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HomeMy WebLinkAboutBuilding Permit #709-14 - Exception 4/15/2014Permit NO: Date Issued: BUILDING PERMIT o ° TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATI Date Received 1• 4q �` n°RATc° .t IMPORTANT: Applicant must complete all items on this page FIX LOCATION Undc(4,0 r,�b A, id v, ._ n "t PROPERTYOWNER, Print MAP NO -PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village ves no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family 0 Industrial ."Iteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain 0 Wetlands ❑ Watershed District El Water/Sewer OWNER: Name: (`l` Address: bo FF—c—ONTRACTOR Name: Address: r &L f PM Identification Please Type or Print Clearly) n Supervisor's Construction License: EpR Date: 7/3J Ps Home Improvement License: , , Exp. Date: , f, resin ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED�COS¢ASED ON $125.00 PER S.F. Total Project Cost: $ I % %% FEE: $ (�1 ` bo Check No.: rZ Receipt No.: 'Zyl -1 NOTE: Persons contracting with unregistered contractors do not have access to theguaranty fund. r it Permit N0: Date Issued: TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION IMPORTANT: Applicant must Date Received all items on this TYPE OF IMPROVEMENT. PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family El Addition 11 Two or more family El Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ElSeptic ❑ Well r` El Floodplain 0 Wetlands- ❑Watershed District, 11 Water/Sewer DESCRIPTION UI- WUMM I U bt: rtKrUKiviCU: Identification Please Type or Print Clearly) OWNER: Name: Phone: AAA,- - ARCH ITECT/ENG I NEER AA,­ ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $, FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund E, 96 of Agent/Owner" „ Slgaure_ of contractor Plans Submitted Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans I r I In L r�c-",AA 'JI I z) V- PIA Location No. tCf, '— Date S t� Check #{/_�� 27447 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $_ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ t Building Inspector Plans Submitted 01 -Plans Waived ,'=_Certified Plot Plan ❑ Stamped Plans F1 �TYP•� 0)� ::SEWERACEDiS�OSAL- - - _ - . Public Sewer Tanning/MassageBody Art .. .Swimming Pools ❑ Well Tobacco.Sales ❑ Food Packaging/Sales ❑ Private {septic tank etc._ _Permanent Dftmpster on:Site THE: FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM -DATE REJECTED - .. PLANNING & DEVELOPMENT- ❑ COMMENTS -CONSERVATION COMMENTS HEALTH COMMENTS DATE APPROVED Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes-.- Planning es.- Planning Board Decision: Conservation Decision: Commen :Comments Water-& Sewer Con nectionlSignature & Date Driveway Permit DPW Tow;i Engineer: Signature: Located 384 Osgood Street FIRE DEPARTit#IE`NT.,=.Temp Dumpster on site yes....: no Located at..124,Mairi Street Fire Departmef�t signature/date COMMENTS `+` ' -Dimension . Number of Stories:_ _Total land area, sq. ft.: Total square feet of floor area, based on Exterior dimensions. ELECTRICAL: Movement of I1111eter.l.ocatron;^ niast-or service drop requires approval of ..'Electrical Inspector Yes No DANGER.Z®NE LITERATURE: Yes No MGL-.Chapter-166.Section 21A. F and G min.$100=$1000:fine NOTES and DATA — (For dp-narfmpnf impl Doc.Building Permit Revised 2010 r- 0 Notified for pickup - Date t i Doc.Building Permit Revised 2010 r- i Building Department ---=`rhe foRowing is=a list of tho retluired.forms to be -filled ouifor the. appropriate. permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits - a B,tailding Permit Application o Workers Comp Affidavit o Photo Copy Of H.1.C. And/Or C.S.L-Licenses o Copy of Contract o Floor Plan Or Proposed Interior Work Li Engineering Affidavits for Engineered products NOTE: All dumpster:permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses a Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) Li 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) o Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit a Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) a Copy of Contract o Mass check Energy Compliance Report a 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 apw• al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.tted with the building application Doc: Doc.Building Permit Revised 2012 Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 11,189.00 m $ - $ 134.27 Plumbing Fee $ 16.78 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 16.78 Total fees collected $ 267.84 60 Edgelawn Avenue Unit 3 709-14 on 4/17/2014 Kitchen Remodel Eq * H w Z LL oz o to c Late+ Y 0 LL > NZ u 0. In u a N z z m C 0 a � LL t m cr T c U m LL O F- a z 2 J a L =3 = m LL O a Z z u I LV L :3 cc U ;_> V) `° LL oC OLLJ W a z a r j W LL E- z H a w o ui LL Q) m O + N N O Y O VI O � O • CL a) r (a +•' (D 0 O o r SSS = E a i 0 -oz Z �0 c = v► �. pop �P O m ,~ V L 0' ** v 3 _ C E � J i N L 4so Lm a O U) 4) Qi � L _ fn as ZO •• •� O 'a > 77 U Q c N_ O OEM E c o -CL o ami 0 0 O ��4 •> 3 "• ° c tacbA r jam 0 _ 0 v o c Q L cv -a O WOO m Q ai N O U)c� m a) •a +�+ O O .0 d y O O 'Q O Z F- O ,= w �.. , W v v E v y= L F • U O O •C G1 . , Z y d _ o U) N -0o4-O H t o- o U > Z s E O o Z C I a (Do� .E m m a. t- s C O �+ aoCL Q C Q O� C v_ M =-O,a; Z U CL Cl) m _ C m O . U LU Z CO c Z E- O -cf) c � y-4� Z LLI xo UJ U cn cnW LLJ -j a. 