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HomeMy WebLinkAboutBuilding Permit #406-12 - 12 GILBERT STREET 11/10/2011 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: 4106 2 /� Date Received, ct4 j o,obll Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION ff Print PROPERTY OWNER C� ,s��� G Unit# f Print MAP NO: _PARCEL: 7 tZ ZONING DISTRICT: Historic District yes no Machine Shop Village yes no 100 year-old structure yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial NAlteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑_Other 19 W- 11 ®)F�l_oodpl� : Wef nds 0 `Wa`fershed _,st DESCR`1IPTION OF WORK TO B,E1�PERFORMED: T1 � o Identification Please Type or Print Clearly) OWNER: Name: ,, sne \du Phone:o li- -Ci4�1)c1 ,I Address: 9 I CONTRACTOR Name: Phone: q,-4k X43 Address: 01 S-1 L Supervisor's Construction License: 1 o W 3'� Exp. Date: Home Improvement License: JC@� ':�Sc Exp. Date: 1 J f 0 � n ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $_ °1 d - ,0 a FEE: $_ // 7100 Check No.: J 19(.o / / 4F Receipt No.: 1�2 y d NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund nt/Owner "� vP. { Si' natureofcorit�actor i =`� Location No. 06 /z Date10 MaRT„ TOWN OF NORTH ANDOVER 3 O F � w A i } Certificate of Occupancy $ sCMUsE<� Building/Frame Permit Fee $ / . ov Foundation Permit Fee $ Other Permit Fee $ y TOTAL $ owG Check # Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Swimming Pools ❑ Tanning/MassageBody Art ❑ 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 P CONSERVATION Reviewed on Signature f COMMENTS �II � I II HEALTH Reviewed on Signature I � COMMENTS i, Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes I Planning Board Decision: Comments y Conservation Decision: Comments Water &Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date 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.$10041000 fine NOTES and DATA— For department use ❑ Notified for pickup - Date Doc:.Building Permit Revised 2011 June/mi i Building Department i 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 V ❑ Buildinpp Permit Application 9 ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract j ❑ 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 VOTE: 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 F ❑ Engineering Affidavits for Engineered products COTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg .Permit I n all cases if a variance or special permit was required the Town clerks office must stamp the decision from the Board of Appeals iat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording lust be submitted with the building application Doc: Doc.Building Permit Revised 2008mi NORTH T0VM Of And No. ,6 o , over, Mass., COCHICHEWICK �. ��ADRATED PP���y S U BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System �/ / BUILDING INSPECTOR THIS CERTIFIES THAT..............0 ............................................................. Foundation has permission to erect..........:.:........................... buildings on ..�....................................................................................... Rough I. �O©� Chimney I tobe occupied as.......................................�.,........................................................................................................................ provided that the person accepting 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 Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION S ARTS Rough z........................................... 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 Until Inspected and Approved by the Building Inspector. BurnFIRE_DEPARTMENT`� - Street No. SEE REVERSE SIDE Smoke Det. t � erair. �} Office of Co-nsums Bi: siness egulation / HOME IMPROVEMENT CONTRACTOR + - 7 Registration: _ 162528 a Type: Expiration: 3/16%2013 DBA M EL FIORI CONSTRUCTION • MICHAEL FIORI 23 CAROL ST ��� DRACUT, MA 01826 !,} y Undersecretary j -�_-_ iil�t�i��!'�f.yt- ♦ I./l{{���t}if�t}.}�}t r��t�A�l�� lI vm �. Poard 4 Bfr�ilritn' 1Fttfi;u .ttit,h� �ritl �t trtrl rr ti4els48 S 04035.i+ £`• .1.,i ' -' }ti a� Restricted fo 00 MICHAEL FIORI ;k + 21CAROL ST:;; .DRACUT, MA 01826 r , w * i. .�: -!PxpiratiA-. 3W2 014'`I Tt'# 104035 -1 i, FIORI CONSTRUCTION 23,1-Carol Street Construction Lic. 'C 104035 Dracut,MA 01826 Home Improvement Lic. 162527 -(978)265-6843 Fully Insured/Workmans Comp Work Submitted to: Christine Lahey Job Name: Christine Address: 12 Gilbert St North Andover Phone Number: 978-685-9559 Proposed Work to Be Performed: -Remove 2 existing layers of shingles -Install new ice and water shield six feet up from the bottom of the roof. -Install ice and water shield in all valleys and weave shingles to prevent leaks -The remaining roof will,be covered in tar paper. -Install new white drip edge on all roof edges. -Install new 30 year architectural shingles. The color is of your choice -Install a new cobra vent of the top of the roof -Install new stink pipe boots of the roof -Retar chimney -Dispose of all material in a legal manner -Apply for a permit prior to starting the job Total Labor and Material $9750.00 The amount of$4500.00 is due upon signing of the contract and receiving all roofing material and receiving a permit. Balance is due upon completion of project. I accept and understand this contract Date M6111 Thank,you and feel to contact me with any questions. The Commonwealth ofMassachusetts Department of Induslria[Accidents Office of Invesfigationg 600 Washington Street Boston,MA 02111 S" www.