HomeMy WebLinkAboutBuilding Permit #57 - 170 GREAT POND ROAD 7/13/2010 BUILDING PERMIT c*NO°T bq�•
TOWN OF NORTH ANDOVER F
APPLICATION FOR PLAN EXAMINATION
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Permit NO: Date ReceivedArea
gsSACH�1`���
Date Issued: " / v
IMPORTANT:Applicant must complete all items on this page
LOCATION + r e
Print
PROPERTY OWNER I-)a 'Iri 4 L,4 Ife
Print
MAP 210L- e, PARCEL ZONING DISTRICT- Historic District yesn
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:
1P c e
do
Idntificati.'on Please Te or Print Clearly)
OWNER: Name: r A Phone:
Address: L`�Q �-c-e CY Clnmd
7
CONTRACTOR dame: P4> .tet Phone: _3�-
f
Address: 1 '7 LJ rC ( ,t
Supervisor's Construction License: S'q Exp. Date:
Home Improvement License: ?fes Exp, Date: 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.
Total Project Cost: $ '� ? �- FEE: $ q3
Check No.: ! ) ( Receipt No.: 0 3ol l
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
nature of A ent/Owner Si nature of contractorp
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
i
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 DEPARTMENT Temp Dumpster on situ yes no
Located at 124 Main Street
Fire Department signature/date
COMMENTS
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 21 A—F and G min.$100-$1000 fine
NOTES and DATA— For department use
I
❑ Notified for pickup - Date
Doc.Building Permit Revised 2010
I
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 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
Location /90
No. Date v
HORTN TOWN OF NORTH ANDOVER -
3? • 0
,41
- 9
c ; ; Certificate of Occupancy $
�'�S'••'° Et'A
Building/Frame Permit Fee $
s�cNus
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
27
230 :� u
Building Inspector
A
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darns t•��e''"��C+1i�l~+t�'i �"lr�stvfa#��v�4�.�14l
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. !fIflIVI INtFI'1 MHNT. t F OR '. ►R'ti #14.t'firira Asp'�1 fie, Ifib-orad rdturn to:
r Boar!of Building RegulationsPa ca4ard9
ate isiratiph 1 9325 I One Ashburton place Rin 1.30,
it3(ration l0l14/�0� .;aT 276257 Boston,Ma.'02108
TYPE: DBA ?
PAUL HAGMAN REMODELING
PAUL HAGMAN
17 BIRCH ST `�'°."C2
HUDSON.f 'dW° Administrsstor
valid Without r a
- Massachusetts- Depsu-tment of Public SatetN
Board of Building Regulations and Standards
Construction Supervisor License
License: CS 72689
Restricted to: 00
PAUL F HAGMAN
17 BIRCH ST ' ;
HUDSON, NH 03b51
Expiration: 9/16/2011
('ununisioncr Tri#: 4461
Contract for Services
1.Names
This agreement is between Patrick Wolfgang(Client)and Paul Hagman,doing business
as Paul Hagman Remodeling(Contractor).
2. Services to be Performed
Contractor agrees to perform the following services for Client:
Contractor will remove and replace 25 windows with Harvey SlimLine Replacement
windows.
Contractor will dispose of trash off site.
Contractor will repair exterior where storm windows were removed and paint for an
additional charge.
3. Time for Performance
Contractor will complete the performance of these services on or before October 1,2010.
4. Payment
Client will pay Contractor as follows: 7828.25.
5. Terms of Payment
Contractor shall be paid 50%of the total fee upon signing this Agreement and the
remaining amount due when Contractor completes the services and submits an invoice.
Client shall pay Contractor within 30 days from the date of Contractor's invoice.
6.Equipment and Supplies
Contractor,at Contractor's expense,will provide all equipment,tools and supplies
necessary to perform the contractual services.
7.Expenses
Contractor will be responsible for all expenses required for the performance of the
contractual services.
8. Terminating the Agreement
This agreement will become effective when signed by both parties and will terminate on
the earlier of the date Contractor completes the services required by this Agreement or the
Contract for Services—Page 1 of 4
i
If Contractor is required to a an federal, state or local sales,use,property or value
q pay Y P
added taxes based on the services provided under this Agreement,the taxes shall be
separately billed to Client. Client shall be responsible for paying any interest or penalties
incurred due to late payment or nonpayment of any taxes by Client.
11. Disputes
If a dispute arises, either parry may take the matter to court.
12.No Partnership
This Agreement does not create a partnership relationship.Neither parry has authority to
enter into contracts on the other's behalf.
13.Entire Agreement
This is the entire agreement between the parties. It replaces and supersedes any and all
oral agreements between the parties, as well as any prior writings.
