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Home My WebLink AboutBuilding Permit #375 - 102 WAVERLY ROAD 11/6/2012 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received I Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION L! � F- An- Prin PROPERTY OWNER Print, 100 Year•bid structure yes jno ) MAP NO: PARCEL:�ZONING DISTRICT: Historic District ye Machine Shop Village ye TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building IZOne family ❑Addition El Two or more family 11 Industrial ❑Alteration No. of units: ❑ Commercial I/Repair, replacement ❑Assessory Bldg ❑ Others: IM ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floo.dplain; ❑,Wetlands.; ❑ Watershed-District •.-'1Water%Sewer _ E RIP ION OF WO K TO BE PERFORMED: `� ^� Identification Please Ty a or Print Clearly) OWNER: Name: lz'_�I[a. 0 Phone: Address: CONTRACTOR Name: G /'� '` � L11Phone:, / r��- �35Y_ - _ Address: ' w:,2 Supervisor's.Construction Licenser . J .SI Exp. Date: �/�5'jf Home,Improvement License: /64ExpDaeSl _ ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOT�A,L-ESsTTVI! TED COST BASED ON$125.00 PER S.F. Total Project Cost: $ �G• (� i' /o?� : $ � `~ 4MI-^6 Check No.: � eeit No '�t� NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund � _ S1 nature of A enUOwner` : �,� ' �:� Signature of contractor __9._._. .. ..._ g. n Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL" g Public Sewer ❑ i Tanning/MassageBody 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 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 Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Tow, Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at`124 MainStreet Fire Departirment signatureldate COMMENTS 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 �0v 7 6- bJ J El Notified for pickup - Date I I Doe.Buildinb Permit Revised 2010 Building Department The fohowing 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 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 ❑ 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: Doc.Building Permit Revised 2012 Location 0-2, kA { j No. Date 1 z _r + • - TOWN OF NORTH ANDOVER e �1 XD�' . + Certificate of Occupancy $ Building/Frame Permit Fee !-�1`JJ Foundation Permit Fee $" Other Permit Fee TOTAL $ Check# � 25915 Building Inspector Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost 70,00'0.00 m $ - $ 840.00 Plumbing Fee $ 105.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 105.00 Total fees collected $ 1,150.00 102 Waverley Road 375-13 on 11/6/2012 Remodel Kitchen and Bathrooms tkORTH Town of Andover O ti `" 0 V4 16 .o �^N, h ver, Mass, L cocaIc"t.m. U BOARD OF HEALTH R T T Food/Kitchen Septic System THIS CERTIFIES THAT ....... BUILDING INSPECTOR .... ........ . .... -. ...............................iu-.t..�................ has permission to erect .......................... buildings on j-bm)o......VJ414A04N. ...... Foundation Rough to be occupied as ...............� �.1....... !�/ :d.........KA. .........14........ ... Chimney provided that the person accepting this permit shall 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-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 NTHS ELECTRICAL INSPECTOR 19 .1UNLESS CONSTRUCTI STA Rough Service ................ .. ..... ............................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. SEE REVERSE SIDE --L-Aluiv tulrt nrtt,II IVb, IIVO , GUI fUNI OWN OF WRKEF i 0;44 10/02;12 EST P9 3-3 J�ppq� p��y p p AcaRla CERTIFICATE OF LIA131LITY INSURANCE DATE (MM;DDIYYYY) 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 poilcy(Ies) 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 riahts to the certificate holder in lieu of such endorsement(s). 'rRODL:CER PGone: i£i7A;657__ Fax: (566)400-4056 ` ;' T Jennifer McNeil HUB INTERNATIONAL NEW ENGLAND LLC "`� ----- -------------------- ?HONE 299 BALLARDVALE STREET' (AIC.N:n.Exi; (978)657-5100 (866)400 4085 E-NIHIL IAfC.N01' WILMINGTON MA 01887 ADD'ESS. )mcneil@ablagency.net rROOL!CcR D 277 ---____ __---- — :�STCfAER i ----.._'--_-_-___II-III---------II-III-..