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License: -CS-094372 LORIANN J LANC`AN © �•,• �_~ 7 CREST ROAD KINGSTON M 03848 fit Expiration Commissioner 07/31/2015 1 (272. cpan�r�onru�i a��� �zcuac�uueG — ffice of Consumer Affairs & Business Regulation f M8 IMPROVEMENT CONTRACTOR egistration: 119623 ` Expirations 8/6/2015 Supplement oh.- Dube Construction !.plus Incl'` LORIANN LANGAN'•. - 10 Bricketts Mill Road, Sute''C" Hampstead, NH 03841 Undersecretary U� DATE (MM/DDIYYYY) ►co CERTIFICATE OF .LIABILITY INSURANCE 1 4/25/2013 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). CONTACT 'RODUCER NAME: Lynn Blanchard PHONE FAX (603)645-4331 FIAI/Cross Insurance (603)669-3218 ac No: E-MAIL lblanchard@crossagency.com 1100 Elm Street ADDRESS: - ----- NAIC # Manchester NH 03101 1INSURERA:Union Insurance R -Acadia Ins Co . INSURED - - Thomas A. Dube Construction -Plus, Inc., Dube INSURER C: Plus & Dirt Pro; Watertown Village, LLC INSURER D: 10 Bricketts Mill Rd, Suite C INSURERE: Hampstead NH 03841 INSURERE: COVERAGES CERTIFICATE NUMBER:Dube Construction 2013 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 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, Kio nr ei iru orm Ir.IPR I IMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CERTIFICATE For Information Only For Information Only For Information Only OLICY EFF M/DD/YYYY POLICY txr MMIDD/YYYY ADDLSUBRpOLICYNUMBER EACH OCCURRENCE $ 1,0Q0,000 PE OF INSURANCEILITY DAMAGE TO RENTED 100,000 $ PREMISES Ea occurrence 26/2013 4/26/2014 MED EXP (Any one person) $ 5,000 CIAL GENERAL LIABILITYIMS-MADE PERSONAL &ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 � OCCUR MAUTOMOBILE PRODUCTS-COMP/OPAGG $ 2,000,000, PA5028190 COMBINED SINGLE LIMIT $ 1,000,000 GATE LIMIT APPLIES PER: X PRO LOC BODILY INJURY (Per person) $ '26/2013 LIABILITY BODILY INJURY (Per accident) $ B X ANY AUTO ALL OWNED SCHEDULED FF Per accident AA5028191 AUTOS AUTOS EACH OCCURRENCE $ 1,000,000 NON -OWNED AGGREGATE $ 1,000,000 126/2013 4/26/2014 $ HIRED AUTOS AUTOS X UMBRELLA LIAR X OCCUR B EXCESS LIAB CLAIMS -MADE DED X RETENTION $ 101000 UA5028192 B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY CA5028193 ANY PROPRIETORIPARTNERIEXECUTIVE N / A OFFICER/MEMBER EXCLUDED? (3a.) NH & MA (Mandatory in NH) If yes, describe under homas Dube excluded DESCRIPTION OF OPERATIONS below DESCRIPTIONOF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Sched the Named Insured during the Covering work performed by ONLY******* n w CERTIFICATE For Information Only For Information Only For Information Only OLICY EFF M/DD/YYYY POLICY txr MMIDD/YYYY LIMITS EACH OCCURRENCE $ 1,0Q0,000 DAMAGE TO RENTED 100,000 $ PREMISES Ea occurrence 26/2013 4/26/2014 MED EXP (Any one person) $ 5,000 PERSONAL &ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 PRODUCTS-COMP/OPAGG $ 2,000,000, COMBINED SINGLE LIMIT $ 1,000,000 Ea accident BODILY INJURY (Per person) $ '26/2013 4/26/2014 BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident Auto Extension Endorsement $ EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 126/2013 4/26/2014 $ E.L. EACH ACCIDENT $ 500,00 6/2013 4/26/2014 E.L. DISEASE - EA EMPLOYEE $ 5.00 00 E.L. DISEASE -POLICY LIMIT $ 500,00 ile, if more space is required policy period. FOR INFORMATIONAL PURPOSES 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 Judith George/LM5 au -- n 1988-2010 ACORD CORPORATION. All rights reserved The Commonwealth of Massachusetts Print Form ' Department of IndustrialAccidents 4a Office of Investigations _ = X Congress Street, Suite .100 T Boston, MA. 02114-2017 ' www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumberg Applicant Information Please Print Leib Name (Business/Organization/Individual): i�sb ws "— Address:16 VkC-A4, W LL- FD City/State/Zip: M M R 0 '-11 Phone #: M� " Are you an employer? Check the appropriate box: �- a Type of project (required): : 4. i.�K 1 .l am a employer with � (j ❑ I am a general contractor and I 6. New construction employees (full and/or part-time).* have hired the sub -contractors listed on the attached sheet. 7_21(emodeling 2. ❑ I am a sole proprietor or partner- ship and have no employees These sub -contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' insurance.1 9 ❑ Building addition [No workers' comp. insurance 5. comp. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised their 11. ❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGI., c. 152, §1(4), and we have no 12. ❑ Roof repairs insurance required.] t employees. [No workers' 13. [1 Other coma. insurance required.] *Any applicant that checks box #1 must also'fill out the section below showing their workers' compensation policy information. Al Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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. lain an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance CompanyName: ,� p Policy # or Sol£ -ins. Lic. #: !!^% C0502_1 Expiration Date: d �� Job Site Address:�1 f`t ��� City/State/Zip: MA 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. I do herebv cer#fv rider the pains andAraalties of perjury Haat the in formation provided above is true and correct 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): l.. Board of Health 2. Building Department 3. City/Town Clerk, 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: i M N CE,I ; ®111® elle N D > I N LL' W' m m LL 00 wG N 0 0 48"