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HomeMy WebLinkAboutBuilding Permit #008-2017 - Exception 7/1/2016 K�4Y ��f_1�\` BUILDING PERMIT o� NORTFr q tt LP TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION T - H (O C Q Co •V` Permit No#: '� Date Received �gSsgTED cHus���y Date Issued: IMPORTANT: Applicant must complete all items on this page I LOCATION Lam✓ 4 ` . Print PROPERTY OWNER o w '. 'Print .100 Year Structure yes no MAP �ZCor 'PARCEL: ZON,INGDISTRICT: .Historic District yes 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 ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other � ❑ Septic ❑Well 0 Floodplain 0 Wetlands El❑ Watershed District ❑_Water/Sewer -- ---- _ _ DESCRI �T O OF WORK TO PE ERFOR ED: I entificat' - Ple�CL4 a Type or Print Clearly OWNER: Name: 1 ��vPhone: Address: DS, It Contractor Name._ 6one: '' � � Email: S Ca /!/ v Address: C t4 Supervisor's Construction License: Exp. Date: - 131-1;to Home Improvement License: [ 7d ` Exp. Date: ` ARCHITECT/ENGINEER Phone: Address: Reg. No. X FEE SCHEDULE:BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ ' 00 FEE: $clL _ (C�' Check No.: Receipt No.: � S � NOTE: Persons contractint with unregistered contractors do not have access to the guaranty fund. Location i NoA2ef Date 0/ Z!?/,/ . - TOWN OF NORTH ANDOVER ' Certificate of Occupancy $ Building/Frame Permit Fee $ ...'-- Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# f i Building Inspector JuJ %� J Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY 1 INTERDEPARTMENTAL SIGN OFF m U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments zConservation Decision: Comments Water& Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT Temp ®f,umpr on shit yes o� dire part.,men�sig an tore/date- G®fM NT Dimension 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.$100-$1000 fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 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 4, 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 Engineering Affidavits for Engineered products OTE: All dumpster permits require sign offrom Fire Department prior to issuance of Bldg Permit Addition Or Decks Building Permit Application Certified Surveyed Plot Plan 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 OTE: 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 4, Photo of H.I.C. And C.S.L. Licenses 4. Workers Comp Affidavit 4 Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) 4 Copy of Contract 4 2012 IECC Energy code 4. 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 Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 143150.00 m $ - $ 169.80 Plumbing Fee $ 21.23 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 21.23 Total fees collected $ 312.25 60 Edgelawn 008-2017 on 7/1/2016 bath and kitchen remodel NORTH own of ndover 0 - - . No. 1 so h , ver, Mass, ® ®/ WJAC cocNIchewlcw � �70 RATED U DBOARD OF HEALTH Food/Kitchen PERMIT T Septic System THIS CERTIFIES THAT BUILDING INSPECTOR ...........t. .r .s. . ..,�............ .. ...�r O!O. .................................... has permission to erect .......................... buildings on .....6.49..... &.40'�"�...4 �... FoundationRough to be occupied askiQtr........ t. ...../�!'!!T. .�'.'�! ......................4�19�.. Chimney provided that the person accepting this permits all in every respect conform to the terms of the application Final on file in this office, and to the provisions.of the Codes and By-Lawsr latin to the Inspectio Alf-ration and Construction of Buildings in the Town of North Andover. r M PLUMBING INSPECTOR Low e Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONST TION Rough Service .. .. .... .. Z .. FinalBUILDING SOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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. Smoke Det. 0 R JSA'COMPANtES INC 55 Chase St. Methuen, MA 01844 Date 1/28/2016 Estimate # 93 ,Name / Address _. Lindsey Riordan 26 Brett Circle Pelham, NH 03076 P.O. # Terms Due Date 1/28/2016 Other Description Qty Rate Total 1-The following estimate is for address 20 Edgelawn 0.00 0.00 Ave. N.Andover, Ma. 01845 2- Fee for all necessary permits and inspections 250.00, 250.00 3- Provide necessary demolition to kitchen area as 750.00 750.00 needed as well as bathroom demo and back room area with wall repairs also needed. No mold found at time of visual inspection. 4-Purchas and install new cabinets, counterto s 4,200.00 4,200.00 per plan in kitchen and bath areas. atena s $3200.00 Labor $1000.00 5- Purchase and install new appliances for kitchen as 3,000.00 3,000.00 per plan. Appliances $2500.00 Labor $500.00 6- Purchase and install new flooring as needed to 1,800.00 1,800.00 kitchen, bath, bed and living rooms as per plan. Materials $1000.00 Labor $800.00 Signature Total ISA COMPANIES INC jsacoinc@comcast.net 1-978-375-8041 1-603-471-1091 Pagel JSA COMPANIES INC 55 Chase St. a Methuen, MA 01844 - Date 1/28/2016 Estimate # 93 Name / Address ! Lindsey Riordan 26 Brett Circle Pelham, NH 03076 P.O. # Terms Due Date 1/28/2016 Other Description Qty Rate Total _ R 7- Purchase and install all necessary paint and primer 1,000.00 1,000.00 as needed for a complete installation. Paint and materials $250.00 Labor $750.00 8-Purchase and install new with finish, as 1,500.00 1,500.00 well as baseboard, window, door trim, etc. as