HomeMy WebLinkAboutBuilding Permit #631 - 1001 GREAT POND ROAD 3/29/2007 BUILDING PERMIT SNORH
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TOWN OF NORTH ANDOVER 3? �� °
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APPLICATION FOR PLAN EXAMINATION
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Permit NO: `3 "A1 'o �4
Date Received p�gArgo
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CHUDate Issued: "
IMPORTANT: Applicant must complete all items on this page
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TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑ Addition ❑ Two or more family ❑ Industrial
❑ Alteration No. of units: ❑ Commercial
'Nppair, replacement ❑ Assessory Bldg ❑ Others:
❑ Demolition /}7f ❑ Otherqw
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D C TI OF WOR TO BE F ED:
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I ification fleaVType rPrint Clearly)
OWNER: Name: vC, 'Al-L _ Phone:
Address:
I sS�POlN1St�#�S
511 ,
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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.
ti Total Project Cost: $ ,O-0 FEE: $ �-
Check No.: n?41? Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have acc ss to th r nd
Plans Submitted ❑ Plans Waived ❑ Certified. Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ . Tanning/Massage/Body Art ❑ Swimming Pools ❑
n
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
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DATE REJECTED DATE APPROVED
CONSERVATION ❑ ❑
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COMMENTS
DATE REJECTED DATE APPROVED
HEALTH ❑ ❑
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature&Date DrivewayP6rmit
Located at 384 Osgood Street
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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
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❑ Notified for pickup - Date
.................................................._..............................................................................................................................................................................................._........................................................................_................................................................_..........................
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Doc.Building Permit Revised 2007
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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
❑ opy of Contract
❑ loor Plan Or Proposed Interior Work "
❑ n ineerin Affidavits for Engineered products
9 9 9
NOTE: All d impster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addit on Or Decks
❑ 3uilding Permit Application
❑ ertified Surveyed Plot Plan
❑ Norkers Comp Affidavit
❑ �hoto Copy of H.I.C. And C.S.L. Licenses
❑ opy 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
New ConstructionSin le and Two Family)
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❑ 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
❑ 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:INSPECT ONAL SERVICES DEPARTMENTMITORNI
1. 07
Revised 2.2007
Location
No. Date
v
'3
I
�O�Th TOWN OF NORTH ANDOVER
O?O•,f`•O ,•,h0 RAl
Certificate of Occupancy
�' b''•'°'At'�'
Building/Frame Permit Fee $
,SSACHU56
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
tf
Check # f /
b;
20 0 6-
Building Inspector
tAO R H .
Town of : Andover
No.
o s= o dover, Mass.,
coC HI CHE W ICK
A0RA7ED i �C.1
S BOARD OF HEALTH
Food/Kitchen
. PERMIT T D Septic System
THIS CERTIFIES THAT....... Oj AqW BUILDING INSPECTOR
.M * ft ...............�..� ...................................................................................
Foundation
has permission to erect........................................ buildings on./....R1......... ..I�,�../ Rough
to be occupied as........ .. ..............�.�... Chimney
provided that the person accept this permit shall in a respect conform the terms of the application on file in Final
this office, and to the provisions of the Codes and By-Laws relating to the I pection, 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 CONSTR S TS Rough
...... ............................................ ........ ...... .. Service
. ...... .... . .
BUILDING INSPECTOR
Final
Occupancy Permit Required to 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.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
' 600 Washington Street
Boston,MA 02111
www.mass.gov/dna
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeLlibly
Name(Business/Organization/Individual)'
Address:
City/State/Zip: 4appro
Phone#:Are you an employer?Check thee box:
L 0_14m"a employer with- 4— 4. ❑ I am a general contractor and I Type of project(required):.
employees(full and/or part-time).* have hired the sub-contractors 6. C1 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
working for me in any capacity. employees and have workers' 8' [3 Demolition
[No workers'comp.insurance comp.insurance.# 9. ❑Building addition
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
myself 11•❑Plumbing repairs or additions
y [No workers comp, right of exemption per MGL
insurance required.]t c. 152,§1(4),and we have no 12 of repairs
employees.[No workers' 13.❑Other
comp.insurance required]
Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
t Homeowners who subrrdt 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
employees. If the sub-contractors have employees,they must provide their workers,comp.policy number.
