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Home My WebLink AboutBuilding Permit #890-13 - 1160 GREAT POND ROAD 6/19/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO:P,$—1-3 Date Received Date Issued: c 11-3 IMPORTANT: Applicant must complete all items on this page 1 ,,fin LOCATION ! v PROPERTY OWNER � Print 100 Year Old Structure yes nAL MAP NO: PARCEL: ZONING DISTRICT: Historic District yes (::no Machine Shop Village yes o TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District. 0 Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification Pleale Type or Print Clearly) OWNER: Name: �i� Phone: Address: CONTRACTOR Name: Phone: Z�3� '' Address: Lb Supervisor's Construction Licenser bl Exp. Date:.- & l Y6 Home Improvement License!�V+b+ Exp. Date: ��-- ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED OST BASED ON$125.00 PER S.F. Total Project Cost: $ �� t3 � FEE: $ �2 I. Check No.: V q-� a Receipt No.: ta NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractok�74- Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ 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 o ' Building Permit Application o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work a Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks a Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract a Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) a 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) L3 Building Permit Application o Certified Proposed Plot Plan Li Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o Mass check Energy Compliance Report o 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 app-,al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.tted with the building application Doc: Doc.Buiiding Permit Revised 2012 Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions_ Total land area, sq. ft.: ELECTRICAL: Movement of fleeter 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.$10041000 fine NOTES and DATA— (For department use El Notified for pickup - Date , Doc.Building Permit Revised 2010 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE'OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/BodyArt ❑. . 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 t COMMENTS 14 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 Tows! ]Engineer: Signature: Located 384 Osgood Street FIRE DLPARTM`_NT - Temp Dumpster on site yes no Located at 124 Mair'Street Fire Departinert signatureldate COMMENTS ocat o t }G No. 0 Date i • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# ` (� <*� I's / P Building Inspector X10RTH Town of E : I� . n over O C, h ver, Mass use. 1 Za o _j A- COC MIC Nl WICM v� 7,9 A�'VA ED 1)"? S V BOARD OF HEALTH P E IT T LD Food/Kitchen Septic System "THIS CERTIFIES THAT Q � BUILDING INSPECTOR .... ...... ............ .. ...................................P . Foundation has permission to erect ... .... buildings on .. . ..... Rough to be occupied as� ...... ......... d 0 ..�... ...2.!... 0. .......................... Chimney h the person accepting this permit shall in eve respect conform to the terMf the application provided that p p g p every p pp 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 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTT S Rough Service .............. ...(S....................................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinw 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 The Commonwealth ofMassachusetts Department of1ndustr1g1Accidents office oflnvestigations 600 Washington Street Boston,MA 02111 www.massgov/ilia Workers' Compensation Insurance Affidavit:Builders/ContractorsfFlectricians/.Plumbers Applicant Information Please Print Le�ibXv Name(Business/Organi'zationllndividual): "7 Address: 7 - City/State/Zip: I e Phone it: !' Z 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 6. [J New construction em oyees(full and/or part-time).