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Home My WebLink AboutBuilding Permit #461 - 121 COLGATE DRIVE 12/23/2009 TOWN OF NORTH ANDOVER ( APPLICATION FOR PLAN EXAMINATION Permit NO: 1 Date Received Date Issued: 23 IMPO ANT: Applicant must complete all items on this page LOCATION /2/ c, /<-- ✓' A 1hdFit�/�� PROPERTY OWNER Z'e A Print MAP NO: _1 PARCEL:L ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building lac ATwo or more family Industrial ataor No. of units: Commercial Repair, r placement Assessory Bldg Others: emo ition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTIONOFWORK TO BE PERFORMED: dentification Ple se Type or Print Clearly) OWNER: Name:_ arc `7;/AI Phone: (q7F- f o —9aoO Address: 12 Col ��✓ � �o ' CONTRACTOR Name: A 44 l L'ti�;� Phone: 97Z ?7,.,3' Address: ?z Supervisor's Construction License: Exp. Date: Home Improvement License: 131 Exp. Date: 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. Total Project Cost: $ $700 FEE: $ lG- dd Check No.: H ( � Receipt No.: NOTE: Person's contracting with unregistered contractors do not have access t the g my un Signature of Agent/Owner Signature of contractor Location No. Date -� MORTM TOWN OF NORTH ANDOVER f � O Certificate of Occupancy $ cMus`� Building/Frame Permit Fee $ Foundation Permit Fee $ _ Other Permit Fee $ TOTAL $ Check # � f U Building Inspector Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body 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 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.$100-$1000 fine NOTES and DATA— For department use ❑ Notified for pickup - Date Doc:.Building Permit Revised 2008 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 ❑ 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 2008 Ac R' CERTIFICATE OF LIABILITY INSURANCE OkTE`a"'°"'"'"' �-•� 12/23/09 PRoa�DER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION M.P. Roberto Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 1060 Osgood Street HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. North Andover, MA 01645 INSURERS AFFORDING COVERAGE MAIC#1 uRED INSUMRA: Providence Mutual BACKRIVER DEVELOR-ENT LLC IN9URER8; Associated Em»lo ems Ins, Co. 231 NORTH END BLVD. INSURERc: HanoverInsuran��• _ SALISBURY, MA 01952 INSUMRD INSURER I- COVERAGES THE POUCIESOF INSURANCE LJ$TE D BE LOW HAVE BEEN ISSUED TO THE INSURED NAMED A30VE FOR THE POLICY PERIOD INDICATED,NOTWRHSTANDI% ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MY BE iSSUM)OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN LS SUBJECT TO A LL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAIDCLAIMS. 8R .. - ..... .... _. POLICY NUMBER POUCY EFFE Y P CY EXPIIWITON —' DATE MW LIMTS 6El1ERAL1lABILITY I EACH OCCURRENCE R 1,000,00 A X CObMERc�ALGFNErtALLIABUTv CPP0063833 ! 4/28jp9 4/26/10 DAW, TORE rE"T P_RFM1Sk4 LrjLpp,, ne., S 100,000 CLANISMADE 191 OCCUR MEDE7�(Anyoropseoi) >) 5 p00 — PERSONALdwADVINNRY S 1,00_ .00o - — I rGC2NLERAL AGGREGAT�E % 2,000000 GEN'L AGGREGATE 0AIT APPLIES PER gODULTS•COINP10P a� l b POLICY. PRI LOC —. 2.,000 000 AUTOMD8"LIABUTY LANYAUTOxa xxtngINGLELMer $ 1,D00,000 UTOS AFN5315048 4/1/094/1j10 CLITO& WDILYINJURY ! UT09 BODILY INJURY ON OaCN7eIIl) L_ _ PROPERTY DANNGE 5 fPef 8C¢Idnrt) GARAGE LIABILITY AUTO ONLY•EA ACCIDENT tDEDUCTIOLA EA ACC $ DTHER nIAN AUTO ONLY; AGG I YlB1UlY EACHOCCURRENCE s CIAMSMAOE -- S VIORKERS COMPENSATION T AND EMPLOYFWLIAB&RY WC STATU• Oiw_ B APFICER RM RPARLIEED)?(,TJ7NE Y/N WCC500587601 4/28/00 a 2B/09 El,ECHACdq� S 5OO DOO #AevwkMAEnNH)EXCLIDEO? � I I AAendebry IA NH) II8de"""usnOaeNr SE .DUS ese. _EASE a 500 000 OTHER I E.L.DI WE-POLICY LkMfT 500,000 M3CRIPTION OF OPERATIONS!LOCATIDNB t VEI6CLRS!EXCLUSIONS ADDED DY ENDORSEMENT I SPEOALPROVM0.n FAX: 978-688-9542 CERTIFICATE HOLDER C CELLATION SHOULD ANY OF THEA9OVE DSSCRIBEDPOLICIES BE CANCELLED BEFORE TWE EXPIRATION TC7WLi OF NORTH At+movER DATE 7MEREOF,THE WSUANO INSURER MILL ENDEAVOR TO MAIL 10 DAYSWRITTEN OSGOOD STREET IIOrct TO THE CERTIFICATE HOLDER NAMED TO THE LEFY,BUT FAILURE THD DO 8O SHALL NORTH ANDOVER, MA 01845 IMPOSE NO OBLIOATIDN OR LIABe.ITy OP ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZEDREPRESENTAYiV / %COR D 25(2009101 1 ! �/'r� Cr 19x8.2009 ACORD CORPORATION. All rights reserved, The ACORD name and logo are registered marks of ACORD Back River Development 231 North End Boulevard,Salisbury, MA 01952 978-804-9383 CONTRACT FOR CONSTRUCTION SERVICES Client: Pamela Hilton 121 Colgate Drive North Andover, MA 01845 Description of Construction Services: Strip and re-roof 10 square; re-roof additional 20 square. Labor and Materials: $6,500.00 Contractor Signature: Brian Lync Clinet Signature. Pamela Hilton The Commonwealth of Massachusetts q1,JVn Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, AM 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information J Please Print Legibly Name(Business/Organization/Individual): ,/ / xpz-� lDe l L-c-- Address:_ 23 City/State/Zip: :f,7 /1,14V�:—AW Dlgt Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.JX I am a employer with---/4-/- 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 1 7• ❑Remodeling 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 10.El Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.RgRoof repairs insurance required.]t employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box C must also fiL out the section below showing theme 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-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address:_ /Z/ 6o11e City/State/Zip: 4e4' Olfff�— 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 Investigations of the DIA for insurance coverage verification. I do hereby certify under pains nd Wallies of perjury that the information provided above is true and correct. Si ature: Date: �Z Q Phone#: 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 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 Revised 5-26-05 Fax#617-727-7749 www.mass.govfdia NORTH Tovm of 4Andover No. 0 - ; o dover, Mass., 12 3 o ls� COC MICMEWICK ADRATE D P`Pp` —`C:) `S BOARD OF HEALTH PER IT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT... ..444.1G..�.-...... �.�.��'1.......................................................:. Foundation n has permission to erect........................................ buildings on ...�2..I....S.. .I. .�4 ..........� 1- 61 ...................... Rough to be occupied as........ +................. ` Z......... .... . C :oa i - Chimney provided that the person accep ing this permit shall in every r pact conform to the terms of the aption 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 (� Z PERMIT EXPIRES IN 6 MONTHS Final ELECTRICAL INSPECTOR DC"Z UNLESS CONSTRUC TARTS 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. ti4tssachusetts - Department of Public Board of Building Rer� Safet} Construction Supervisor and Standards License: or License CS 65005 • Restricted to: 00 BRIAN A LYNCH 31 SEVEN STAR RD GROVELAND MA 01834 onnniscirrner Expiration: 111151201, Tr#: 12553