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am an employer that is providing workers'compensation insurance for my employees Below is the policy and fob site
informadom
Insurance Company Name: /
Policy#or Self-ins.Lic.#: e 6 j F0,,�
Exp ira on Date:
Job Site Address:
City/State/Zip: 2/
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
Investi ations of the DIA r ins a covers a verification.
I do hereby c f er !ties of perjury that the information provided abov.is tr a and correct
Sigmtur /
Date: Q 7
Phone#: — —
FOther
only. Do not write in this area,to be completed y city or town offlclal
n: Permit/Lice
ase#
hority(circle one):
Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PluEInspecto]r
son•
Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all emploin the service of another under any contractvide workers'compensation for their
�of hires
Pursuant to this statute,an employee is defined as ...every person
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 aJoint enterprise,and including the legal representatives of a deceased employees. However or the
he
receiver or trustee of an individual,partnership,association or other legal entity,employing Y
owner of a dwelling house having not more than three apartmentsCides therein,or the occupant of the
end nstruction or repair wok on such dwelling house
dwelling house of another who employs persons to d
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 bundlency s in the commonwealthwithholdtheis force r
renewal of a license or permit to operate a business or to construct g
applicant who has not produced acceptabl "Neither the evidence of opliance with the mmonwealth nor any of its political subdivisions shall
nsurance coverage required."
Additionally,MGL chapter 152,§25C('n statesi
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 thatheir t toficur situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along
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 for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city ti 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 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 app
licant
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 nto the
town)."A copy of the affidavit that has been o (cityfficially stamped or marked by the city or town may be provided
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 can.
The Department's address,telephone-and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. #617-727-4900 ext.406 or 1-877-MASSAFE
Fax#617=727-7749
Revised 11-22-06 www.mass.gov/dia
03/29/2007 13:49 19766641430 DH SMITH IND PAGE 02/02
GhvnW,21401 OHSMf
ACORD. CERTIFICATE OF LIABILITY INSURANCE 08107AOD`r"�'
PRODUCER TH13 CERTIFICATE IS ISSUED AG A MATTER OF INFORMATION
O'Brien 81 Gibbons Ins.Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER.THIS CERTIFICATE bogs NOT AMEND.ExTEND OR
52 Highland St. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P.O.Box 1084
Worcester,MA 01813 INSURERS AFFORDING COVERAGE NAIC A
INSURED INSURER A. Trwelers Indemnity
D H Smith Industries INSURER B!
I t HiliYiew Road 01SURER C:
North Reading,MA 01864 INSURER D,
INSURER E
COVERAGES
THE POLICIES OF INSURANCE LIS'T'ED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PIERIOD INDICATED.NOTWUHSTANDING
ANY REQUIREMENT.TERM ISI CONOITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE I40k*CE Ai'FORITED"LYTHE POLICTE'BbESCRIBtb AMEIi 10 SUBJECT TO ALLTHE TERMS;EXCLUSIONS AND COND11i0NS OF-SuCw• -
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
pan L TYPE OF INSURANCE POLICY NUMBER P EFFEC Y UC LIMRB
GENERAL LIABILITY "CH OCCURRENCE S
RNTLM
COMMERCIAL GENERALLVABKITY PRFMF90EaeeeYna - r
CLAIMS"OE F�OCCUR Mep E)LP Ory one person) 8
PERSONAL&AOV INJURY S
GENERAL AGGREGATE f
OENi AGGREGATE LIMIT AFPLICO"R; pRODVCTS-COMP/OP AGO S
POUCY p.at LOC
AUTOMOBILE UABILITT vED SINGLE LIMIT
ANY AUTO ) f
ALL OWNED AUTOS 000aY INJURY
(Per peownl i
SCHEDULEDAUTOS
HIRED AUTOS BOOILY INJURY
(Per accident) S
NON-OYyHEO AUTOS
1pr•.,asrwa>
OARAOE LIABILITY ALIIQ OMY.EA ACCIDENT
ANY AUTO OTHER TNAN EA ACC S
AUTO ONLY: AGGL S
EXCESWUMBRELLA LIABILITY EACH OCCVRRENCE S
OCCUR FICLAIMS MADE AGGREGATE f
f
DEDUCTIBLE 8
RETENTION
TH-
A WORKERS COMPENSATION AND 0626MBOS 08102106 08102107 wC, Lm sTTiYu o
EMPLOTERE'LUANUTY E.L.EACH ACCIDENT 5100 000
OFFICCEERIM MBER EXCLUDED?
