HomeMy WebLinkAboutBuilding Permit #675 - 0 WINTER STREET 6/8/2009 NORT#t
BUILDING PERMITOrob F'"
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
e
Permit NO:'� �6' Date Received »,T.co)•PP�(5
SSAc U`��
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION Ad
Print $
PROPERTY OWNER;.- '' � %�!'Nldt
Print -
MAF' NO: PARCEL: ` ZONING DISTRICT: Historic District yes no
1Vlachine Shop Village` yes no
TYPE OF IMPROVEMENT PROPOSED USE
Resid Non- Residential
Ne ing One faMi
Addi ' Two or more family Industrial
Alteration No. of units: Commercial
Repair, replacement Assessory Bldg Others:
Demolition Other
:Septic Well' Floodplain Wetlands Watershed District *
ater/Sewer' i
DESCRIPTION OF WORK TO BE PREFORMED:
� f t
A 669 t--04 P�(
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Identifica ion Please Type or rant Clearly) /�,,
OWNER: Name: �✓�✓f!�i� - FcS��/ Phone: 7 /5'ig�����
Address:
µCONTRACTOR Name: Phone: .
Address:
I
�g e
Supervisor's Construction License: 106lo Exp. ;Date:
:Home Improvement License: Exp. 'Date:
ARCHITECT/ENGINEER Phone:
Address: k/ 1 Reg. No.
FEE SCHEDULE.BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED OST BASED ON$125.00 PER S.F.
GG �xc>a
Total Project Cost: $ �C `rrs FEE: $ I
i
Check No.: �� Receipt No.: 2 2 D f
NOTE: Persons contracting -th aristered contractors do not have acces uara and77;,7 77771
I
ignature of Agent/Own yam , 15,
nature o cf (intra
_�., _
i
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
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS _._.L fi ` �1 e
YD CONSERVATION Reviewed on Signature
COMMENTS I, _
n ,,
q
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals:"Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments.
Water & Sewer Con nection/Sinature &Date " " Driveway Permitrt
DPW Town Engineer:Signature:
n
j Located "384 Osgood Street
FIRE DEPARTMENTTemp_Our it ster on site yes no m
Located.at.124=Wain Street'
Fire Departrnent.signature/elate
COMfUIENTS
Dimension
Number of Stories: Total square feet of floor area based on Exterior i
� d mensions.
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)
i
i
❑ Notified for pickup - Date
Doc.Building Permit Revised 2008
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 _
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from 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/Crossection/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
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit !
'Now ConstructionSin le and Two Family)
11
� 9 Y)
❑ Building Permit Application
❑ Certified Proposed Plot Plan l
❑ 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
❑ Mass check Energy Compliance Report
❑ 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 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 DEPARTMENT:BPFORM07
Revised 2.2008
{
Location
No. �� Date
40RTN TOWN OF NORTH ANDOVER
t Certificate of Occupancy $
sACMUSEt� Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $ -+
TOTAL $
Check # a 0f9 Z--
Y
2092
^3
wilding Inspector
BOSTON
DEVELOPMENT
GROUP
contact
Tel:617-332-6400 ext.32
Cell:617-212-8104
Email:ts@bdgi.com
address THOMAS SLAYTON
93 Union Street,Suite 315 Vice President
Newton Centre,MA,02459 Condominium Properties LLC
N0RTH
own of
IV,. _ a dover
No. 7S
1Li_ 6a 169
C, S- A K E o dover, Mass.,
COCMIC..MCK
7�ADRATED
S E BOARD OF HEALTH
Food/Kitchen
PERMIT - T D Septic System
BUILDINGANSPECTOR
..........
................ .........................................................................THIS CERTIFIES THATun 6
has permission to erect........................................ buildings on ... / . ldc�✓..5 ........................................ oug
t0 be OCCUp18d as.:............... . .rz»i�1............... ....................................................................... 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 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
PERMIT EXPIRES IN 6 MONTHS
ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION S TS Rough
..........................
Service
BUILDING IN CTOR Final
Occupancy Permit Required t0 Occupy Building GAS INSPECTOR
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.
SEE REVERSE SIDE Smoke Det.
gORTM,
TOWN OF NORTH ANDOVER ` --
�•'"_•� '`•'� OFFICE OF
BUILDING DEPARTMENT
1600 Osgood Street Building 20, Suite 2-36
'°•,;.:.�" North Andover, Massachusetts 01845
C�ws•`�
Gerald A Brown ` Telephone(978)688-9545
Inspector of Buildings Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
Please,p�i�
DATE:
JOB LOCATION: Al jt/( 6t-A.
Number Street Address Map/Lot
HOMEOWNER 27;—fp�S—
Name Home Phone work Phone
PRESENT MAILING ADDRESS
City Town State Zip Code
The current exemption for"homeowners"was extended to include owner-o=ipied dwellings to two units or less
and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the
owner acts as supervisor). State Building (Code motion 108.3.5.1)
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended
to be,a one or two family structures. A person who constructs more that one home in a two-year period shall not
be considered a homeowner.
The undersigned"homeowner"assumes responsibility for compliances with the State Building Code and other
Applicable codes,by-laws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Department
minimum inspection procedures and that he/she will comply with said procedures and
HOMEOWNERS SIGNATURE `
A
APPROVAL OF BUILDING OFFICIAL
Revised 10.2005
Foam Homoomm F.xea�pfim
BOARD OF TPE.'1LS 699-9541 CONSERN'.vrio\689-9530 ITEAL111 688-95.30 PLANNING 688-9535
Residential Property Record Card
PARCEL_ID:210/103.0-0119-0000.0 MAP:103.0 BLOCK:0119 LOT:0000.0 PARCEL ADDRESS:115 WINTER STREET FY:2009
PARCEL INFORMATION Use Code. 101 µ ` sSale Price 1U0,000 Book _ 05571 Rodd Type`' T Ins ect Date 10/25%2004
ro
P
Tax Class T Sale Date 10/04/99 Page 0023 Rd Condition P Meas Date 10/25/2004
Owner: Tof'Fin Area 4589 'Sale T ®eL Cert/Doc Traffc M :Entrance X
MESSINA, MARY A _ YP _ _... .0 ' _
ANNE M MESSINA Tot Land Area 4.13 Sale Valid A Water Collect Id RRC
Address: nx „ raptor MESSINA;SA�ITQ. Sewer” �Inspect`Reas M
115 WINTER STREET
NORTH ANDOVER MA 01845 Exempt-B/L% / Resid-B/L% 100/100 Comm-B/LP/o Indust-B/L% / Open Sp-B/L% /
RESIDENCE INFORMATION LAND INFORMATION
Style:: CL Tot Rooms �9 "Main Fn Area: 1534 Attie NBHD CODE 6 NBHD CLASS: 6 ZONE: R2
"" T e Code` Method FSgt`t f,'Acres %Influ Y/N Value "" Class t
Story Height 2 50 Bedrooms 4 Up Fn Area" " 3055 Bsmt Area: 1524 $fig „ yp _.., _ ,
Roof:``M H Full Baths 3' Add Fn Area Fn'Bsmt Area 1 P 101 S 43560 1.000 208,652
Ext Wall: +___FB�,Half Baths.— _1 UnfinArea:" � " "BsmtAGrade: 2 R 101 A 0 3.130 23,788
MasonryTnm Ext Bath Fix i4Tot rin Area' 7777= VALUATION INFORMATION
Foundation:' CN" Bath Qu a-1 M RCNLD 616096 Current Total: 848,500 Bldg: 616,100 Land: 232,400 MktLnd: 232,400
Ketch Qual M EffYr Built2001) 'Mkt '�" �y�a° .� Prior Total: 880,900 Bldg: 648,500 Land: 232,400 MktLnd: 232,400
Heat Type... SFA.. Ext Kitch: 1_ Year Built: 200 '0Sound Value.
Fuel Type E Grade
Fireplace: rt V "Cost Bldg „ 616;100
0 ,.a Bsmt Gar Cap: Condition:_ " VC _Att Str"Val1: "f
Central AC """BsmtGad S� "Pct Complefe 100;"� AttStr Val2:""`'""
Att Gar SF: 800%Good P/F/E/R. ///99 � �
Porch Type Porch Area Porch Grade Factor
P 54
W 794
SKETCH PHOTO
_ W.. G
14' 794 Sq.F 14 224 SiF ..
P
SO-,.Ft,
FU0.5/FUJFM/B Ux341 /FU
341
1183 Sq.Ft zz33 576 Sq.F
27_ 27 24 24
2� IA V",, alc_t: DFi
te"',
1 .18 jFIAWL&MMI., I .Ft
q. q:Ft I c
Parcel ID:210/103.0-0119-0000.0 as of 6/4/09 Page 1 of 1
The Commonwealth ofMassachusetts
j I Departrnent of Industriad Accidents
• Office of Investigations
ii�U 1 600 *ashington Street
Boston, MA 02111
c www_massgov/dia .
Workers' Compensation Insurance Affidavit: Builders!
Contractors�le
A Iicant Information Ch
p '►c�
ans/Plumbers
Please Print LeQibl
Name (Business/Organizafion/Individual):
Address:
Citystate/Zig: —
^'6 Phone #:g1�
Are ou as employer?Ch ---------------
ectt.the aupropriste boz: —
I. I am a employer with gS 4. �].I am a ene Type of Project(reguir�:
em fo ees ye and/or g ral contractor and I
p Y ( part-time).* have Dred the sub-contractors �. ❑New coristrvction
2.Q I am.a.sole proprietor orpartner- listed ori,the attached sheet.I �• Q Remodeling
ship and Have no employees' These sub contractors have
working for mein arty capacity, g Q Demoiitian
workers' comp.insurance.
