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Home My WebLink AboutBuilding Permit #550 - 110 MARBLEHEAD STREET 2/16/2007 TOWN OF NORTH ANDOVER 11 APPLICATION FOR PLAN EXAMINATION o'"�oT: ,, �o C� +' Permit NO: s Date Received 441 'sem Date Issued: ` - e"U'1 ssACHug IMPORTANT: Applicant must complete all items on this page LOCATION J I D l M A 6 LE { &Ac( Print L PROPERTY OWNER M I C hya.c-C I? D c--hiI Print MAP NO.: PARCEL: ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑New Building ❑One family ❑ Addition two or more'family ❑ Industrial ❑ Alteration No. of units: ❑ Repair,replacement 0 Assessory Bldg 0 Commercial ❑ Demolition 0 Moving relocation ❑Other ❑ Others: 0 Foundation only DESCRIPTION OF WORK TO BE PREFORMED A Identification Please Type or Print Clearly) OWNER: Name: 1 C�A--c L I --0(--N)l z Phone: 42 Address: l!d 'IM Aatb1-,r- eAd Ale A moi 61s,16- CONTRACTOR 1s,1sCONTRACTOR Name: ? o LA 1L Phone: S5 Address: - o , 5-bo 2 Supervisor's Construction License: Exp. Date: Home Improvement License: / 7A ,6 Exp. Date: 7ZL0 8 ARCHITECT/ENGINEER Name: Phone: Address: Reg.No. FEE SCHEDULE.BULDING PERMIT. $12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER SF. Total Project Cost :$ 1316,06 FEE:$ Check No.:.— Receipt No.: Page I of 4 i 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 Doc:INSPECTIONAL SERVICES DEPARTMENTMFORNIN Page 4 of 4 I J TYPE OF SEWERAGE DISPOSAL Public Sewer ElTanning/Massage/Body Art ❑ Swimming Pools 11 Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Permanent Dumpster on Site ❑ Private(septic tank,etc. ❑ Electric Meter location to project NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund Signature of Agent/Owner Signature of contract I Plans Submitted El Waived F] Certified Plot Plan 01Stamped 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 FIRE DEPARTMENT - Temp Dumpster on ite no Fire Department signature/date COMMENTS Zoning Board of Appeals:Variance,Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments r Water& Sewer Connection/Signature& Date Driveway Permit Building Setback ft.) Front Yard Side Yard Rear Yard Required Provided Re uired 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 j I Page 3 of 4 Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM05 Crated JMC.Jan.2006 I I r Location No. 156c) Date t1 „oRT„ TOWN OF NORTH ANDOVER f � 0 9 4 y v Certificate of Occupancy $ CMUs�� Building/Frame Permit Fee $ A10 Foundation Permit Fee $ Other Permit Fee $ }` TOTAL $ Check # aa� r 19989 Building Inspector � NORTfy " 0 0 _ over 0 .. _. : _ LA E dover, Mass.,997A Itp COCMICKEWICK V O'R'ATED PP C3 BOARD OF HEALTH Food/Kitchen PERMIT T Septic System BUILDING INSPECTOR THIS CERTIFIES THAT.......... . . . . .. ........ .. ��......lc................. rr .............................. Foundation has permission to erect........................................ buildings o .. �. ....... !. � .�..•..••• Rough to be occupied as......... h.. .. ..... Chimney provided that the person accoiting_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 3 - Final • PERMIT EXPIRES IN 6 MO UNLESS CONSTRU O ST ELECTRICAL INSPECTOR Rough . ... . .. . . ...... ... ... ........... Service BUILDING INSPECTOR Final Occupancy Permit Required to Omipy 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 UT 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name(Business/Organization/Individual): �/��'L } �C Address: 0, City/State/Zip: J3Y D0 cla2-14 AW Q phone#: to�'y (o '0Z - %'9S Are you an employer?Check the appropriate box: 4. am a general contractor and I Type of project(required): 1.0 I am a employer with � g 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' comp.ins 9. ❑Building addition o workers co mp urance.t [N comp. 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.[I 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.] *My 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. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractom and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:({ & -A�s Policy#or Self-ins.Li c.#: �/&Q(20 ?j A 2�/ Expiration Date: 3 Zi 0 e Job Site Address: // a —j/� /��l�L�2 City/State/Zip: �W, n�46"� 1 . Attach a copy of the workers'compensation policy declarationpage(showing thePolicY number and e_xpiration� 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 uPrisonment,as well as civil penalties in the form of a STOP WO RK 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 insurancoves G a a verification. ti I do hereby cert' under th pains and penalties of perjury that the information provided above is true and correct Signature: Date: Phone#: 9� 'S 9/^ Offlcial use only. Do not write in this area,to be completed by city or town of,flciaL 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 bum 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 11-22-06 www.mass.gov/dia VZ/V612VVI 10:0f tAA yivly4VvlJ �N. J. UUK�NU 1NJUf;14Nl;t tgjVVZIVV3 ACORD- CERTIFICATE OF LIABILITY INSURANCE MOPP ID LAR-n DA Ef 4"WffY"I' PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Samuel. J. Durso Insurance Agcy ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Charles S. Random HOLDER,THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 198 Massachusetts Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES 9ELOW. North Andover MA 01945 Phone: 978-662-5175 Fax:978-794-0313 INSURERS AFFORDING COVERAGE INSURNAIC#ED INSURER A: Arballa Drsrection Ins. Co_ 41360 INSURER a! Safety Insurance Co. 33618 Polar Bear Insulation Peter & INSURER C: ir_awm iaro Zn�uranCawonr _ Steven Leblanc D/B/A P 0 BOx 959 INSURER p, – Andover MA 01610 COVERAGES INSURER E: 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,AGGREGATE LIMITS SHOWN MAY HAVE SEEN REDUCED 8Y PAID CLAIMS. imam 0174 LTR NSR TYPE OF INSURANCE POLICY NUMBER DANE MAAID DATE M UNITS GPN811ALLlA6111TY I I EACH OCCURRENCE 31000000 A R COMMERCIAL GENERAL LIABILITY 8500033619 i 03/24/06 ! 03/24/07 FREMISE�rence _8_100000 _ CLAIMS MADE a OCCUR i MED EXP IP Any one person) $5000 .. ,._ PERSONAL BADV INJURY S1000000 GENERAL AWREGATE s2000000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGO S 2000000 POLICY P9a lOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT B ANY AUTO 2100926 01/04/07 01/04/06 (Eeacddem► 31,000,000 ALL OWNED AUTOS X SCHEOULEDAUTOS BODILY INJURY & � � (Per person) j[ HIRED AUTOS – BODILY INJURY X NON-OWNED AUTOS (Per moddon1) $ PROPERTY DAMAGE 3 (Peraaadanl) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S ANY AUTO OTHER THAN EA ACC S 1 AUTO ONLY. AGG $ ' EXCE88NMBRELLA LIABIU7Y EACH OCCURRENCE $1000000 A OCCUR cLAIMIsMADE 4600033624 03/24/0603/24/07 AGGREGIAIE $1000000 3 DEDUCTIBLE S Ex RETENTION S 0 3 "'— WORKERS COMPENSATION AND EMPLOYERS'LIABILITY X TORY LIMBS_ , ER C ANY PROPRIEfOR/PARTNERIEXECUTIVE 31£E B>Q7+o4P 12/30/06 12/30/07 ELEACHACCIDENT 31000000 OFFICER/MEMBER EXCLUDED? M yyaae,dessnne Under E.L.DISEASE•EA EMPLOYE $1000000 SPECIAL PROVISIONS beIOW E.LDISEASE-POUCYLIMIT 3 OYHER 1044044 DESCRIPTION OF OPERATIONS/LOCATIONS I VQMCLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL RF6d91ONS Insulation Work - Mineral: Workers Compensation Certificate to follow directly from company. CERTIFICATE HOLDER CANCELLATION BONEITZ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES U CANCELLED BEFORE THE EXPIRATION DATE THEREOF.THE ISSUING INSURER YYILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO MALL Michael Boneitz 110-112 Marblehead St IMPOSE NO OSUGATION OR LIABILITY cF ANY KIND UPON THE INSURER,IT$AGENT'S OR l7nstija As.d�voa; 2� 01845 aevr:£sEroretive_s. ``�-.�_ AUTHORIZED REPRESENTATIVE Charles S. Randone ACO RD 25(2001108) ®ACORD CORP N 1888 2007-02-07 16.02 9787940313 Page 2 g gBoard of Building Re ulations and Standar ds o One Ashburton Place - Room 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration Registration: 102726 Type: DBA POLAR BEAR INSULATION CO. Expiration: 7/2/2008 Vincent LeBlanc --- ---------- P.O. BOX 958 ANDOVER, MA 01810 __- Update Address and return card.Mark reason for change. DPS-CA1 0 5oon-05/06-PC8490 E, Address Renewal C Employment C Lost Card