------ -- _--------------.. AD?nCyLl:.a_ ;75:?;IG? -------------I ---- ----- --- --------------__-- --. !NSURER_1 AFFORDING COVERAGE INSU.RECI- a--- VENUTO CONTRACTING,INC. INCUREA General Star Indemnity Company 36 TOWER HILL RD ;NsuRERa .Wesco NORTH READING MA 01864-2431 NsuRER INSIIR= L, INiSURER E COVERAGESCEINauR-R F RTIFICATE NUMBER: 6862 ..? THIS IS TO CERTIFY THAT THE POLICIES OF INSUCE LISTED BET LJIN HAVE BEEN ISSUED TO HE INSUREDNA MED ABOVE VISION'NUMBER.FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT 1MTH RESPECT TO b%,,HICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, .- Q1 I RIQNS AND IN8R T l LTR_:- -- TYPE OF INSURANCE ADD'll SUBRI ---------.____-_----_ INSR V,-VD POLICY NUM9ER I POLICYEFF POLICYEXP A GENERAL LIABILITY ---f-- ----_-POLICY I_RNMODNYlMi' I LIMITS I I -- IMA7s99o7B 1 -r-----------------------___.------------- 12109111 12/09112 BEACH OCCURRENCE s 2,000,000 I��:011+AERCIAL GENERAL LIABILITY I DAMAGE To REN'I'D I---- --- ICLAIMS_p4ADE I X IO(„C:UR FREI141SE5!'c-a r,_-urns-, _-- I .i -- 100,000 Ir I I 1 HIED.EXP(Ani'Cri?prrSOrj I I I I -� I PERSONAL&.AD:�INJURY %y 1,000,f,00 GENERAL`M-REGATE 1 g GEN'L AGGREGATE LIMIT APPLIES PER: I _ 2,000,000 AUTOMOal E LfABI PRC -` PRODUCT,-ccmPp,cP p,,,G T S 2,000 000 ------ MOBILE _ LIN - i---�- - -- i----�--- -- `; r- I CONIBINED SINGLE 1-0,11T I ANY AUTO I I �------------- i Cca accltlent! ALLOb'1NED.AUTOS I I --- -------- -- 5' OUiil'INJURY;Per per;vrl g SCHEDULED AUTOS I 5ODlLl'INJURI'tPer,actidentlT. ---- L HIR-D At1TOS r - GN-0'i N ED AUTOS i Pw'ar.:idrnt? i -, UMBRELLIAB LA ---- ----- ------ $ 1 ._ OCCUR --- ---------- ------------ _ ;EXCESS L{AB EACH OCCURRENCE IcLAIMs_naa.DEl I I I _.m__.___..m...__.-- --._................._. t----l'DEDL!C.TiB I AGGREGATE LC --1_ I !REr_NncN B -— ----- --------- - y iNORKERS COMPENSATION I I TWC33018 1 0 1AND EMPLOYERS' LIABILITY YIN I ' 01/12/12 01r 12/13 ANY PROPRIETCRIPARTNERIEXECUTIVE I I S OFFICCRIMEMBER EXCLUDED? I _^. I N lA {Mantlacory in NH) —� I 1 E.L.EACF ACCOENT 100,000 ��---. -. OJas.dscrtx:antler !=L DISEASE-EAE114r^LOYEE ---- 100,000 OcSCRIPTiON OF OPERATONS Ua!aa' i �.-__--- i -- E.L.C!SEASE-PGI ICY LI.NiIT ----�--- ! 500,000 �---- ----TION---------- - ------ ------- ------- DESCRIPTION OF OPERATIONS i LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) -------`-'— JOB LOCATION-2 BULLI LANE CERTIFICATE HOLDER CANCELLATION d' NrrA "�lu,vGr SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN [ /(701 63soG ACCORDANCE WITH THE POLICY PROVISIOt4a. ;rte G r AUTHORIZED REPRESENTATNE I Attention: ' I I ACORD 25(2009109) __ The ACORD name and logo are registered marks o8 ACORt3CORD CORPORATION, AI!rights reserved. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): t�//Gcy�y CIS //'(—C 1 L/_& Address: i t-Z� d. �>'?f(C/ , U, ✓✓1 %k City/State/Zip: Phone#: o2 0/- ;35Y Y Are you an employer?Check the appropriate box: 1. [2;/l am a employer with 3 4. ❑ I am a general contractor and I Type of project(required): employees(full and/or part-time).* have hired the sub-contractors 6. ElNew construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 1 7 modeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.E lectrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.[O'lumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.[]Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 13.0 Other *Any applicant that checks box 41 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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. tam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ?olicy#or Self-ins.Lic.#: 71t Expiration Date:_/z/�. - lob Site Address: /Uv.. GJaV(e /�' /�1 dfn/00-1•L City/State/Zip: ✓�r� �S attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ,ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ine 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 if up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. do hereby certify under the pains sand penalties perjury that the information provided aboveistrue and correct. ignature: �r, �l�, l/� Date hone#: 7-;,Z U/- 5� 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 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 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 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 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 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 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"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: 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 5-26-05 www,mass.gov/dna