(No workers'comp.insurance 5. We are a corporation and its F.Q Building addition
required) officers have exercised their 1 Q•Q Electrica) airs or
3.❑ 1ama
p additions
homeowner doing o all work right a
gh f exemption per MGL I I.Q Plumbing repairs or additions
myseIf[No•w.arkers'comp. c, i52, §1(4),and-we have no
insurance required]t em to ees. 12 Q Roof n�tairs
• P Y [No workers'
COMP. insurance required.] 13.[].Other
`Any applicant that checks bole t 1,mast also fill out the section below showing their workerti''compensation policy information
t Homeowners who submit this affidavit indicating they am doing in worts and thea him outside contractors must submit a new affidavit indicating such,
;Contractors that check this box rnastattPched an additional sheat showing the name ot'the soh-cwetraetors and their Fo••��wortcets'xnr^. ::...
r ..fnm:ation.
!am.an er„ployer that u'prgvi&nrWorkers'compensadon insurance or
information �' p�J' Below is the policy and job site
Insurance Company Name:
Policy#or Self-ins.Lie.
/ Expiration Date: •Z,Vr .
Job Site Address:
ity/StatelZip: C� 0-70
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 penuries of a-
fine up to $1,500,00 and/or one-year imprisonment,as well as civil penalties in the form
of P r•m of a STOP PW•
5250.10 a lay against the violator. Be advised that a copy of this statement may be forwarded t the Office of a fine
Investigations of the DIA for insurance coverage verification.
!do hereby era n par perjury that the information rovided
. p above is[rue and correct
5i tore: Date: (ea ' 7i
Phone 5
O}j`Icial use only. Do not write in this area,to be completed or town official
. by�J'
II� City or Town: Per mit/License#
Issuing Authority(circle one):
1. Board of lieatt6 Z Building Department 3.Ci own Cleric 4.Electrical Inspector 5. Fluosbing Inspector
6.Otber
Contact Person-
Phone#:
Information a nd Instructions
Massachusetts General Laws,chapter 152 requires all emp Ioyms to provide workers' compensation for theieemployees.
Pursuant to this statute,an employee is defined as"..:every person in the service of another under any contract of hire, -
e)q=ss 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 includirig the legal representatives of a decreased 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 apa-tments,"d who resides therein,or the occupant of the
+ dwelling house of,ahbth,er who employs persons�to do=mairrtenance;uconstruction or repair work on such dwelling house
or`on the grounds or buildmg 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 license of permit to.operate a business or--*e construct-buikiings`in the 6timmonwealth for any
applicant who has not produced acceptable evidencevt compliance with the insurance coverage required."
Additionally, MOL 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
requiremearts of this chapter have been preseTited 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-contractors)name(s),address(es):a>nd phone numbers)along with then certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partnas,are not required to carry worker's'co,snpensation insurance. If 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 reti rmed to the cityor town that the.application for.the permit or license is being requested,notthe Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
oompensation policy,please can the Department at the nurimber listed below, Self-insured companies should enter their
self insurance"license number on the'appropriate line.
City or Town Officials
•`J A
Please be sure that the affidavit is completa and printed-legibly, The Depaslmerrt has provided a space at the bottom
of the affidavitfor you to fill out in the event the Office of_.Investigations has to contact you regarding the applicant
` Please be surd to fill in the permit/Iicense.niuhber which will be used•as a reference numbei In addition,an applicant
`that must it multiple permit/iicense.appiications m any given yeaar,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 be=.officially stamped or marked by the city or town may be provided to the
f applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. When 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 bum leaves etc.)said person is NOT required to compiete 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 Departinent'.s address,"telephone and fax number
The Commonwealth of Massachusetts
Department of Endustriai Accidents
Office of Lnveatfaigztions
600 Washington Street
Boston, 1vIA 02111
TeL#617-7274900 ext 406 or 1-977-MASSAFE
Revised 5-26-05 Fax#617-727-77451
www.mass.gov/dia _.
06/03/2009 12:46 19787457386 ROSE INSURANCE AGENC PAGE 01101
DATE{INMIDW YY;I
ACQR'P. , CERTIFICATE OF LIAE11LI71r INSURANCE 06/02/2009
pRODUCER (979) 745-fi464 -.51—IS CERTIFICATE IS ISSUED AS fl°MATTER OF INFORMATION
OI9LY AND CONFta"RS NO RIGHTS UPON THE CERTIFICATE
f3LOER. THIS GEIj'I'IFICATE DOES NOT AMEND, EXPEND OR
Rase insurance HED By THg PgUCIES BELOW,
66 Loring' Avenue Af LID,.T THE COV6R4G6 AFFORD
P.O. Box 958
Salem Lh 01970^ T - misuRERS AFFORDING COVERAGE AIpIC#
INSURED
IN!6 JRER A; + C9AS i0sup"CE
"
seed
�W81Ivm Builders 1'.OK�I r INSURER B: _
16 Coilm rcial street IN%IRF!.R C:
IMSURFR O1.
Salem MA 01970- 1n�SLIRERF• ---
COVERAGES -10TV14THSTANDiNG ANY
-
TIiE POLICIES OF INSURANCE LISTED BELOW HAVECT ISSUED
i R DCC iT WITH RESPI T TO
THE
TNIS p ABOIIM FOR 114E CCERIIFICATE MAY BE ISSUED OR MAY PERTAIN.
REQUIREMENT,TERM OR CONDITION OF ANY CO 9 EXCLUSIONS /NtlE] CONDiTICt1S OF 5UCH pOLICIE'.S_
THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUSJECT'to ALL TIiE= TERM .
A�REGATI2 LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. paf�tRveTIVE POUF EXPIRATION
1NSR pDL POPCYNUMBER ply(MwIDOI°rY) DATE{gpn100(lY) LIMITS
LTR NERD TYPE OF INSURANCE 1.1°/ 9.000000
GENERALLUI9lk nY CCP1042994 17/2009 11/11/2009 EACH OCCURRENCE 9
000M TO RENTED 100(00
X COMMERCIAL GENERAL LIABILITY PReA159S aecurlr rIa5000
CLANS MADE 00CC0 pERFO10001]00
NAL R ADV INJUR' A
GI]dERALAGGR-EGATE C 2000000
/ FROOUCT:L-COMPI (-2G 9 2000000
GEN4.AGGRF.dATG LIMIT APPLIES PER: , / /ri /
POLICY I IC-GI LOC
AUTOMOBRELIABILRY / / I (:OMDINEDSIHGLELIMII 9
(EQ segdnnk)
ANY AUTO —�
BODILY IN.
ALL OWNED AUTOS &
(Prtrpeteon)
SCHEDULED AUTOS
HIRED AUT03 BODILY INJURY 9
mar pcddefM
NON-OWNED AUTOS
PROPERTY DAMAGE
— {Par pccL7o1'tt)
..
AUTO ONLY-EAACCIDI!NT d
GARAGE IJAIIILITY
ANY AUTO OTHER TFfAN -RACG 8
A=ONLY: AGG S
EXCOSSIUMBREI,LA LIABILITY ~/ / EACH=.URRVCF
OCCUR CLAIMS MADE AGGREGfITE $
DEDUCTIBLE
�Tqq�T
RETENTION $ I� 07/2009 0SM/202.() R SATO [R
$ WORKERS COMPENSATION AND 10A9f'Cdb8722 5/ 1000
EMPLOYERS'LIAIIII-ITY El,EACM ACCIDENT 9 1 O{�
ANY PROPRIETORIPARTNER/EXECUTIVEJ° 10()000
OFFICERNEMIAER EXCLUDE137 / / / / E.L.DISEASE-G4 E'MPL O a
If yes,deerAbe under E,L,DISEASE-POLICY -WI $$ 500000
SPECIALPRaNiS10NBonkM 52 OOC
]� OTHER Inland Marine CCP1042394 ).SL/17/?-009 17./9 7/2009 Deo,82500 r
J,
DESCRIPTION OF OPERATIONWLOCATR)N.WENICLESIEXCLUSIONS AIMED DY ENI10 RSEMENTAAPECIAL PROVISIONS
CERTIFICATE HOLDER �~ CANCELLATION
— SHOULD ANY qF 'IMV ABOVE DESCRIB60 POLICIES OR CANCELLED BEFORE THE
EXPIRATION DATE TFIEREDR THE ISSUINR "SURLR +.HILI. ENDEAVOR TO MAR
I
30 *AYS WRITTEII NOTICE To THE CERTIFICATE HOLE-ER NAMED Tp THE LEFT,LiuT
FAILURE TO DO SO'StVILL IMPOSE no OBLIG4oT13H OR LIAI Wry OF ANY KIND UPOPI THE
For instt�edrS records INSURER ITS AG ENTS(IRREPRESMATM
/�`ORrapREPRESENTATNE
a
ACORD 25120011081 _ o AG ORD CORPORATION 19(
Page 7 v
INS026 poo).oR
Boar&A. mgegu atio s an tan f.rs
/ Construction Supervisor License
Lise CS 38856
Expiration 1 /20/2009 Tr# 20683
j ERIC R RUMPF -
6
PO BOX 4483
SALEM,MA 01970 Commissioner