HomeMy WebLinkAboutBuilding Permit #259-13 - 164 HILLSIDE ROAD 9/18/2012 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
7�
Permit NO: _ Date Received
Date Issued: I V
IMPORTANT: Applicant must complete all items on this page
LOCATION L47 f,IIL4 /7� -
—' Print
PROPERTY OWNER � -
( Print 100 Year Old Structure yes no
MAP NO: _PARCEL: VVZ(�J ILONING DISTRICT: Historic District y s
Machine Shop Village y s ?0
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑Addition D Two or more family ❑ Industrial
D Alteration No. of units: ❑ Commercial
repair, replacement ❑Assessory Bldg ❑ Others:
D Demolition ❑ Other
❑ Septic ❑Well ❑ Floodplain ❑Wetlands D Watershed District
❑Water/Sewer
//��__ DESCRIPTION OF WORK TO BE PER ORMED:
62 i0Y&_ 2bv)5 XM4G 42 200 S e f 7 o o Fi�lr—
Identification Please Type or Print Clearly)
OWNER: Name: ,",9(I I W E7L_L(e_!r Phone: �7g gZlo�
Address: I l S
CONTRACTOR Name:.s7V0V;r=x/ (. Uriy Phone: 47 AV
Address: 3(0
rH s2tr >2 PG-4PO-4 � U0,30:26
Supervisor's Construction Licenser /40/✓04i Exp. Date:
Home Improvement License: A Z /� � Exp. Date:l ly^�
ARCHITECT/ENGINEER Phone:
Y
Address: Reg. No.
FEE SCHEDULE:BULDING P MIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
.�G a v oe
Total Project Cost: $ FEE: $-,
Check No.: zcReceipt No.: L?!�j 7
NOTE: Persons contracting with unregistered contractors do not have access to t e guaranty fund
Signature of Agent/Owner � `Fgnature of contractor Jk_
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
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
L3 Building Permit Application
o Workers Comp Affidavit
o Photo Copy Of H.I.C. And/Or C.S.L. Licenses
o Copy of Contract
u Floor Plan Or Proposed Interior Work
u Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
o Building Permit Application
o Certified Surveyed Plot Plan
o Workers Comp Affidavit
o Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Mass check Energy Compliance Report (If Applicable)
o 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)
o Building Permit Application
o Certified Proposed Plot Plan
a Photo of H.I.C. And C.S.L. Licenses
L3 Workers Comp Affidavit
o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (if Applicable)
L3 Copy of Contract
u 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: Doc.Building Permit Revised 2012
i
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
U Notified for pickup - Date
Doc.Building Permit Revised 2010
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
&nservation Decision: Comments
Water & Sewer Connection/Signature& Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Os ood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at'124 MainStreet
Fire Departmentssignature/date '
COMMENTS
Location ((q4 — ti' S' �
No. 72 Date �^Z--
• - TOWN OF NORTH ANDOVER
•
,:77 Certificate of Occupancy $
Building/Frame Permit Fee
Foundation Permit Fee $
° Other Permit Fee $
47, c
TOTAL $
Check#
25774 13Lridi6Inspector
OORTH
Town of E : �� , ndover
O �., y �►
No.
T h ver, Ma
ss>
o '
Co'"Khl.WK„ �'�•
ADRgTED PPp,`'��
S U
BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
THIS CERTIFIES THAT 1� BUILDING INSPECTOR
. ... .. . ......... ....
. Alem-4.111,
Foundation
has permission to erect ......................... buildings on fi1�. . �.r....�1 ...........
Rough
RP.---R0J-ito be occupied as .............. ....................................................................................... Chimney
provided that the person accepting this permit shall in everyrespect 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 CONSTRUCTIr4UILD1=NG
Rough
Service
............... ................ Final
I PECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building 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.
SEE REVERSE SIDE
s
Oct 1 2012 12:34 P. 01
Rd DATE(Mha/)Dn)iYY)
CERTIFICATE O '
F LIABILITY INSURANCE 1A,1/2D12:
HIS'CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO-RIGHTS UPON THE CERTIFICATE: HOLDER. THIS
'CERTIf idATE;11JOE3 NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES.
.BELOW. THIS CERTIFICATE 0'F INSURANCE"DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRF.SNTATNE O12 PI#ODUCER,AND,THE CERTIFICATE HOLDER.
IMPORTANT: If:ttie certificate holder Is an ADDITIONAL INSURED, the pollcy(les) must be endorsed. If SUBROGATION IS WAIVED,subject toi
the.terms'and conditions of the policy,certain policies may require an endorsement. A statement on this Certificate does not Confer rights to the
certificate holder in Miu'of;such endorsement(s).
PRODUCER CONTACT
NAME: Cynthia St.. Amand
TNSLVJWCE• SOLUTIONS CORPORATION PHONE 050311382-4600 FAX (603)382-2034
60 West y�1Te Rd' AOe 1t 1A10 Noll oatamand@ iscinaureas.aom
INSURER(S) AFFORDING COVERAOE .NAIC A
'Plaistow NH 03865 INS RERAk�tG Inaurarice Company 15997
Iit6uRED'
lNstiree e-
Staphen C. Morin Carpentry INSu ER c-
36 South Shore Dr INsuRERD:
INSURER.E:
Pelham NH 03076 INSURE F:
.,COVERAGES CERTIFICATE NUMBER:CL1210107180' REVISION NUMBER:
THIS.IS'TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOw HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD,
INDICATED: NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
'CERTIFICATE MAY HE'ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
' ADDL SORR .
LTR TY06OF INSURANCE POLICY NUMBER POLICY EFF POLICY EXPMM/DD LIMITS
GeneRALUABiL1TY' EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY DAMAGE
3 re occurrence $ 250,000'
A CLAIM'S-'MADE, OCCUR 8CO117027 9/17/2012 9/17/2013 .MED EXP(Any one ermn) $ 5,000
PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE g 2 j 000 1 000
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS,COMPlOP AGO 9 2,000,000
X POLICY PRO- ' LOC $
AUTOMOBILE LIABILITY'• COMBINED SI
,ANY AUTO BODILY INJURY(Por person) $
ALL OWNED SCHEDULED
'AUTOS AUTOS BODILY INJURY(Per accident) $
NON-OWNED PROPERTY D E
HIRED AUTOS AUTOS ar IdeM
$
:.UMBRELLA LIAR OCCUR EACH OCCURRENCE $
EXCESS LIAB' CLAIMS-MADE
AGGREGATE $
PED RETENTION$ $
WORKERS COMPENSATION YVCSTATU- OTH-
AND',EMPLO`(ERS�'LUIBILITV v/N
ANY-PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? El N/A E.L.EACH ACCIDENT 8
(Mandatory in NH)
E.L.DISEASE-EA EMPLOYE $
' M &de�acri[x'under � '
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS•/VEHICLES (Attach ACORD 107,Additional Remarks Schedule,K more space in requlmd)• •
CERTIFICATE HOLDER CANCELLATION
(978)688-942 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE.'
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
North Andover'Building. Department ACCORDANCE WITH THE POLICY PROVISIONS:
1600 Osgood •3treet
N Andover, .MA 01845 AUTHORIZED REPRESENTATIVE
Cynthia St;. Amand/CLB •' /ti � nxr•�a�^
ACORD:'25(2010105). 9 1988=2010 ACORD CORPORATION. All rights reserved.
IN8625:(2'010os).01, The ACORD narne and 1060 are registered marks dfACORD
;�: /6��,
Office o onsumer Affairs B siuess Regulation
HOME IMPROVEMENT CONTRACTOR
Registration: ry,-162101 Type:
Expiration: 1/14/2014 DBA
S fEF' `EN C. MORIN_;CARPENTRY
1f F
STEPHEN MORIN-&--
36 SOUTH SHORE LIR:=='
PELHAM,NH 03076 Undersecretary
i
1
i
C
*� Nlassachusetts- Department of Public Safety
Board of Building Rewrlations and StandartlS
Construction Supervisor License
License: CS 101566
Restricted to: 00
h
STEPHEN MORIN
36 SOUTH SHORE DRIVE
PELHAM, NH 03076
Expiration: 1/25/2012
('ununissiO°`r Tr#: 101566
7.
` + G
Massachusetts-Department of Public Safety
'Board of Building Regulations and Standards
Construction Supervisor
License: CS-101566
STEPHEN C MORIN_.._.
gX
36 SOUTH SHORE+DRIVEj
PELHAM N# 03676 `i ti
�0
11 14�CNN Expiration
Commissioner 01/25/2014
j'
r
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 ,Washington Street
Boston,MA 02111
U. www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leizib�l TT
Name (Business/Organization/Individual):
s f 1649,e,a/
Address:, 3! Sak%u QF
City/State/Zip: pt-F �(. Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4• 111 am a general contractor and I 6. ❑New construction
e to ees full and/or art-time .* have hired the sub-contractors
p y ( p ) listed on the attached sheet.# ? E]Remodeling
2. I am a sole proprietor or partner-
ship and have no employees These sub-contractors have 8. E]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.❑Electrical repairs or additions
required.] officers have exercised their
right of per MGL 11.❑Plumbing repairs or additions
exemption 3.0 I am a homeowner doing all work g p p
myself. [No workers' comp. c. 152, §1(4),and we have no 12,E�'IZoof repairs
insurance required.]i employees. [No workers' 13.0 Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their 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.
tContractors 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 thepolicy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: 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$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.
T do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Si nature: Date:
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 CIerk 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 burn 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
-vised 5-26-05 Fax#617-727-7749