E.L.DISEASE.FA EMPLOYE 1100 000
It yes.descet s wider
SPECIAL PROVISIONS tMIm MEASE-POLICY LIMIT 000
OTHER
OESCRIPTWN OF OPERATIONS I LOCATIONS I VENICL.ES•1 EXCLUSIONS ADDED By ENDORSEMENT I SPECIAL PROVIvQNv
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLEO BEFORE TNR EXPIRATION
S&H Construotion DATE THEREOF.THE ISSUING INSURER WILL ENDEAVOR To MAIL 1f DAYS WRITTEN
Attn;Emily NOTICE TO THE CERTIFICATE NOL MR NAMED TO THE LEFT,BUT FAILURE TO 00 SO SMALL
20 Now Street DIPOSE NO OBLIGATION OR LIA&LITY OF.ANY KIND UPON THE INSURER,ITS AGENTS OR
Cambridge,INA 02138 EPRESENTATME
6 01
617 8641850 AVTHOR1ZEJf RPA
ACORD 25(2001108)1 of 2 #15314 AOENCiAWC. 0 ACORD CORPORATION 1286
my�y
.'T'... . Il Biflview Road-Aforth Reading-lila 01864
T" David Smith-Owner
z ,a Res"eidial&Commercial
978 664-21666-978 664--1430fxr
January 6S,2007
n, Manuel Arista
1001 Great Pond Read
North Andover,Mo. 0'•1845 978 796L-9010
We hereby submit spec ons and esawartes for propeHy located 10/11 Great Pond Road,N&AnAnw,
Ma.
Apply tam to ballon.edge of mof hangeng down to ground to proted sMM and shnAL
>.w Shv roof down 10 roofboards.
Re-nail&ose planking or plywood sheathing as needed
Replace rotted boards as needed fust 100 tineaf ft.free adds Tonal$3.50 per linerrtlt
Lnstatf we and water harrier alnrg'bottom e4w in valleys and around aft roof
Appy alum age around perimeter..
Apply 35I6 fib paper over rrmain ttg roof areax
Insaff30 yr Are*SkhWlex over roof area.
CW and install_rhkevent,.and cam.
Atl flashing of chanteys,:vents,and walk to conjp'ly with roof system
Install'20So; ve a to again#or:se
Rake bnwm sweep,and Ategnet sweep groun&for nails and small dehns.
Crean and remove joie related debrl&
Ill yn guarantee on worbMWshil►
We hereby proposepfurnlik labor and.d,materialr-complete In accordance with the above VwYkadium for
the sura of• Seventy Nine IIa#*aMgkty Dollars 1($7,9;0M)
With payarent to be madeas follows: iY Ma.10depo*and St,98Q011 upon d n.
All material is guaranteed t.o be as specified'All work to be completed in a workmanlike manner according to
standard practices Any alteration or deviation from above specification involving extra cans,will be erecuted
only mlionwrittenardars,-and di,becbme 4 ertra c&r.ge o .and above the a e. All agsieer
contingentupon strikes,-accidents,or Marys beyond our control Owner to eanyftiE tornado and other
necessary ins wnce. Our workers are fully covered by workmen's compensation: Amurance. This c irad
maybe withdrawn:ajer 3D days: Unfinished attics are the responsiblity of the homeowner eowner to cover and pnvted
belongings and clean up
Authorized S'�lrutrrre
ACCEPTANCE
The aboveprices,moons and wxdidons Ore satisfactory and are hereby armed You are audzor&ed
to do the work as Wired Payment will be made as oudked abo
Dae S e f
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GAIT. Aui/wrked quaW Fm can hum since 1886-FromAmerke's largest rooftn Mj$- G41-W LiCENSEA#VWA
Member of the Better Business Bum=since 2003
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�i BQARD OF BUILDING REGY1
x� lic8nFe CpNSTRUCTfON ATIONS
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Numb EfZVISOR
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Birthdate
09/29/4956
Ex fres
07 Q9/29/20
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