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HomeMy WebLinkAboutBuilding Permit #501 - 100 MAIN STREET 1/10/2007 TOWN OF NORTH ANDOVER NpRTi� APPLICATION FOR PLAN EXAMINATION o�t.�.e �•�tio s5_01Date Received Permit NO: to-.0 Date Issued: ��srow �cMus IMPORTANT: Applicant must complete all items on this page LOCATION i© l Print PROPERTY OWNER •� — Print MAP NO.: PARCEL: ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Building ❑One family 0 Addition 0 Two or more family ❑ Industrial ❑ lteration No. of units: Repair, replacement 0 Assessory Bldg 0 Commercial 0 Demolition 0 Moving relocation 0 Other ❑ Others: ❑ Foundation only DESCRIPTION QF WORK TO BEeREFORMED t -�(v�� �1- .5��^ > C�►^ej1- �s���l v.: ice- C'�4" S��?5�..`�C� �Ap-i Identification Please Type or Print Clearly) OWNER: Name: (0C.) M(Ath Sof-,Pf ,k Phone:'q-yb 35-6639 Address: 100 tylct 5�t - CONTRACTOR Name: Phone:9?--7-n'-733-7 Address: 28 0�9 �-">W`VC VV- O fA C#ic:kLe-kU`\ , vV,A `0tCt4 Supervisor's Construction License: 0(%)-3 4 cl Exp. Date: I— Z y— ° 7 Home Improvement License: 1 1 -7 7 c�, Exp. Date: Z C ed'7 ARCHITECT/ENGINEER Name: Phone: Address: Reg. No. FEE SCHEDULE.BOLDING PERMIT.•.E12.00 PER 51000.00 OF THE TOTAL EST/MATED COST BASED ON$125.00 PER SF. Total Project Cost :$ ; L/, Soo FEES Check No.: N or Receipt No.: q ' Page l of 4 TYPE OF SEWERAGE DISPOSAL ❑ Tanning/MassagelBody Art ❑ Swimming Pools ❑ Public Sewer Well ❑ Tobacco Sales ❑ Food Packaging/Sales El ❑ Permanent Dumpster on Site ❑ Private(septic tank,etc. _ Electric Meter location to project NOTE: Persons contractin with unrigistired contractors do not have access to the guar my fund Signature of Agent/Owner ! Signature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ StamZ 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 ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS 1 1 FIRE•.DEPARTMENT -Temp Dumpster on site yes no c 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/Sismature&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 Page 3 of 4 Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM05 Crated JMC.1m.2006 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) ❑ Copy 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 Doe:INSPECTIONAL SERVICES DEPARTMENTMFORMOS Page 4 of 4 Location I D6 t lly, f, 1 S ) No. 5, Date NORTp TOWN OF NORTH ANDOVER 9 Certificate of Occupancy $ sACX t� Building/Frame Permit Fee $ Foundation Permit Fee $ r Other Permit Fee $ TOTAL $ c Check # Me e X927 Building Inspector �.%ORTH Town of : Andover No. Sd - - �` dover, MassLA ., '' O COC MICMEWICK A_ V 7� ADRATED Ppb` �C2 `S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT �h � �t �....... ............... ............ ....mA.oj.r....................................................... Foundation has permission to erect........................................ buildings on ..�.................... ...... ........................ Rough to be.occupied as �e. �►, R-WChimney mg provided that the person accep this permd shall in ev respect conform to 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 5c) GOP PERMIT EXPIRES IN 6 MONTHS Final ELECTRICAL INSPECTOR UNLESS CONSTRUC71ON S TS Rough S Service ..: .. .. ....... . .......................... BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal 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. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' a 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Ledbly Name(Business/Organization/Individual): Address: 2� 0 1 ' ,, w� ,Q►c !t_c/� City/State/Zip: dln c!tcl�'�cr >>^^ 61q'45 Phone#: q?P' "?'?') 7 3e,? Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time). * have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' g Buildingaddition [No workers'comp.insurance comp. insurance.# E] required.] 5• ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.[1 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other 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 submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors 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. Iam an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site information. Insurance Company Name: Policy#or Self-ins. Lic.#: P57�g 39�_ Expiration Date: 2­1c—c>7 Job Site Address: (tom tMr~ S�- 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 I do hereby cern he pains and penalties of perjury that the information provided above is true and correct. Si ature: Date: 1"-Cis p 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.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 employee§. 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 152E§25`Q6)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 p kiitners,'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 maybe 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 Ythat 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 lie 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"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: Z. 