needed for a complete installation. Materials $750.00 Labor $750.00 9- Purchase and install new electrical materials for 650.00 650.00 new lights as well as updating kitchen wiring. Materials $400.00 Labor $250.00 10- Purchase and install new toilet with valve, seal, as 1,000.00 1,000.00 well as lav piping, kitchen piping as per plan brought to complete installation. Materials $400.00 Labor $600.00 �J` 0 4gnature - --- - --_ Total $14,150.00 1SA COMPANIES INC jsacoinc@comcast.net 1-978-375-8041 1-603-471-1091 Page 2 The Commonwealth of Massachusetts x ' h Department oflndustrialAceidents I Congress Street,Suite 100 Boston,AM 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information A A A Please Print Le 'bl Name(Business/Organizationibidividual): c&ut as e Address: k (A— City/State/Zip: kVeAa& nZ"�Phone#:#: Are you an employer?C$eck t)ie appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).' 7. New construction mam a sole proprietor or partnership and have no employees working for me in 8 emodelilig y capacity.[No workers'comp.insurance required.] 9. Demolition 3..❑I am a homeowner doing all work myself[No workers'comp.Insurance required.]t 4.F1I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 0 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions propYietors with no employees. ' 12.. Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ � 13.[�Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑We are a corporation and ifs officers have exercised their right of'exemption per MGL c. 14.❑Other 152,§1(4),and Nye have no.pm.loyees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who subnut 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 fiave employees,they must provide their workers'comp.policy number. i 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:/,Ud Attach a copy of the wor ers'fiompepsationi 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. I do hereby cert46ixnd ai enaldes ofpefjury that the information provided bo a is true and correct. Signafore: Date: / Phone#: 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): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.EIectrical 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 Me, 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 b6 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'contractoi(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 foi-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' compensatioli 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"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.e.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 100 Boston,MA 02114-2017 Tel.#617-727-4900 ext.7406 or 1-877-NUSSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/clia ACO DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCEF �••� 06/30/2016 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). PRODUCER NAME:CONTACT KEITH BEAUSOLEIL FORTIFIED INSURANCE AGENCY HON o Exf 603-644-3700 a/c No: 603-644-0001 911 CANDIA ROAD E-MAIL ADDRESS: INFO FORTIFIEDINS.COM MANCHESTER NH 03109 INSURERS AFFORDING COVERAGE NAIC# INSURER A: MERCHANTS MUTUAL INSURANCE CO INSURED INSURERB: JEFF AGNEW DBA JSA COMPANIES INSURERC: 11 ESTHER DR INSURER D: BEDFORD,NH 03110 INSURER E: INSURER F: 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 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSO WVD POLICY NUMBER MM/DDIYYYYI iMMIDDIYYYYILIMITS A X COMMERCIAL GENERAL LIABILITY BOPI084614 04/09/2016 04/09/2017 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE a OCCUR DAMAGE TO RENTED 500 000 PREMISES Ea occurrence $ MED EXP(Any one person) $ 10,000 PERSONAL BADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY® ECT F LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED ( )AUTOS AUTOS dent Per BODILY INJURY accident) $ NON-OWNED PROPERTY t DAMAGE HIRED AUTOS AUTOS Peracciden $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I S A INLAND MARINE 7PI084614 04/091201604/09/2017 LIMIT OF INSURANCE:$50,000 DEDUCTIBLE:$500 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) RESIDENTIAL PLUMBING AND CARPENTRY REMODELING CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS. 1600 OSGOOD ST. N.ANDOVER,MA 01845 AUTHORIZED REPRESENTATIVE JSACOINC COMCAST.NET ©1988-2014 AC ORD'CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Massachusetts -Department Of Public Safety Board Of Building 'Regulations and Standards Construction SuPerVisor License: CS-065690 JEFFREY S AGNFVy 55 CHASE ST �`t METHUEN MA 61849 # Commissioner Expiration w 07/31/2016 �e�7icnujizetkcctl�0��/�7a9ac�uJc!(J " -_Office of Consumer Affairs&Business Regulation - OME IMPROVEMENT CONTRACTOR egistration: 172928 Type: xpiration: 8/14/2016 Individual JEFF S.AGNEW JEFF AGNEW 11 ESTHER DR. BEDFORD, NH 03110 Undersecretary xc/�Jj� �1Q a3H1S3 k k Mallov S ASN:l � :xas•9k $HOZ/�•�/AGO �dX3•gy b21'8:�IeR•gk, t1�e :a,c3 � Z96N6£/LO :eoa-s 4 ' aoz :an+i' I,£Z9f MVLO Z ,'18H pp nq:j Safi All MR Qt 2< „ 4d. ?,Wt: 2010 07AWJ6231 i $.Eye: BLU ` .Dos. 0713111962 1s,Hair:BRd 0713112018 JS.Sex: M JEFFRv S AGNEW .11 ESTHER DR � .� „.�..W..,MMa. .o...,..A.M OIVIMONWALTH OF MA MAffil + ® ® ' ® UW r>: { PLUMBEISM ,>AN'UGASFIT ISSUES THE FOLLOWING l ICNS' L.�CENS�D AS A MEISTER PLUMBER�*�,,� J.URS AGNEW 11 ESTHER BEDFOR1:` .HI`<:b31'10-412 <>.., :`; .. . 53444 ;: �'�01 l "'12060 "0'S/ l2018