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Home My WebLink AboutBuilding Permit #808-16 - 160 WAVERLY ROAD 11/14/2016 AN LFBUILDING PERMIT o� NOD bq't'o 7 ��VE I TOWN OF NORTH ANDOVER o2 APPLICATION FOR PLAN EXAMINATION '" i Permit No#: Date Received DR �gSSACHUS�� Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION JJ Print PROPERTY OWNER___-- L� Print. 100'Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE _ Residential Non- Residential ❑ New Building ❑ One family ❑Additionwo or more family El Industrial ' ❑Alteration No. of units: L3 ❑ Commercial XRepair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other .:Septra ❑Well'' ❑ FlootlpJain Wetlands: �� ❑, 1Natershed' t[ictu L71'-M7ef DESCRIPTION OF WORK TO BE PERFORMED: 2Y Id ntiificat'on- Please Type or Print Clearly p ,p OWNER: Name: � e� %�er'�'a-'�S`� Phone: �J—Q �U �� Address: OA Ply p` ro Contractor ame. Phone: / 0 j Email Address: Supervisor's,Construction License: �7 ?4�Sl Exp.- Date:. . J12-L506 Home,Improvement License: 7`2. J-r-)2- Exp. Date: 3 6 l6 1 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. I' Total Project Cost: $ d� FEE: $ l� Check No.: Receipt No.: NOTE: Persons contracting wit I�e�is r ntractors do not have access to the guaranty fund // c JPlans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ f TYPE OF SEWERAGE DISPOSAL E Public Sewer ❑ Taming/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ I THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ 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 DEP°A �M� erne ll er on site Located at 11►2,4 Main S reet 't k " Fire Departmen sig atu e%te, ..r .F , ,. •;,t ..' tai ' -s mY. � t $ ' °i. ''�=' �+Ly'�' -•L�'�"Cajy.{L�]�",y tyf+'��ra'�'�":t z i , '=, s �-' C°M E. 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) CO Q n OWAl rd P-�j ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 - 1 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 4 Building Permit Application � Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses 4� Copy of Contract Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks I Building Permit-,Application Certified Surveyed Plot Plan Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract 4. Floor/Cross Section/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 OTE: 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 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: 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 2014 Location v �' No. Date •'- TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee TOTAL $ W> Check# / 2,991 .4 . building Inspector a Dempsey Roofing LLC 978-670-8904 Fax 978-362-3102 Radek Cell 978-808-667.8 P.O.Box 383 Billerica,MA 01821 �- �Lw./�if 6S-oos,wnm��4 Gam! Dempseyroofingllc@gmail.com scare uc.#99661 www.dempsey-roofing.com GAF I.O.#CE24636 r -i NORTfj _ . w: .. . . _ 1c . . ve. No. ver Mass ,o0."h COCHICNEWICH x.95 R�rEo rPP,�gS U BOARD OF HEALTH PERMIT Food/Kitchen L D Septic System THIS CERTIFIES THAT lG BUILDING INSPECTOR . .. . -.L............. ...... . .. .. ........................... . { has permission to erect „ ,p„ ,, ,,�ts � � Foundation .......................... buildings on ...... ....... ............:................... Rough to be occupied as ......... ..��.............?.`..�.��./.�eve �. .......":�".—.................................................... Chimney provided that the person accepting this permit shall ispect conform to the terms of the application Final on file in 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 CONSTRUCTI0 T TS Rough h Service .. ... .................................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Reguired to Occupy Buildine- 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. Smoke Det. The Commonwealth oflVmassachusetts Department of industrial.Aceldents M 1 Congress Street,Suite 100 Boston,MA.02114-2017 www mass.gov/dia r l� •: SV.V• Workers'Compensation insurance Affidavit:]Builders/Contractors/Electxicians/Plumbexs. TO BE FILED WITH T]HE)PERMITTING AAUTHORITY. A, licant Information Please Paint Le ibl NaMe(Business/Organization/Individnal): City/State/Zi-P: c /�( C� Phone Are you an employer?Ci.eckthe appropriate box; Type of project(required): 1.�I am a employer with employees(full and/or part-time).* 7. n New construction 2, I am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling any capacity.[Noworkers'comp.insurance required.] 9, ❑Demolition 3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 0 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. - ---12:E]Plumbing-repairs-ox additions•,,_. S.F1 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ]3.Q Roof repairs These sub-contractork bade employees and have workers'comp.insurance.$ 14 ❑Other 6.Q We are a corporation and its offf ers have exercised their right of exemption per MGL c. loyees.[No workers'comp.insurance required.] 152,§1(4),and we have nq.emp *Any applicant that checks box 41 must also fill out the section below showing their workers'compensationpolicy information. Homeowners who subriiit this affidavit indicating they aro 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 state whether or not those entities have employees. If the sub-contractors have employees,tliey must provide their workers'comp.policy number. f am an employer tliat is pi'dviding workers'compensation insurance for my employees'Below is the policy and jolt site information. �G/-MBU 'kd�44 lost4�,,_-e 6`' Insurance Company Name: � 7� - 2& exiration Da te: Policy#or Self-ins,Lic. � � fob Site Address: �C@ 1i P� City/State/Zip: „d•J Attach a copy of the workers' c. pensatio olzcy declaration page(showing the policy number and expiration date). 152,§25A is a criminal violation punishable by a fine up to$1,500.00 Failure to secure coverage as required under MGL e. 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA.for insurance coverage verification. T do hereby cern def ,ie dpenalties ofperjury tliat the information provided above is true and correct. Si afore. �p Date: Phone#: 1 (° N 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 Lfealth 2.Building Department 3.City/Torun Clerk 4.Electrical Inspector 5.Plumbing inspector 6.Other Contact Person: Phone#. Information and Instructions ' Massachusetts General Laws chapter 152 requires all employers loyers to provide workers'compensation for their em to ee P p p , g y s. Pursuant to this statute,an employee is defined as"...every person_ in the service of another under any contract bfliire, 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 anotherwho 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 issixance or renewal of a license or permit to operaie 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 ofpublic 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-(L-L-C)-or-L-imdted Liability-FaTb rshi�(T LPrith no employees other than tha members or partners,are not required to carry workers'compensation insurance. If an LLC orLLP 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 Afidavit. 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 yo'u'are required to obtain a workers' compensation policy,please call the Department•at the number listed below. Self iii'sured 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"fob 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. Anew 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Xn.dustrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 TeX.##617•-727-4.900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia 6/9/2015 2 : 22 : 16 PM 8618• 0 02/03 r- c CERTIFICATE OF LIABILITY INSURANCE F°" THIS CERTIFICATE 18 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND. EIMWD, OR ALTER THE COVERAGE:AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(Sk AU HOR¢ED REPRESENTATIVE OR PRODUCER.AND THE CERTIFICATE HOLDER IMPORTANT.ff the cerlRica:e holder Is an ADDITIONAL INSURED,itLe poficy(ies)must be endorsed R SUBROGATION 6S WAIVED.subject to Unto. and emmitiats ofthe policy Policies may require an en�rsement A statement on Uds ceRificate does rM confer rights to the corilicate holder In Bou of such ondorsonnnt(s). PRDDUCER 01 227-0®11 PreSWtt R Son km Agcy Inc (781)322-2350 qo (781)322-3093 963 Eastern Avenue mss Malde%MA 02148 ICA;UIRm,: A.M.Mutual hnslNaloe Company 33758 ensuRM D-Vvey Hoofing LIC aeSURER : PO Soot 383 eeAl ®_ Bfllesim, DA 01821 E: COVERAGES CERTIFICATE NUMBER_ REVISION NUMBER_ THIS M TO CERTIFY THAT THE POUNCES OF 815URANCE LCSTED BELOW HAVE BEEN ISSUED TO THE D&SURED NAINED ASOM FOR THE PCLWY PERMD INDICATED. NOTWHIISTANONG ANY REOUIREIIAOKT, TOM OR CONDBT= OF ANY COTUTRACT OR 01HER DOCUMENT VAf1H REST TO WHICH THIS CERTF"TE MAY BE ISSUED OR MAY PBRTAR, THE DOURAWE AFFORDED 8Y THE IMMES DESCRIBED HERON IS SUWECY TO ALL 7HE 7t7tbtSi EXCLUSIONSAHD CONDtII US OF SUCH POLICIES-LW11rS SHOMIN IBAY HAVE SEEM REDUCED BY PAIDCLAINS. GENERAL LUAtKM EACH ®NICE $ CONrJERCLAL GENERAL U BUTY DPAAWvE TO RoPiTEDPMEMBSESIEsommemdq ( CdGrsdAlAw ®DUAP WMEXPIAWampammS PERSONAL6AWnf4A!11.44r S GENf2AL AGGREGATE S AG ATE Mw APPLES K ft P lICIS-Q7aSLAIPlQ1PAA8�s S CY OC AUTO N SPLELMS LrnY CII RI®SRMEUNff s ANY AUTO BODILY IrttllUBiY B�moo) s ALL B WNEI) SCHEDULED AUFOS AB VOS $ HLREDAuras "ONADVAmffms P HY OD.OAL!lGB= $ s -A 1l�lLAB Dwm EAQf S Iu" CLAM AGGBdB 6A7E S 0® r3E-T-01 M s s Alrr YIN A OFrI NMIA AWC400-7027487-2W5A 7nM5 7111 M8 E.L_E&CHAaal�Eff $ E 1.Qpp,OQppQ dun° Ek.CISEASE-EA EMPLOYEE s 1.000,000 BD TImIUSBt ro FE DLSEAsE-F0 CQ Y U"flf s 1.000,0Q0 00 06 °F a'fiRA�l L1bCA41a6lY®[CLES G�ACOIiD t®4,A�i�l Ra�a1�Sdr�e.dFno�e sp�e Bs I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE OERCRMED POMES BE CANALED MORE THE EIUtA711001 DATE 7NE1tBOF ND7RE ,1InLL BE DELIYEIN3) DI ACOONDIINCE MItH TOME P01JCY PROYIMpIS AfiUn MN0ZED 1fAT1NE 01988-2M 0 ACORD CORPORATION.M dgtts reelved. 1 ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD III I j 4886 r Massachusetts -Department of Public Safety V}!' Board of Building Regulations and Standards Construction Supervisor Specialty License: CSSL-099681 ERIC DF WSEY 7 RICI•IARDSON:S -U3'-N s BILLERICA MA;: is, Expiration Commissioner 05/23/2016 I d7%, r(l6JJl/)[011ffk;'Cfr/IfG pffC.U'Gr�ClJJ[/C�IIdCIIJ Office of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR Vxegistration:: 178026 Type: ptmtion: 316/2016 . LLC e DEMPSEY ROOFING"LLC. 4 ERIC DEMPSEY 7 RICHARD ST BILLERICA,MA 01821 (Indersecretary i {