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers A licant Information _ please Print Le ibl Name(Business/Organization/Individual): uG t� Address;`1'S ale S City/State/Zip_� � A C� Phone#: J• ' 3 Are you ani employer?Check thea ro riate box: PP• P � TYP project 1.1(I am a,employer with tA 4. ❑I am a general contractor and I e of ro'ect(required): - 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 sheget.1 7. ❑Remodeling ship and have no employees These sub-contractors have working for me in any capacity. workers'comp.insurance. 8. ❑Demolition [No workers'comp,insurance 5. ❑ We are a corporation and its 9• ❑Building addition required.] officers have exercised their to ❑Electrical repairs or additions 3.0 I am a homeowner doing all work right of exemption per MGL 11.[]Plumbing repairs or additions . myself. Wo workers'comp. c. 152, §1(4),and we have no insurance re uired. f 12.❑Roofrepairs q ] employees.[No workers comp,insurance required.] 13.�Other c ,, fZ�:�a� *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I 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-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for information. my employees Below is the policy and job site Insurance Company Name.- • zQ/•,�� Policy#or Self-ins.Lie.#:_ Cl l l q t'nnla y Expiration Date: Job Site Address:'10 Gid}, City/State/Zip-_N,4 , V� L„ti-r ill ,q Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). !i 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 o£ Investigations of the DIA,for insurance coverage verification. I do hereby certlyy under flte pains andpenalties of ury tliat the information provided above is true and correct. Signature: Date: �J !O 11 ?hone FOfficialonly.' Do not write in Mis area,to be completed by cdty or townofficial n• Permit/License# ority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Iinspector 5.Plumbing Inspector 6 Other Contact Person: Phone#: Information and Instructions tions 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 insuranc6 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-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. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation ofinsurance 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/licepse applications in any given year,need only submit one affidavit indicating current Policy information(ifnecessary)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 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: Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,M-A,02111, TO.#617-727•-4900 ext 406 ox 1-877-MASS.A,FE Revised 5-26-05 Fax#617-727-7749 Www-mass.gov/dia From:Georgetown Insurance 978 352 7719 11 /07/2011 17:10 #493 P.001 /001 DATE(MM/DD/YYYY) ,a►coRn CERTIFICATE OF LIABILITY INSURANCE 11/7/11 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIRCATE 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 policy(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 rights to the certificate holder in lieu of such endorsemenl(s). PRODUCER CONTACT NAME: Georgetown Insurance Agency PHONE 978 352-8000 FAX No: (978) 352-7719 10 West Main Street ADDRESS: info@Geor etownlnsurance.com Georgetown, MA 01833 PRODUCER 10588 INSURERS)AFFORDING COVERAGE NAIC N INSURED INSURERA:Zurich Insurance Michael riori INSURER B: 23 Carol St INSURER C: Dracut, MA 01826 1 INSURER D:' INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT 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 CONTRACTOR OTHER DOCUMENT WrfH 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 OFSUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD SUB POLICY EFF POU CY EXP LTR TYPE OF INSURANCE INRVWD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAISES .a occurrence)GE IE $ P Mcc CLAIMS-MADE r_1 OCCUR MED OW(Anyone person) $ PERSONAL&ADVINJURY $ GENERAL AGGREGATE $ GEN'LAGGREGATE LIMTAPPUESPER PRODUCTS-COMP/OP AGO $ POLICY P O LOC $ AUTOMOBILE LIABILITY COMBINED SINGLELIMIT $ (Ea accident) ANYAUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ HIRED AUTOS (Per accident) NON-OWNED AUTOS $ $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS CIAB CLAIMS-MADE AGGFEGATE $ _DEDUCTIBLE $ RETENTION $ $ A WORKERS COMPENSATION 4179P334 4/1/11 4/1/12 WCSTATU- OTR AND EMPLOYERS'UABIUTY ANY PROPRIETOR/PARTNEREXECUTNE Y/N E.L.EACH ACO DENT $ 100,000 OFFICERMIEMBEREXCLLDED? 7 N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPE RATION S/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more apace ie required) operations typical of a residential carpenter Fax 978-688-9542 Sole Propietor, Michael Fiori, has not made an election for coverage under the WC policy. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood Street North Andover, Ma 01845 AUTHORIZED REPRESENTATIVE Mar aret Smith ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 26(2009/09) The AC ORD name and logo are registered marks of ACORD Code End PU3 apo