14. Successors and Assignees
This agreement binds and benefits the heirs, successors and assignees of the parties.
15.Notices
All notices must be in writing. A notice may be delivered to a parry at the address that
follows a party's signature or to a new address that a party designates in writing.A notice
may be delivered:
• in person
• by certified mail, or
• by overnight courier.
16. Governing Law
This agreement will be governed by and construed in accordance with the laws of the
state of Massachusetts.
17. Counterparts
This agreement may be signed by the parties in different counterparts and the signature
pages combined will create a document binding on all parties.
18. Modification
This agreement may be modified only in a writing signed by all the parties.
Contract for Services—Page 3 of 4
ORTH
Tovm of And
No.
007• ON
�o t-_= EKE O clover, Mass.j ' t w
COCMICKEWICK
�d ADRATED GP����
SS BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT........ ....�i .. ..
//��
!fR.. . --..II................................................. Foundation
has permission to erect........... buildings on ...17 4....�� �.,.
Rough
to be occupied as� rr2 & Tli�lln
.�! \R��1A �'. ...... Chimney
1 ............. ............................................
provided that the person accepting this permit severy 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
3 PERMIT EXPIRES IN 6 MONTHS
UNLESS CONS TRU TIO TS ELECTRICAL INSPECTOR
Rough
.. . .�i6........................... Service
INSPECTOR
11,, Final
Occupancy Pel mit 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.
07/12/2010 11:32 6038826137 FRENCH INSURANCE AGY PAGE 01
ACORD CERTIFICATE OF LIABILITY INSURANCE 07//TE 12/20
PRODUCER (603) 882-9532 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
French Insurance Agency HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
12 Derry Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Hudson NH 03051- INSURERS AFFORDING COVERAGE NAIC 0
INSURED INSURER A;PEERLESS INSURANCE CO
PAUL HAGMAN fNSURER B;CASCO 114DEMITY CO
17 BIRCH ST INSURER C;
IN$U r•LD:
HUDSON NH 03051- INSURER E:
COVERAGES
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 BE ISSUED OR MAY PERTAIN,
THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 13 SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.
AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADD'LD TYPE OF INSURANCE POLICY NUMBER DATE(EMfOOm TIVE PLATE MLICY MfDD ft-Y) LIMITS
A GENERAL LIABILITY CCF82000605 10/03/2009 10/03/2010 EACHOCCURRENCE S 1000000
X COMMERCIAL GENERALLIABILITV OAMAGE70REQO $0000
PRE ISES(Ea occurrenc�L S
CLAIMSMADE OCCUR / / / / MED EXP(Any one pars
on $ 5000
PERSONAL&ADV INJURY $ 1000000
GENERALAGGRFGATE S 2000000
GEN'LAGGREGATE 4p1UoTAPPLIES PER; PRODUCTS-COMPIO AGG S 2000000
FRI POLICY JEGT [71 LOC / / / / NOWND
AUTOMOBILE LIABILITY / / / / COMBINED SINGLE.LIMB
ANY AUTO (Ea accident) S 500000
B ALL OWNED AUrOS CA1001756 11/10/2009 11/10/2010 BODILY INJURY
$
R SCHEDULED AUTOS (Per person)
HIRED AUTOS / / / / BODILY INJURY
NON-OWNED AUTOS (Per occidenl)
PROPERTY DAMAGE
(Per accident) $
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S
_ ANY AUTO / / / / OTHER THAN EA ACC 6
AUTO ONLY: AGG 1
EXCESSNMBRELLA LIABILITY / / / EACH CPRRENCZ
OCCUR CLAIMS MADE AGGREGATE $
S
DEDUCTIBLE
RETENTION 8 cC S
WORKERS COMPENSATION AND / / / / TWOPtY MITE °�
EMPLOYERS'LIABILITY
ANY PROPRIETOR/PARTNERIO(ECUTIVE E.L.EACH ACCIDENT ..�.
OFFIGFLR/MFJWBER EXCLUDED? / / / / E.L.DISEASE-EA EMPLOYEEI S
IF yes,describe under
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $
OTHER
DESCRIPTION OF OPFRATIONSILOCA'nONSIVEHICLESIFXCLUMONS ADDED BY ENOORSEMENTISPECIAL PROVISIONS
CARPENTRY
CERTIFICATE HOLDER CANCELLATION
— ( — SHOULD ANY OF THE ABOVE DESCRIBED POLICIF_S BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
.10 DAY$wRrrmN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT
FAILURE TO DO SO SHALL IMPOSE NO OBLIGATH)N OR LIABILITY OF ANY KIND UPON THE
PATRICK WOL>:GANG INSURER ITS AGENTS OR REPREEWATIVES.
