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Home My WebLink AboutBuilding Permit #512 - 127 HIGH STREET 4/1/2009 `�� CoA o �d `cam BUILDING PERMITcf N%.1D qti �t�,lD , TOWN OF NORTH ANDOVER F? APPLICATION FOR PLAN EXAMINATION x Permit NO: - V� Date Received ORAi[O'•PPS�h Date Issued: 'd IMPORTANT:Applicant must complete all items on this page LOCATION Print PROPERTY OWNER eA'+� > �- -G Print MAP NO PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no 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 Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: _ ne,"Ploy-L. %� - �. Y�Go� ,S'�t I`Si.c lis e,vo't! ,�-.,�S cr �( -c.✓ �L A4 r f 3 Identificati9on Please Type or Print Clearly) OWNER: Name: C_<_1 Phone: Address: CONTRACTOR Named `Phone: , v Address. Supervisor's Construction-License: S� Exp. Date: /i7- p p Home Improvement License - Exp. Date 1 -7 o O ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. PI Total Project Cost: $ FEE: $ � Check No.:/ f Receipt No.: NOTE: Persons contractin unrokisteAleh contractors do not have access to theIguaranty fund ggnnature of Agent/Owner Signature of contractor 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 PP 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:Building Permit Revised 2008 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 e 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.: I 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 0 Notified for pickup - Date Doc.Building Permit Revised 2008 Location No. s'S/�"" / Date d MOR�� TOWN OF NORTH ANDOVER "o' s r " Certificate of Occupancy $ Building/Frame Permit Fee $ sACHU Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # /0 f 21899 �-�- Building Inspector 17_.�N The Commonwealth of Massachusetts Department o P .f Industrial /J� Accidents. i lH.,l O Ice .fJ of IavestiQations } 600 W ashinoQton Street Boston, MA 02111 dia Workers' Compensation Insurance.Af davit: $uilders/CongactorslEiectricians/Pf>�mbers A ficant Information �____, Please Print Leaibfv Name(Business/Organization/Individual): �L o �� t l Lv Address: S T— City/Slate/Zip: Phone#: EAon an employer?Check the appropriate box: Ian a employer with 4. ❑ I am a QA Type of project(required): contractor and I employees(fill and/or part-time).* have hired the sub-contractors 6• ❑New construct ?.❑ 1 am a so}e proprietor or partner- listed ozi the attached sheet : ?• [] RetnodeIing. ship and have no employees These Sub-contractors have working for me in any capar workers 8. ❑ Demolition P ty ' comp. insurance. [No workers' comp. insurance 5..❑ We are a corporation and its 9. ❑ Building ad.diti. 3.❑ required] officers have exercised.their 10.[] Electrical repai I am a homeowner doing all work right of exemption per MGL myself. [No.workers' c 11.❑ Plumbing repairs or additions ompc152, C. l(4),and we have no 12(❑ Roof insurance required.]t ernplayees. [No.workers' repairs comp, insurance required.] 1.3•❑ Other Any applicant that cheeks box#i.must also fifl out the section below showing thcrir workers'compensation polio} inromlatioa. t HDn1C YWllet6 wllU sublllll.tilis aiLldavll indicatin"titer art doiftc,EN lilo;'L:fiCl Ekon hire Otl�ide COnlns tion muni'f,lUlnjl n nCW al2ldavlT IRd1Wnn xContlactars Thal ehecl;this box must attached an additional sheat showjnr the noune-of tFe suh ec laactors and their workers'com . oIj g such. I art art employer that is providing workers'co ensatiorc i P p miomlation, information. asurance,for ng,empLoyees. Below is the polio,and job site Insurance Company Name: L,n/,' ti^l'vI e Policy#or Self.ins. Lic. Y `y Expiration Date: `7 G Job Site Address:_12_2 _ City/State/Zip: 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 YI,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.S250.00 a day against the violator. Be advised that a co Investigations of.the DIA for insurance cov,,age verification. Py of this statement may be forwarded to the Office of 1 do herebp certify under the paint and penalties of per.jurf, that