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HomeMy WebLinkAboutBuilding Permit #77 - 1401 GREAT POND ROAD 7/27/2009 e_ TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received : -7 i2 7-of Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION f f C#/! --- �* / Print PROPERTY OWNER !/tC C 1041 — Print MAP NO: C? G `PARCEL: PO ZONING DISTRICT: Historic District yesAn Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteratio2of No. of units: Commercial i Repair, replacement✓ Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTIONOF WQRK TO BE PERFORMED:. 54'r i &rgas fie' #1 Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: CONTRACTOR Name: JCMe5 Phone; Address: r �trlc� 't" C�carE�'�/l /y Supervisor's Construction License: �� Exp. Date: / Home Improvement License: Exp. Date: `a`� 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: $ i� FEE: $ Check No.:1 0 \0 Receipt No.: �� NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund nature of Agent/Owner Signature of contrac r Plans Submitted Plans Waived Certified Plot Plan ped Plans J ^ 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 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 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 'J Zoning Bc,^ard 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 Location //0/0/ C7 r 01/1 mo No. Date i'�' MORTM TOWN OF NORTH ANDOVER oAL F 9 Certificate of Occupancy $ '�i�s'•^°''<� Building/Frame/Frame Permit Fee $ s+cMust 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # /0 [. L ,D :� _ Building Inspector NORTH ® of : 19Andover No. i r dover, Mass., I� LA COCMICMEWICK V %ADRATED C5 `r E BOARD OF HEALTH PERMIT - T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT...... �( �G......... !� , ..... ...............MAir .................................................................. . ,- Foundation has perfnission to erect....................................... uildings on ...... .. .. ............ .. .. ..... u.............. Rough to be occupied as...S ......... ............Ir....... .......... .. ......� ..............��►.en......AToI...1.. �................. Chimney provided that the person acc ting this permit shall in eve respect conform to the terms of the appl ation on file in Final this office, and to the provillons 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 (41 PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRU ST TS ELECTRICAL INSPECTOR 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. The Comma},eakk of M=aciiuseft �' � DePartmerzt of 1'nrfustrial Accidents I Wce of InvestiQado ns 11 600 600 ffrashin n Street V Boston, MA 02111 Workers' Campetasafion Iasitr-aace Wssgouldia AHidavi But�ders/Contractors/Eiectc'iciiaas/Piulmbsrs Applicant In&racation Please Print LeQibi Name (Business/Orga _ /o�',z�a6on/Endividrual): Addms CityVista€zip: Phone A�r�e,You an employers Cheek.the apprup iate•bots l:�i'I am a employer with 4 T of : etiiPloyees(full and/or * ' ❑ I am a ganwal contractor and I Type Project(reqs . part time). have himd the sub-eotttsacwn 6. ❑'New construction . 2.Q I MM"Ole proprietor or partner. listed on the attached sheet 3 7. ship and have no em io ees' ❑Remodeling P .Y These scib-contractors have working liar me in any capacity. workers' comp.insurance. 8' Q Demolition (7�io worlcEzs'comp,insurance 5. D We are a corporation and its 9. Building addition required.] officers have exercised their 10.11 Electrical repairs 3.❑ 1 am a homeowner doing all work right of exemption per MGL 1!. °r additions Myself[No-workers' Q Plumbing repair'madditions insurance•required. t�� •c' 1$Z �1(4),'and•we have no �;�• ] •employees:[No workers' 12.UJ ',ao'f repairs comP. irmusance required] I3.�]-Other `krry epplicam that checks bas:#I moat atao IM out the wnsection blow attow.irtg theirworkars'o r homeoers who submit this affidavit indicating they ars doing an where. °�"ain Policy imbrmation, _ ;Coanaatonr that check tW box mustat,sn ndtF.�tioas]shin end than hila otn*ds contractors inlet submit n.aeiv afrtdnvit indi showing tate nems of the sub- ° S such' Vii. E [O er t(sat Lots and their'worketr' mP y is pts ,aaurgVorp".7' ` Pc.. ,irfmmo6on. infararasrEnrL �r�saraace for fiv MFIOTeM Bow is edea Pommy�i jon site Insurance Company Name Policy#or Self-ins Lie.