The URL can be used to link to this page

Home My WebLink AboutBuilding Permit #Exception - 1665 GREAT POND ROAD 5/1/2018 BUILDING PERMIT NORTy OF� 6�� t 9 TOWN OF NORTH ANDOVER � h�;i,f .`'.• 6 APPLICATION FOR PLAN EXAMINATION * _ 21 " Permit No#: Date Received �iRp�RAre I gSSACHUSS�R Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION �C�� eT l�U✓► / — Print PROPERTY OWNER ie t C l &L/4c&; Q Print t 100 Year Structure yes MAP Z PARCEL: i Z ZONING DISTRICT: i Historic District yes n Machine Shop Village yes na TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building R<ne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ZRepair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition _ ❑ Other jc ..®We ii ❑ Frbkd lain, j ;e® eRUN,, 'urate 4®istrict OWater/Sewe_ _ DESCRIPTIO {OF W%RK TO BEP RFORMED: c ` half S%1''uoyz t tI-17 IAV^�lC' Zl�?(�s� E��'1 .�%6 C� ' 6!It t tL/ 6ed(boq, o,17� -r e.,,)-,YNee S,?�& Oil 5 e "QUAJ0011 . UJ/ _27e, LVi. �- Identification- Please Type or Print Clear OWNER: Name: Phone: Address: Contractor Name: Phone: 977 2-/120-2 . Email: uo Address: d e cel�/y Supervisor's Construction License: S 0S ! Exp.. Date: h:2 Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ I 000 , 0 FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund of Agent%®caner° !�ionature}ofc= �° `� Plans Submitted Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer K 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 \K/ PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on ( Si nature . 4A(jLt 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 DEPARmT - Ternp D mpsfer site `yes' - no Located at 1►24 Main Street ~' z k' t ♦.:'mt. r✓.,.. I 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) I' i i ® Notified for pickup Call Email Date Time Contact Name Doc.Buildinb 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 Copy of Contract aFloor 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 pp Building g Permit Application 4. Certified Surveyed Plot Plan Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract 46 Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) 4� 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 Doe:Building Permit Revised 2014 I� Authorization of Representation 20, 2 1 May 0 5 i I Suzanne Wright,Trustee,Technical Training Foundation Trust give my authorization and consent to have Glenn T.Saba, Century Builders, Inc represent me in the application process for a Building Permit for 1665 Great Pond Road, North Andover, MA. Sincerely Suzan a Vh g i 1 The Commonwealth of Massachusetts Department of Industrial Accidents ...W . 1 Congress Street,Suite 100 Boston,MA 021142017 .�~ www mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/El ectricians/Plumbers. TO BE FILED WITH THE PERIVHTTING AUTHORITY. Please rint Le ibl Applicant Information �,,, P Name(Business/0r'ganization/Individual): Address: City/State/Zip: �``�' c, tVC4 `p Phone#: 7 l � Are you an employer?Check the appropriate box: Type of project(required); 1.F1 I am a employer with � employees(full and/or part-time).* 7. ®New construction 2.F1 I am a sole proprietor or partnership and have no employees working for me in 8. ❑`Remodeling any capacity.[No workers'comp.insurance required.] 9, ❑Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Building addition 4.F1 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 11.0 Electrical repairs or additions proprietors with no employees. 12,-0 Plumbing repairs or additions 5.F]I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E:]Roof repairs These sub-contractors have employees and have workers'comp.insurance 14.❑Other 6.Q We are a corporation and its officers have exercised their right of'exemption per MGL c. 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 mast also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that checkthis 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,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: toy. 2WW2 4`t!)0 0 1/6 d 6 ® Expiration Date: 6 ® J Job Site Address: e, Gf�r A !r1 e eel City/State/Zip: olicy declaration page(showing the policy number and expiration date). Attach a copy of the workers' compensation p Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify der the pains and penalties of perjury that the information provided above is true and correct. • � �� - ..' Signature: ate: 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 Clerk 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 an Industrial Accidents. Should you have questions Y y q ons 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-NUSSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia 4 ACD-RD. CERTIFICATE OF LIABILITY INSURANCE 05%20//20 S A PRODUCER (978)373-S623 FAX (978)S21-2751 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ANTHONY & MALCOLM INSURANCE AGCY., INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 3 50. CENTRAL ST. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR BRADFORD, MA 01835 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC# INSURED Century Builders, Inc. INSURERA Nautilus Insurance Company PO BOX 907 INSURERS: Acadia Insurance Methuen, MA 01844 INSURERC: Western Surety Company INSURERD: Hanover Insurance INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NO ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. tNSRINSRr ADVILTYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY NNSS3816 04/01/2015 04/01/2016 EACH OCCURRENCE $ 1000 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ SO,000 CLAWS MADE Q OCCUR MED EXP(Any one person) $ 510001 A PERSONAL&ADV INJURY $ 11000,000 GENERAL AGGREGATE $ 2,000,000 GEML AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ include POLICY F1 PRO- JECT 7 LOC AUTOMOBILE LIABILITY AWN3299646 07/25/2014 07/25/201S COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 1,000,00 ALL OWNED AUTOS BODILY INJURY $ D X SCHEDULED AUTOS (per Pe—) X HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) eARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG S EXCESSAIMBRELLA I'ABILITY EACH OCCURRENCE S OCCUR F-1 CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WC202000016806 08/16/2014 08/16/2015 X I WC STATU- oTH- EMPLOYERS'LIABILITY �ICLW lL B ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $ ZOO 000 OFFICERIMEe SERand EXCLUDED? E.L.DISEASE-EA EMPLOYE $ I00,00 H yyas,describe under SPECIAL PROVISIONS beim E.L.DISEASE-POLICY LIMIT S 500 00 treet opening Bond - 22168722 03/30/2015 03/30/2016 $S,000 C Town of Methuen DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS eneral Contracting i ERTIFICATE HOLDER NCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL Town of North Andover 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Building Department BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 1600 Osgood St. OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATrM. No. Andover, MA 01845 AUTHORMED REPRESENTATIVE Frederick Malcolm 7r. 7A G��``�" e ��'�`�'(�` ACORD 25(2001108) FAX: (978)688-9542 ©ACORD CORPORATION 1988 F v IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED,subject to 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 lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s),authorized representative or producer,and the certificate holder,nor does it affirmatively or negatively amend,extend or alter the coverage afforded by the policies listed thereon. I ACORD 26(2001108)