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-$77-MASSAFE Revised 11-22-06 Fax#617-727-7749 www.mass.govidia _ American International Companies Specialty Workers Compensation 5 Wood Hollow Road, 3`d FI PO Box 409 Parsippany, New Jersey 07054-0409 Phone: 800-645-2259 Fax: 973-331-8599 &1 Fogarty Builders Llc 28'Old Haswell Park Rd 5~Middleton, MA 01949 December 29, 2006 =;`Re: Renewal Quote - Policy 8738342 'Re—Expiration Date- 2/23/2007 Dear.lnsured:�. - ' .. Enclosed iOthe renewal quote on your expiring policy. Please note the following 'instructions if you wish to have us renew Cgmpensation policy. yths premium in full, which is$3,841. Yi n Plea ;.n ` e remittance advice and your check for the required deposit premium to American Inte national 427 Network PlaceChicago,.IL 60673-1224. _ Please your policy number on the check. n, H tiQ eyour.'premium by 2/03/2007, you will not have any Workers Compensation coverage. awr w, ' tsit premium will constitute the employer's acceptance of and agreement to the terms of the ., - r assistance to you now or in the future, please call our Customer,Serwc&Department at 800-645- -' y rs of 8:30 A.M. and 5:00 P.M. Eastern Standard Time. i gS \f f t Notice about the Office of Foreign Assets CO bi er the.continuation of any bound insurance and'- a ' enfs-to 4 ou to a claimant or to 4 be affected' b the administration and enforcement-6U U.S:.economic embargoes and trade Assets Control OFAC if wb�'deteirmine Ghat an -,such a is on the "S eciall N r.8bcked Rersoras"list=maintained b OFAC: ty fw ' 'Member Companies of American International Group Inca �.1 Amkncan Home Assutrutee,Jne„•All7lnsuranee Company, Granite State Insurance Company,Illinois National Insurance Co.,New Hampshire Insurance Company,National Union Fire Insurance Company,Insurance Company of the State of Pa r,. Pro osal Shingles EF Fogarty Construction Co. Ed Fogarty Rubber P.O Box 177 (978) 777-7337 Siding (978) 777-5600fax Billerica, Ma 01821 Proposal submitted to Phone Date 100 Main Street Realty Trust 978-835-6630 12-15-06 Street Job name 100 Main Street Same City, State Zip Job location N. Andover, Ma Architect Date of plans Job Phone We hereby submit specifications and estimates for: Roofing Work (Front of main building) 1. Hang canvas to protect siding and windows. 2. Strip existing roof down to roof boards. 3. Replace any roof boards (if needed) up to 100 sq. ft.(no charge) 4. Place 8" dripedge on all bottom and side edges of roof. 5. Apply water and ice shield to the first 6 feet of all roof bottoms. 6. Apply 15 Ib. felt paper to the remaining roof areas. 7. Install GAF Timberline shingles as per manufacturers specifications. 8. Re-flash and re-tar any areas needed. (counter flash all chimneys) 9. Install new pipe flanges to all pipes. 10. Clean all gutters and remove all debris from premises. During striping of roof some debris may fall through spaces in roof boards please cover all valuables Workmanship carries a 10 year warranty. Shingles carry manufacturers warranty. Mass Home Improvement Contractors Member Lic.# 111772 -617-727-8598 National Roofing Contractors Member Lic. # 136814 Mass Builders Lic#062349 We Propose hereby to furnish material and labor- complete in accordance with above specifications, for the sum of: Four thousand three hundred dollars ( $4,300.00 ) Payment to be as follows All material is guaranteed to be as specked. All work to be completed in a substantial workmanlike manner according to specifications submitted,per standard Authoriz practices. Any alteration or deviation from above specifications involving extra costs Signaturelow will be executed only upon written orders,and will become an extra charge over and above the estimate. All agreements contingent upon strikes,accidents or delays beyond our control. Owner to carry fire,tomado and other necessary insurance. our Title owner/opera or workers are fully covered by Workmen's Compensation Insurance. Note: This proposal may be withdrawn by us if not accepted within days Acceptance of Proposal-The above pries,specifications and conditions are satisfactory an are hereby accepted. You are authorized to do the work as i�e"3! erd II made a4 outlined above. Buyer: Signature: 1 Signatur , Signature: Date of Acceptance: • • i ��e �amv�xon a�✓�aaaaa/uucrk2 rte', -__ Board of Building Regulations and Standards 5r' HOME IMPROVEMENT CONTRACTOR .. ' Registration: .111772 Expiration: 1126/2007 Type: DBA E.F.FOGARTY CONST'CO EDMUND FOGARTY 28 OLD HASWELL PARK FDS�o MIDDLETON,MA 01949 Administrator ✓ice �omr�navui�e� a�./f�.unvrrcluael� BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR ! Number: CS 062349 i Birthdate: 07/24/1960 Expires:07/24/2007 Tr.no: 6402.0 Restricted: 00 EDMUND F FOGARTY 28 OLD HASWELL PK RD G— MIDDLETON, MA 01949 Commissioner a: