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Home My WebLink AboutBuilding Permit #602 - 122 LISA LANE 4/9/2010 BUILDING PERMIT yORTFf of�t,to ,bgti TOWN OF NORTH ANDOVER c� APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received 4,p �gSSACHUs Date Issued: f� IMPORTANT:Applicant must complete all items on this page LOCATIONLL - .,, A - Print' PROPERTY OWNER 'S -C�r,�' T . ` Pint MAP 210 PARCEL_--=, ZONING01STRICT - Historic,District yes o Machine' Shop Village yes A o TYPE OF IMPROVEMENT PROPOSED USE Res' ntial Non- Residential New BuildingOne Addition Two or more family Industrial Alteration No. of units: Commercial Repair replacement Assessory Bldg Others: Demolition Other Septiclltitell' Floodplain ;Wetlands Watershed`District r Water/Sewer v DESCRIPTION OF WORK TO BE PREFORMED: Identification :,Please Type or Print Clearly) OWNER: Name: Phone: Phone: Address: CONTRACTOR "Name: _w Phone a t y y Address: _ Supervisor's Constructtofi license "' 6:_'3 '`7 Exp. Date; .. ;. Home Improvement Licer-se: 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: $ /�/ /� C) FEE: $ Check No.: Receipt No.: x;01-3 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund ignature_of Agept/Owner Signature ofscontractor . - 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 pineeri mit Application a mp Affidavit. ❑ Of H.I.C. And/Or C.S.L. Licenses ❑ tract r Proposed Interior Work o -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 o 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) L3 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 L3 Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit Li Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Li Copy of Contract ❑ 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 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:Building Permit Revised 2008 Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/ ody 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 � _r 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 2010 Location .1-2-"7 No. Date �� d Mo�Th TOWN OF NORTH ANDOVER 3? � . 04 F 9 + Certificate of Occupancy $ • orb+��..*'' • j Building/Frame Permit Fee $ wcNus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 0 2293 Building inspector I Pae No. of Pages Tom. DeFUSCO 23'Dutton Road Pelham, NH 03076 Home-1'ptovement Reg. # 117756 Tel 603-635-3017 Constr. Lic. #071037 FaxT 603-635-3751 PROPOSAL SUBMITTED TO "PHONE DATE STREET ryry JOB NAME G> L.I' L . CITY,STATE AND ZIP CODE JOB LOCATION ARCHITECT DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for ✓ -� (/� ................................... ...... ........................... .............. ..•............. .. ........ ........ ..... .... .... ...... .. ._.. J'....r / � 1 ' 9 .' r 7�... n . ................................................ ....a .... ..._. �.... ?`......... f _>.......... ... ..... ..__. ....................... ..... ........ .... ......... ......:.. ..... .... ......... ..................... r .......:.. {� k ..........W r.. ✓ ' / r ....... ... _.. ... .... le 41 ........... .:.............. .. ................... ... ... '"" ,. �� •� C ✓fII rJ � t ..... ...... t .. " ...... .. ! ...f ................................ f } ..... ................. - ' .............................................................................. ........ ........... .. ............. ..... ....... .. ......... ........ ........... ........ ...._....... .. .............. .. r... '�..U .:......._� rl P TD DSP hereby to furnish material and labor, -complete in accordance with:the'above sp¢Ci atlpns�fo ll e �m of: j � .r(�.w�. !Y! �rtr. P•4., .f i �r't/ i.. %� ' rf .� —< do iiars ' �:... �. Payment to be made as follows: ! f-'>,i /':i./ " r.. t`l,(..1 t'�.i.;«t/� 'r/✓C+�-�[7'r (r j` C=•� All material is guaranteed to be as specified. All work to be completed in a workmanlike. Authorized ' manner according to standard practices. Any, alteration or deviation from above Signature specifications involving extra costs will be executed only upon written orders,and will become an extra charge over.and above the estimate.'All agreements contingent upon.strikes, T accidents or delays beyoNote:This proposal may be withdrawn by e: not r oo nd our control. Owner to carry fire,tornado and other necessary, pted within. days. insurance. Our workers are fully covered by Workmen's Compensation Insurance. { h � t�pfl r \�l t 1�,, iturr of Fra'pQ$a1—The above prices,specifications Signature and conditions are 'satisfactory.and hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. Date of Acceptance: `� ��i � r Signature 0 0 0 f Andover No. OC LA dover, Mass., q J4 bb HIC HEWIC E BOARD OF HEALTH Food/Kitchen PERMIT T D §eptic System BUILDING INSPECTOR THISCERTIFIES THAT...........r0M....614V.................................................................................................................. Foundation has permission to erect........................................ buildings on ./2_.' .......1,4.f ...................................... Rough 4� ot Chimney to be occupied as.5... ..........................9�.V'�................................................................................................... provided that the person accepting this permit shall in4very 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 Building; 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 STARTS Rough ......... Service ........ ...... BUI PECTOR 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. i 9 07'�Gf[S'Q.C�fU1eLL(f Board of Building Regulati us and Standards HOME IMPROVEMENT CONTRACTOR Registration: 117756 Expiration 1.1115/2010 Tri✓'• 277330 ,Type: DBA TOM DEFUSCO GENERAL.CONTRACTING THOMAS DEFUSCO } 23 DUTTON RD �^� PELHAM,NH 03076 Administrator -�_ �'lassachusrtts- Dcltsirtment trf Pttltlic fiafetc Board tt1'Bttiidin''_Regltlations and Standards Constructior;Supervisor License License: CS 71037 Restricted to:..00 THOMAS A.'DEFUSCO " ` 23 DUTTON ROAD PELHAM, NH 03076: k,. - --'` Expiration: 6182011 C'rnnmissi nur Tr#: 17284 i AORDCERTIFICATE TIFICATE OF LIABILITY INSURANCE i x`08/07` 0 d TH<S CERTIFICATE IS fSSIIED AS A IMA7TER OF INFORMATION PROOUCER ONLY AND CONFERS NO RPXM UPON THE CRATE T. A. Sullivan Ins- Agcy, Inc, r HOIDM THS CERTIFICATE CK=NOT'AMID.WMW OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW- 344 S. Union St. yawx-Qmce, mh 01843 INSUE-RAFFORDING COVERAGE * MAIC# phone: 978-683-4700 ,tea 6resbaot C Assoc of RI Inc. g V�,ay� Siding � to Mass.ilvrkera .Aesi D�/aH'/�� Contracting a Sons c 45 �7in�broo � gppj ng NH 0 042 q�SURER E TPOLICIES OF R�URANCE LISTED SOW HAVE Seat TSSUED TD THE 9MIRM HAMM ABM HE THIS CERflFIGCfE MAY SE ISSUED OR ANY REQUIR�.TERMOR rCONDRM OF ANY CONTRACTOR OTHER S TQ ALL THE TetMS,OICLUSIM AND C MAY PERTAIN.THE MSURAHCE AFFORDED BY THE POUGES DESS POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIM& LADS TE LTR T'VPE of reuRaNCE PDLICII NU118� OA FA o $1000000 mat LIAew.m► 04/23/09 04/23/10 P tEaooueenoe) * A X COMMERCIAL GENERAL LIABILITY 3DH5940 MEDEXP(MY ene Pew+) $ CLAIMS WOE ®fit pERSONAI a ADV WJRY $1000000 X tet. QBfERAL AGGREDATE *2000000 pRom=s-cowmpAm s2000000 GEN1aci(iRE(3ATE LIMIrAPPLIEs Pet: POLICY PRO- LOC COM AUTO LUIBLLRY Beoolede�nR)m"LUT y ANY AUTO _ ALLOWNED AUTOS (Per OL.Y. ly t SCHEDULED AUTOS _ TOS (Per Lex HIRED AU3dent NON-OWNED AUTOS _ (PerPERTY s AUTO ONLY-EA ACCIDENT * GARAGED OIHERTHAN EAACC * ANY AUTO AUTO ONLY: AGG• $ EACH OCCURRENCE * �A LIABBJiY AGGREGATE * OCCUR F-1CLAMMADE * s DEDUCTIBLE S RETENTION * X TORYLBARS ER EmPLOYOW uaenmr B pR0pR�o��uEC� WC 446-95-91 r07/22/09 07/22/10 �+� T $100000 oFFlcewMEIaBER ELOISEkBE-E1►EIriPI s 100000 a aesa�e uner E.L.DISEASE-POttCYLIMIT *500000 s�uu.PRovISIONs DINER A Commercial AWlica 3MS940 04/23/09 04/23/10 DEsc *TwN of ,WUMIOWADMW er ENDORSEMBITi vinyl yl siding installation, minor carpentry. dential hme painting and roofing CERTIFICATE HOLDER 8HOliLD ANY OF'IFe A9DVE POI.ICIFB sE CANCUJtD BEFORE TTiE EXPIRAT DATSMMW.THE MSUMG OMURER WLLL ENDEAVOR TO W& 10 DAYS WRITTE TauDerusco NOTICE TO THE CERTMATE HOLDERHS NAMM TO TLEFT,BITi FAILURE 1b DO SO SHA Gweral Contractor, Tar DIP08E ND OOLOATM OR LIABUTY OP AW MM UPON MM VMWM%fM AGENTS oR 22•Dutton Road Pelham NH 03076 AMTna ®A CORPORATION 1 ACORD 25(200MM I �� 10 ry t e . 00 , .l♦ FIS. won c 5 . 7 .. •,.. _ '. � x .( _ n 15 ..r ...— � � � ��. .. ._ ... jilt �1 ' 1 '77_..._ r j 0 now too 7p .. r "r• . _r.. is ttL i .,,. { _•w. _ �-'t:'^J4+, +, p, r Information an d 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 apartmLents,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 ibusiness or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of co=npliance 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(LLQ or Limited Liability Partnerships(LLP)with no employees other than the members or partners,.are not required to carry workers'comp ensation 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 permaitor 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 bke to than 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 Qf Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-72.7-4900.ext406 or 1-877-NIASSAFE Revised 5-26-05 Fax#617-727-7749 Vt�R�V.Il1aSS._gOV/Cjla The Commonwealth of Massachusetts Department of Industrial Accidents Office of rnvestigations o, 600 Washington Street Boston, IVL4 02111 www.mass-gov/dia Workers' Compensation Insurance Affidavit: guilders/Contractors/Electri Applicant Information PIease Print Lm_ bl Name (Business/Organization/Individual): Address: City/State/Zip: //Q7,(_,( A ,.-i Al Phone#: 9 63 G ?<S- 3crz 7 Are you an employer?Check the appropriate boa: 1.❑ I am a employer with 4. [ `a Type of project(required): general contractor and I. employees(full and/or part-time).* have hired the sub-contractors 6• ❑Nev,construction 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 working for me in any capacity. workers' comp.insurance. 8. ❑Dem°Irhon [No workers' comp. insurance 5. ❑ We are a corporation and its 9. ❑Building addition 3.❑ required.] officers have exercised their 10.❑Electrical repairs or additions 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 insurance required.] t 12.❑Roof repairs q ] employees. [No workers' comp.insurance required.] 13.❑ Other ------------ *Any applicant that checks box#! must also RE out the sectio__below:shoe.ag r^r ch _ formation- Homeowners who submit this affidavit indicating they are doing all work and Ci thea hire outside contractors mustsubmit new affidavit indicating such. xContmactors 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 workerscompensation insurance for information. my employees Below is the policy and job site Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: 7 Z G11 S/+ GILJ - City/State/Zipl J Attach a copy of the workers'compensation P policy declaration page sho ' (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 her certify under the pains and penalties of perjury tlirrt the information provided above is true and correct Si ature: - Date.:-4, l .a. Phone#: G Official use only. Do not write in this area, to be completed by cite 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#: