. P�Iremodelirlg 9. ❑ Demolition 10 [� Building addition 11.0 Electrical repairs or additions 13. [] Roof repairs 14. [] Other `Any applicant that checks box 41 must also till out the section below showing their workers' compensation policy information. Homeowners who submii 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 ctors have employees, 'they must provide their workers' comp. policy number. employees. If the sub contra . X am an employer drat is providing workers' compensation insurance for my employees.' below is the policy and joh site information. r Insurance Company Name:w,ii r����-��� _� 5r��� ExpirationDate: Policy # or Self ins, Lic. lob Site Address: City/State/Zip: i( gr. %�ti h,,k 41m, 0), 'q -S^ Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A. copy of this statement may be, forwarded to the Office of investigations of the DIA for insurance coverage verification. pdo h areby certii uR der, t�epains andpenalties ofpedy,rry, that the information provided � ov, is true and correct. Phone #: official use only. Do not write in this area, to be completed by city or town official. City or Town.: Permit/License M. Issuing Authority, (circle one): 1. Board of health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6, Other Phone Contact Person: Massachusetts General Laws chapter 152 requires ag 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 litre, 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 ofthe foregoing engaged in a joint enferprise, 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. Hova ever 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 iha boxes that apply to your situation and, if necessary, supply sub'contractors) name(s), address(es) and -phone numbers) along with their certificates) of insuranee.—L-imited Liability-ompanies-(LL-C)-oxLimited L-iaWliiy Rartrterships(LLP)wr h no employees other lian- the members or partners, are not required to cant' 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 ofinsurance coverage. Also be sure to sign and date the affidavit. The affiidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidenis. Should you have any questions regarding the law ox 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 - selfinsurarice 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. Ili 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 "fob 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.a. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 1.00 Boston, MA 0211.4-2017 Tel. # 617.727-4900 ext. 7406 or 1.-877-MASSAFE Fax # 617•-727-7749 Revised 02-23-15 www.m.ass.gov/dia Client#: 490547 IOHNHORA ACORDTM CERTIFICATE OF LIABILITY INSURANCE M/DD/Y 6/23DATE (MMIODNYY1� 2015 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 USI Insurance Services LLC 3 Executive Park Drive, Suite 300 Bedford, NH 03110 855 874-0123 CONTACT NAME: al NE:855 874-0123 ac No E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Maine Mutual Group Insurance Co 15997 INSURED INSURER B: EastGuard Insurance Company 14702 John Horan Construction LLC 21 Evergreen Dr. Hampstead, NH 03841 C: -INSURER INSURER D INSURER E: INSURER F: PREMISES Ea occurrence$25O OOO COVERAGES CERTIFICATE NUMBER: 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 CONTRACTOR 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 INSR SUBR WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP LIMITS MM/DD A GENERAL LIABILITY SC10965638 04/01/2015 04/01/2016 EACH OCCURRENCE $1 f0009000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence$25O OOO CLAIMS -MADE FxI OCCUR 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/OPAGG $2000,000 POLICY E LOC $ A AUTOMOBILE LIABILITY KA10955638 4/01/2015 04/01/201 EO garde SINGLE LIMIT $1,000,000 ANY AUTO BODILY INJURY (Per person) $ ALL OWNEDX SCHEDULED BODILY INJURY (Per accident) $ TEDSAUTOS X OS NON -OWNED X PROPERTY DAMAGE $ HIR AUTOS Per accident A X UMBRELLA LIAB X OCCUR KU10955638 04/01/2015 04/01 /201 EACH OCCURRENCE $1,000.000 EXCESS LIAB rl CLAIMS -MADE AGGREGATE $1,000,000 DED RETENTION $ $ B WORKERS COMPENSATION JOWC667818 04/01/2015 04/01/201 X WCSTLT T OTH- AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $600,1000 OFFICER/MEMBER EXCLUDED? � N / A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $500,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 1$500,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) FOR INFORMATIONAL PURPOSES ONLY John Horan Construction LLC 21 Evergreen Drive Hampstead, NH 03841 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE © ISRR-2010 ACORD CORPORATION_ All rights reserved ACORD 25 (2010105) 1 of 1 The ACORD name and logo are registered marks of ACORD #S15615641/M15613375 LAKCA ha G%�e `Ea�n��ro�rrnr�r�/�, afC/�%r3fcrc�rr;cll �Q Office of Consumer Affairs & Business Regulation OME IMPROVEMENT CONTRACTOR a=` '�Type: i egistration 102071 UDBA ;Expiration 6l3U/2016 JOHN V. HORAN CONSTRUCTION John Horan 21 EVERGREEN DRIVE = HAMPSTEAD, NH 03841 Undersecretary 1�( Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supen•isor License: CS -047989 JOHN V HORAN 21 EVERGREENil € Hampstead NH 03841.,, Ex Pi ration Commissioner 03/02/2016 License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, MA 02116 Not valid without signature 1