* haveliiredthe sub-contractors 2 am a sole proprietor or partner- 41-1 on the attached sheet. 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g, [].Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.[]Electrical repairs or additions required.] officers have exercised their 3.El am a homeowner doing allwork right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c.152,§1(4),and wehave,no 12.QRoofrepairs insurance required.] employees.[No workers' q ]� 13.❑Other comp.insurance required.] 'Any applicant that checks box#1 must also fill cutthe sectionbelow showingtheirworkers'compensation policy information. T Homeowners who submit this affidavit indicating they ire 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. lam an employer that 1s providing workers'compensation insurance for my employees. Below is the policy and job site information. _ Insurance Company Name:. {Jit��,/' Policy#or Self-ins.Lic.#: 7 A�y64 Z 2, /'Y6'^ Exph'ationDate: �L Job Site Address: Al pity/State/Zip: PZ4? Attach a copy of the workers'compensation olicy tleclaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby cert19 under thepains andpenadti ofper' . that the information provided above is it a and correct. Signature: Date: e(A Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing.A.uthority(circle one): 1.Board of Health 2.Building Department 3.CitylTown CIerk 4.Electrical Inspector 5.PIumbing Inspector 6,Other 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"...everyperson in the service of another under any contract ofhire, 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 ofpublic 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-contractors)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. B e advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign anddate the affidavit• The affidavit should be returned to the city or town that thee 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 permithicense number which will be used as a reference number. In addition,an applicant that mast 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 maybe provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each Year.Where a homeowner or citizen is obtaining a license or'-permit not related to any business or commercial venture (i.e.a dog license orpermit to bum leaves etc)said person is NOTrequired 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: Tho . oanmolimaXth ofMusaeftsetls Dap.artrnezat ofItIdustdal.A.ocxd.onis Qffiqe of fav stigatious 604 wbbpll St tot Boston .02111 TO,#61.7-727-4900 e 406 or 1:-877�MASS.AFB .. Ti. X E-1 r7 t7<lt7 ezn An PROPOSAL STAMP & SON CONSTRUCTION 37 Rumford Street Lowell, MA 01852 • (978) 937-7455 May 29, 2013 Submitted to: rooks School 1160 Great Pond Road orth,Andover, MA 01845-1298 ,. We hereby propose to furnish materials and labor necessary for the completion of: BARKER BUILDING 1. Install 2 square feet of rubber. $ 1,200.00 2. Strip �6 square feet of roof. . Install 26 square feet of Architect Shingles. $.10,400.00 4. Removal of all debris. PV Contractor's registration #1.16404 E PROPOSE hereby to furnish material and labor, complete in accordance with above specifications. For the sum of$11,600.00 Eleven Thousand Six Hundred Dollars & 00/100. Payment to be made as follows_ Please make check payable to: Anthony R. Stamp__ $11,600.00 "Total All material is guaranteed to be as specified. All work to be completed in a substantial workmanlike manner according t specifications submitted,per standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders and will become an extra charge over and above the estimate. ACCEPTANCE OF PROP AL: r above prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specifi SIGNATURE: ATE CONTRACTORS SIGNATURE: 4//3 ATE t Massachusetts - Department of Public Safety ll Board of Building Regulations and Standards ('mOruction Supervisor License: CS-079082 PRICE A PETERS,9N - 61 FARM POND RD DRACUT MA 01$26 Expiration (:ommissioner 08/18/2014 Unrestricted - Buildings of any use group which contain less than 35,000 cubic feet(991 m;)of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For DPS Licensing information visit: www.Mass.Gov/DPS '•t t i 1' I 1 License or registration valid for individul use only " before the expiration date. If found return to. Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,MA 02116 1 'Not va ' hout signature , Office ofoomer airs uSin`� t` te I .,a HOME IMPROVEMENT CONTRACTOR Registration: .,;�116404 Type: Expiration: 6/13)2014 DBA S SON CON8t, T1 ... V V, ANTHONY STAMP`•'. 37 RUMFORD ST j LOWELL,MA 01852 Undersecretary l'i f� NORFOLK & DEDHAM MUTUAL FIRE INSURANCE COMPANY SPECIAL BUSINESSOWNERS POLICY ' RENEWAL DECLARATIONS f OliCy# R0639424A Named ANTHONY STAMP Agent BYETTE INS. AGENCY, INC. Insured 37 RUMFORD STREET LOWEL14 MA 01852 Phone (978) 851-6678 t. Agent# 20434 FORM OF BUSINESS: ,OTHER • Policy Period: 1 YEAR from 07/14/13 to 07/14/14 This declarations page together with the policy jacket, the policy form and any endorsements, completes this policy Coverage begins at 12:01 A.M. Standard Time at the covered residence premises. I: PO`.LICY• ,PREML'UM;S AN+D `CfRE1,Djl tS 9 Basic Annual Endorsements State Taxes Total Annual Additional/Reb Premium Premium or Fees Premium Premium $ 1,662 $197 $ 1,859 II -I N SUER E D; �P RE M'I S`E.S f. Building/Location 1 37 RUMFORD STREET LOWELL MA 01852 Address if Different Mortgagee Information Business Des.4ition P CONTRACTOR -CARPENTER - RESIDENTIAL/L IIIARRO` :ERT:Y COVER"A-GES - Premium POLICY DEDUCTIBLE $250 OPT. COV./EXT. BLDG GLASS DEDUCTIBLE $500 BUILDING (COV A) Limit ACV OPTION (Yes/No) NO AUTOMATIC INCREASE (%) 8% Included BUSINESS PERSONAL PROPERTY Limit $10,000 Included IVB TI'O.`NWt - COVEWAGE•S. ` }Premium OUTDOOR SIGNS Limit EMPLOYEE DISHONESTY Limit MONEY&SECURITIES Limit ACCOUNTS RECEIVABLES Limit VALUABLE PAPERS Limit FORGERY&ALTERATION Limit TOTAL PREMIUM PER BUILDING $ 1,859 Vi LI A-BI L I. Y A N'D . M .E D I L A L- P AYiM &-N, S " EXCEPT FOR FIRE LEGAL LIABILITY, EACH PAID CLAIM FOR THE FOLLOWING COVERAGES REDUCES THE AMOUNT OF INSURANCE WE PROVIDE DURING THE APPLICABLE ANNUAL PERIOD. PLEASE REFER TO PARAGRAPH DA OF THE BUSINESS LIABILITY COVERAGE FROM LIABILITY&MEDICAL EXPENSES LIMITS PREMIUM, OCCURENCE $ 1,000,000 Included GENERAL AGGREGATE $2,000,000 Included PRODUCTS COMPLETED OPERATIONS AGGREGATE $2,000,000 Included MEDICAL EXPENSES $5,000 Included DAMAGE TO PREMISES RENTED TO YOU $ 100,000 Included E- "END0R'S EMEN7TS Premium SEE ATTACHED PAGE } OT THE PQLICY,P.ROVISIONS,REQUIREIITH V+ �1 j} �'4 ,,;COUNTERSIGNED BY AUTHORIZED,REPRESENTATIVE ", lids PJM PI2'EINIUM CFiItGE NORMAL'LYrAPpLIES,IF YOIJ G�4NCELk. yr "• �. RIdrTb E P7A7i�ONbATE;IMESIiALIrRET/IN �'REGdRDLES$'O�TERA�I , �` ��' � •3 {` )t�r� °}. r ; ., BOP-1 (REV.04/05) Tvpe of Pavment: DIRECT BILL NON EDP 10 INSURED COI i VDAC CNA '�� THIS IS A QUOTE , NOT A POLICY — WORKERS COMPENSATION AND _ • EMPLOYERS LIABILITY POLICY QUOTE PROFILE — VERSION 01 Y' POLICY NUMBER: (6S59UB-4193P65-4-13) RENEWAL OF (6S59UB-4193PG5-4-12) FINSURED'S NAME AND ADDRESS ,•STAMP, ANTHONY DBA WORKERS COMPENSATION STAMP & SON CONSTRUCTION INSURANCE PLAN 37 RUMFORD STREET A/R (WCIP) # MA XOWELL MA 01862 POLICY PERIOD FROM: 04-16-13 TO 04-16-14 t '�+ .TOTAL ESTIMATED ANNUAL STANDARD PREMIUM $ NONE PREMIUM DISCOUNT NONE 0900-20 EXPENSE CONSTANT 159 TOTAL ESTIMATED PREMIUM 500 DEPOSIT AMOUNT DUE 500MP Employer's Liability BI Limit: $ 100000 Each Accident 500000 Policy Limit 100000 Each Employee INSURER: CONTINENTAL CASUALTY COMPANY Adjustments of Premiums shall be made ANNUALLY Deposit Amount Due: $ 500 *** ************************** POLICY NUMBER: (6S59UB-41 93PG5-4-1 3) • DATE OF ISSUE:02-19-13 WC OFFICE: CNA 04 J ST ASSIGN: MA PRODUCER: BYETTE INS AGENCY INC 25GSF