# dt 6 g �!✓j V Job Site Address: ®� r F- pirafion Date Attach a copy of the workers' coot Ctty/3tate/gm; o compensation Policy declaration page(sbowiag the policy number and e Failure to secure coverage as required.tinder Section 25A of t�KJL c. 152 can lead to the imposition of criatinaf iratioa date}. . fine up to$1,500.00 and/or one-year imprisonm p-nabin of a of up to$250.00 a as well as civil penalties in the form of a STOP WOitK ORD anti a fine �3 against the violator. Be advised that a copy of this statement may be forwarded to the O{ci�of Investigations of the DIA-for insurance coverage verification. I do frerehy certify under th pertalti ofpejz, lsfiat the utfnrmation Provided above is true and conrd 5i !tn•e: Date: p� ..�• Phone#: iciQl Me nJ*. DD not write inthis area, be completedbj,a Jr or town.of ICW City or Town; # Fssuittg Authos-iiy(circle one): Permit/Licanse 1. Board of Health 2- Building Department 3.City/Tewo Cierk 4. 6.Other iriectrica(lnspector 5. Plumbing Inspector Contact Person: Phone#: Information a nd Imo" tructions Massachusetts General Laws chapter 152 requires all emp Ioyers 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 Aire, ; express or implied,oral or writtcn." ` 1' An employer is defined as"an individual,partnership,assvdiation, corporation or other legal entity,or arty two or more of the,fomping engaged in a joint enterprise,and includi"g the legal representatives of a deceased employer,or the receiver or trustee-of an individual,partnership,associatiori or other legal-cmity,employing employees However the owner.of a dwelling hour having not more than three apa-rtments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintz moc,construction or repair work on such dweltinghouse 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 6eensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct butter is the commonwealth for any appTcaut who has oiot produced acceptable evideo<ceAre compliance with the,.insarance'coverasge required" Additionally, WOL chapter I52,§25C(7)states"Neither the commonwealth nor arty of its political subdivisions shall enter into any contract for the performance of publir.work- until-accepfablo evidence of compliance with the insurance rscpuremCft.of this chapter have been presotmd.to the cQr&ac&g 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(sl adddress(es):2ond phone nrnnber(s)along with their ce rrificate(s)of insurance. Limited'Liabiiity Companies(LLC)or Limited Liability.Partnerships(LLP)with no eanpioyees other than the members or partners,arc not rcquired,to ca3rry workers'oC,%,znpensafion insruance. Ifan LLC orUP does have empioyees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidzrris for confirmation of insurance coverage. Also Ere sure to sign and date the affidavit The affidavit should be returned to the city or town first the application for the ped or license is being requested,notibe Department of industrial Accidents Should you have any questions rcPr%i ng the law or if you am requimd to obtain a workers' compensation policy,please-caR the Department at the-nurartber listed below, Self-insured co-mpanies should errfzr their self insurance'liccrrse nuatber on thc•approprurte tin:. City or Town Otfa iris Please be sure that the affidavit is complefo and printed Iegibly. The:Department has provided a space at the botrom of the affidavit for you to fill out in then event the Office of Investigations has to contact you regarding the applicant Please be sure,to fill in the permit/license numbe:rwhich will be used as a reference number. In addition,an appiicent that mustsvbmit multiple peumit/iicxinsc applications in any given yet,need only submit one affidavit indicting current policy:information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or txYvm)."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 the a valid afridmit is on file for future pormi#s or liccrises. A new affidavit must be Med out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture C.c. a dog license or permit to bum leaves etc.)said person is NOT.required to complete this afFidaviL The Office;of Investigations would like to drank you in advance for your cooperalion 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 Fmidustrial Accid=ft Mee of Envesk-gt ions 600 Washington Street Boston, MA 02111 TeL 9 617-727-4900 i= 4.06 or 1-977-MASSA:FE Fax#61 7-727-7741 IL vise 5-26-115 www.mass.govidia MASSACHUSETTS TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 05/11/2009 forms a part of Policy No. WC 203-29-21 Issued to JAMES DEBREC IN I By GRANITE STATE INSURANCE COMPANY This endorsement addresses requirements of the Terrorism Risk Insurance Act of 2002 as amended and extended by the Terrorism Risk Insurance Program Reauthorization Act of 2007. Definitions The definitions provided in this endorsement are based on and have the same meaning as the definitions in the Act. If words or phrases not defined in this endorsement are defined in the Act, the definitions in the Act will apply. "Act" means the Terrorism Risk Insurance Act of 2002, which took effect on November 26, 2002, and any amendments resulting from the Terrorism Risk Insurance Program Reauthorization Act of 2007. "Act of terrorism" means any act that is certified by the Secretary of the Treasury, in concurrence with the Secretary of State, and the Attorney General of the United States as meeting all of the following requirements: a. The act is an act of terrorism. b. The act is violent or dangerous to human life, property or infrastructure. c. The act resulted in damage within the United States, or outside of the United States in the case of the premises of United States missions or certain air carriers or vessels. d. The act has been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. "Insured loss" means, any loss resulting from an act of terrorism (including an act of war, in the case of workers compensation) that is covered by primary or excess property and casualty insurance issued by an insurer if the loss occurs in the United States or at the premises of United States missions or to certain air carriers or vessels. "Insurer deductible" means, for the period beginning on January 1, 2008, and ending on December 31, 2014, an amount equal to 20% of our direct earned premiums, over the calendar year immediately preceding the applicable Program Year. "Program Year" refers to each calendar year between January 1, 2008 and December 31, 2014, as applicable. Limitation of Liability The Act limits our liability to you under this policy. If aggregate Insured Losses exceed $100,000,000,000 in Program Year and if we have met our Insurer Deductible, we are not liable for the payment of any portion of thie amount of Insured Losses that exceeds $100,000,000,000; and for aggregate Insured Losses up to $100,000,000,000, we will pay only a pro rata share of such Insured Losses as determined by the Secretary of the Treasury. WC 20 01 01 (Ed. 01/08) k © Copyright 2008 National Council on Compensation Insurance, Inc.All Rights Reserved. Page 1 of 2 a� n„ d MIAdau rd� uildiI.t'o►ls�TRAC-fpR Board of S MEt4 CpP! HpME iMPRpVE 223g5 Tr# 277 4007 Registrat+o�� 1 SI?.r,612010 ~? ExP+fit+orAs a TYPe pgA THERS,04,i J&pJP, WEA BRECENI rf. at MES DE., tiAdOW ti 2 ONDRaY NM 03053 L r, 1(a<,asi�ttsctt� l)c�l+ irtfuc+tt +�� ac > �t s� Beau-d of Builtlin�,, ReFgulatiuna and Standw t3`�• Construction Supervisor Specialty License License: CS SL 99685 ..Restricted to..'RF JAMES DEBRECENI .2 TANAGER•WAY LONDONDERRY, NH 03053 Expiration: 12/6/2011 Tr#: 99605 AL FOURNIER JAMES DE13RECENI Family Roofers & Painters 168 MAPLE STREET METHUEN, MA 01844 978-683-5127 EXTERIOR PAINTING – CARPENTRY– ROOFING FREE ESTIMATES N � Date: NEW ROOF STRIP_ C- LAYOVER Install 8" 5" Drip Edge Entire Perimeter Install 3ft6»ft/—of Ice & Watershield at Eaves Install Ice & Watershield at Valleys & Chimney Install 151b Felt Paper rest of Roof Install Vent Pipe Flanges Install 30yr--j L*' 40yr 50yr Architectural Shingles Install Ridge Vents RUBBER ROOF Install '/Z" Insulation Board Install Drip Edge Entire Perimeter Install Fully Adhered .060 Rubber Install Cover Tape Install Neoprene Around All Protrusions TOTAL s� ON ACCEPTANCE WHEN STARTED HALF COMPLETE O All Workmanship guaranteed 10 years BALANCE WHEN COMPLETEA,5. All checks paid to James Debreceni or Albert Fournier