the information provided above is true and correct Signature: Date: 1Y Phone#: Official use onlp. Do nnf write in this area, to be completed by cit},or town offccia! City or Town: Lr Issu}ae Authority(circle one): Permit/License 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector fi. Other p 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 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 incluciirrg the legal representatives of.a deceased employer,or the receiver or trustee of an individual,partnership, associati on or other legal entity,employing employees. However the owner of a dwelling house having not more than.three ap:artments and who resides therein, or the occupant of the dwelling house of another who empioys 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 o r 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 o,f 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 worl< until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Piease fill out the workers' compensation affidavit comps-etely,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 certificates)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 maybe submitted to the Department of lndustrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. Tae affidavit should be returned to the city or town that the application for the permit or license is being requested.mot the Department of Industrial Accidents. Should you have,any questions reg&-rciirg the lana-or if you are requimd to obtain a wort:,.,-n' compensation policy;please call the Department at the ntuLmber:Iis+.ed belovr. Self-insry-ed companies should eater their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the of da%i t is complete and printed legibly,. The Department has provided a space at the bottom of the affidavit foryou to fill out in the event the Office of Investigations has to contact you regarding the appiioant. Please be sure to fill in the permitliicense number which will be used as a reference number. In addition,an applicant that must submit multiple permit/beense applications in arty given year,need only submit one affidavit indicating curmit 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. Mrh= a home owner or citizen is obtaining a Iicens—_ 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 like to-thank youin 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 Imdustt-ial Accidents Office of Lavestieations 600 'WashEington Street Boston, lA (12111 Tel # 617-727-4900 z t 406 or 1-877-MASSAFB Revised 5-26=05 Fax 4 61 7-72.7-7749 WWW- zass.govldia i i e3w1WREir, %M 4I\I 11 IRr/!"\I ` 1w e-,v PRocLIo�R THIS CERTIFICATE 18188U8D A8 A MATTER OF INFORMATION Wilmington inanranae A 0AC7 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE rive K1dd1@sex AV*hae Vnitt 14 HOLDER. TM18 CERTIFICATE DOEO NOT AM CND,EXTEND OR P. ®. Box 1.010 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Wilmington MA 01807-0580 Phone 1 978-658-3805 Fax1978-657-5724 INSURERS AFFORDING COVERAGE MAIC 9 i INSURED INS�JRFRA: Essex IFl!:�.'REAB: O�,rsz• !: 1� a C+en�i6 Sae 9sal Fso ert Maintenance IINSd-PtRC: Axbella VretoetLan 41310 5 LLase KOMI �INSURP D. Tewixburg MAL 01876 --- IfV°.aJRER E' COVERAGEN THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURRO NAMED ABOVE FOR THE POLICY PBRIOD INDICATED.NOTWITHSTANDING ANY RRQVREMENT,TERM OR CONCITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES tESCRI®ED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLIC156,AGGRBOATE LIMITS SHOWN MAY HAVE BEEN RiDUCAD BYPAIO CLAIMS, LTR NS PE TYOF NSURANCE POLICY NUMBER OATS T1 MMIRIT TEIM LIMITS OVAIRALLIABILITY EACH4CCUWMt4CE $ 1000000 A X Ce*W9 AL&rzrrQAI.LIAPILIT �4�6616 Q7I1P/O0 j 07/1�/Q!� asiMlcaaj�.�::��:�y s CLAIMS MADE a OCZL14 MED EXP(Any one rro-scmj s PERSMAL&AOV INJWe 11000000 I I ( NC04t.AGGRRGATE s2000000 I nEML.Ar..RELATE LIMIT APPLIES PER P owr,5-rONF1GD ACC $1000000 j POLICY I PECT 71 LOC I C IAUTOMOBILEUARILIW Cc4mtrveoJuNIXI!LIMT I$1000000. ANYAUrO 02139500000 09/03/061 06/05/09 (EAIcclalny 1 I IX ALL OW r�ALTOS f9D0!LY INJLFtY S C X SO-GOULCDAUrOs 02139400000 016/06/OBI 06/08/09 We,ImSol') C g HIPEDAuros 02139400000 06105108 06/05/09 BODILYIr6JURY �$ C }[ iJGf40N'fJEDAIJTOS 02139400000 06/05/06 06/05/09 (Peratithnt] PRQrT:F 7 OAMAOC S GARAGE LIARILIPY I ALTO Orly•EA ACGDL'vr s AW AUTO I OTIHrR.R,AN EA Ar:C 4 AUTO ONLY: A.GG S i EXCEOWUNSRSLLA LIABILITY EACH OCCORRENCE S OCCUR F7 CLAIMPKA4DCr i W".GR: ATF DEDUCTI@LE S RI7MMON S S WORKERS COMPENSATION AND I 7L LIMI I E EMPLOYERS'LIASILRY APIrFpPRIFTOPIPARTNEREI<ECUTIYE 1�G0001250-05 06•/24/08 06/24/09 EL.EaC+�ArGsQEtr 4100000 OPPC IMO EXCIUG ? 61..DISSASE.CA 6MALOYEE s 100000 j If yes,flmiibv vndps SPECIAL PROVI&ONdSD9Iow E.L.DISEASE.PC&JCY LINT S 500000 OTiiSR DESCRIPTION OF OPERATIONS I LOCATIONS I VBHICLFS I EXCWIIONs ADDEO BY P400R491I SPECIAI PRO-M'MNS CERTIFICATE HOLDER CANCELLATION . F'11?I8tT01d WOULD ANY OF THE ABOV@ DCSM19ED POLICIES 46 CANOELLM IlEPOAE SNE PYPINATION DATE THEREOF,THe ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS W KITTEN NOTICE TO THS CERTIFICATE HOLDLIR NAMED TO THE LEFT,SUT FAILUM TO DO 40 SMALL TONn of Franklin IMPOSE NO OBLIGATION OR LIAISILITY OF ANY KIND UPON THE INSURER,ITS AOEIYrs OR 355 East Central Street REPRESONTATIVES. 111 11 Franklin NA 02038 ACORD 25(2001/05) 0 KCORD GORPORAT[ 11060 __ I F ,AoRTH ToVM of .. �` 4 L over . ��Z o No. o LAKE =1 dover, Mass., ' COCMICKEWICK ORATED `S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT.........Z)Ww:4� a.4�......................... ............................................................ Foundation has permission to ere t........................ .............. buildiAs on .......1 k .. .......... ...... .... ... .....a..................... Rough to be occupied as....' ..jww.....1 0.4 �...GO! ...1�/!!... ............................................................................ Chimney provided that the p son accepting t ' 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 CONS U`2" STARTS Rough Service BUILD ECTOR 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 IDEAL PROPERTY MAINTENANCE Estimate 96 LAKE STREET ' TEWKSBURY, MA 01876 COPY Date Estimate# 3/16/2009 363 Name/Address 127 HIGH STREET CONDO 127 HIGH STREET NORTH ANDOVER MA 01845 P.O. No. Project Item Tota Description I p 1 REPAIR ROOF FROM ICE DAMNS. SHINGLES WERE PULLED UP FROM 0.00 THE ICE. STRIP OFF EXISTING SHINGLES AND INSTALL NEW SHINGLES IN VALLEY AREA ALONG LEFT SIDE OF THE HOUSE. I REMOVE WALL BOARD TO RE-INSULATE WALL ON THE 1 ST AND 2ND 0.00 FLOOR WHERE WATER DAMAGE OCCURRED. REPAIR WALL AND PAINT WALL. 1 REMOVE,REPLACE AND PAINT WOODWORK AROUND THE WINDOW 0.00 ON THE FIRST AND SECOND FLOOR WHERE WATER DAMAGE OCCURRED. I 1 3RD FLOOR BATHROOM 0.00 1 PICK THE COLOR OF ROOF 0.00 1 TRASH REMOVAL 0.00 1 7,950.00 '1/3 TO START, 1/3 AT HALF POINT AND FINAL WHEN COMPLETED Total $7,950.00 Signature Phone# 978-658-2211 i EState of New Hampshire Childhood Lead Poisoning Prevention Program Memut r of c N E S T A Massachusetts - Departulent of Public Safety BRIAN MOORE q Board of BuildingRelmilation and St tndurtl LEAD ABATEMENT CONTRACTOR 1 Construction Supervisor License License Number: DC-219 3 Expiration Date: 2/25/2009 �. License: CS 54380 �/0 T�,� Restricted to: 00 i Mary Ahn Cooney-Director- i BRIAN J MOORS division of Public Wealth 34 E SHIRLEY LA NOT A LECAL'FORM OF lO SHREWSBURYNMA 01545 3� p Expiration: 7/24/2010 (onunis3i +tcr Tr=: 29274 i Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR CommOrawealth Of Mc?SSaC/3USe1*S Registration 108329 Division Of Occupational Safety Expiration8/17/2010 Laura M.Marlin,Commissioner Type Supplement Card DeleaIder-Contractor BRIAN MOORE IDEAL PROPERTI'MAINT{CORP. BRIAN'MOORS f Eff.Date 01%25/08 �) Exp.Date 07/24/09 �""`°'�s 96 Lake Street why DC001683 TeWksbury,MA 01876 Admini%'gator1 Member of C.O.N.E.S.T. ' __. BO3� IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII�III�III�IIIIIIIIIIII�I BOSS ON REN E' I i I I