170 GREAT POND ROAD AUTHORIMOREPREBF,NrATIVE
NORTH ANDOVER MA 01845-3027
ACORD 25(2001108) Q ACORD CORPORATION 1988
ftTM INS025(0108).05 ELECTRONIC LASER FORMS,INC,-($40). 7 0045 Po9n 1 of
19. Waiver
If one party waives any term or provision of this agreement at any time,that waiver will
be effective only for the specific instance and specific purpose for which the waiver was
given. If either party fails to exercise or delays exercising any of its rights or remedies
under this agreement,that party retains the right to enforce that term or provision at a
later time.
20. Severability
If any court determines that any provision of this agreement is invalid or unenforceable,
any invalidity or unenforceability will affect only that provision and will not make any
other provision of this agreement invalid or unenforceable and such provision shall be
modified,amended or limited only to the extent necessary to render it valid and
enforceable.
CLIENT
Dated: N t7 ` t l
By:
Pa h olfgang
17 Grea Pond Rd
N. do er,Massachus tts 0 845
CONTRACTOR
Dated: >11-2— fa
By:
ej—
Paul Hagman,doing b mess as Paul Hagman Remodeling
17 Birch St
Hudson,New Hampshire 03051
Taxpayer ID: 034-36-4088
Contract for Services—Page 4 of 4
The C'ommonwenith of Massachusetts
Department o f jndustrial Accidents
Office ofLnvestigations
..600 Washington Street
Boston, M-4 02111
Www-Mass
Workers' Compensation Insurance A��vi gra s/Con
An Leant Information tractors/Electricians/Plumbers
PIease Print Legibly
Name (Bmsiness/Orgmization)lndividual):
/ 4he o t
Address: 2 Pi rc G
City/State/Zip: .4 . A - �
Phone#:
Are.you an employer? Check the appropriate box:
1.0 I am a employer with 4. 0 I am a general contractor and I7�4�emode
(required): .
2•J2employees(fill]and/or part-time).* have hired the sub-contractors ruction
--T a sole proprietor or partner_ listed on the attached sheet 1
ship and have no employees ees gP Y These subcontractors have oon
working for me in any capacity, workers' comp.insurance.
[No workers'comp. insurance 5. El we area corporation and its 9. 0 Building addition
required-) officers have exercised their 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work right of
myself -exemption4),ager MGL 11.0 Plumbing repairs or additions
Y [No workers'comp, c. 152,§I(4) and we have no
in required.] t [No Y emP to ees_ workers 12-E]Roof repairs
` comp.insurance required. 13.0 Other
=.��=:`alicaut that:.h;.�.;boy,.�i i ]
. mt:s.,y.so a,cu!the sece�eeeop•
Homeowners who submit this affidavit indicating,are do:. ;.. = =a'Or-ers'comrs_�+ocr
g aL,rork and tom hireoutside contxac*
'Contractors that Chen), �box must ached au additional sheet showing the s~.submit a new amdavit indicating such.
name of the sub-contractors and their w,mkecs,co
I am an employer that is providing workers'compensation uisurance for niy a mP pQ�tnfonn ticm
information. employees. Below is the policy and job site
Insurance Company Name:
Policy#or Self-ins.Lic.#:
Expiration Date:
Job Site Address:
Attach a copy-o City/State/Zip:
f the workers' compensation P Policy declaration P c3' as .
e
Failure to secure coverage as required under Section 25A of MGL c.. 152canlead to the impost cy
Hoof c nriminal ration date).
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 maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify er the ns and penalties a er
fP ! ] that the informationrovided
Signature:
P ab is
iru and correct
"
. -
Phone#: e?'3- 2(J^ <—
ol
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
#
Issuiva Authority(circle one): Permit/license
1. Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5. PIumbinR
6. Other b Inspector
Contact Person:
Phone'#:
Information an- d 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 engaLyed in a joint enterprise,and including t1ae legal representatives of a deceased employer, or the
receiver or trustee of an individual,partnership, association ox-other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartal ents and who resides therein,or the occupant of the
dwelling house of another who employs persons to do mainte:ance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not be cause 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 c onstruet buildings in the commonwealth for any
applicant who has not produced acceptable evidence of cor3nipliance 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 ua-sil acceptable evidence of compliance with the inc�ranre
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 cerdficate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or parinern,.are not required to carry workers'comp ensation 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 si u-e to sign and date the affidavit. The affidavit should
.be mturned to the vi or town that the auuliGauan iiir the^ainrit or lice^...°e uq being re .},not.{....e g. aues+e� :sepsriWt.of
Industrial Accidents. Should you have any questions reaarri;.. az-- •r / ,
b L-b LY is K'ar it jfUt4 art i:.t"ti'yre.7 to t3G'1Sin a workers
compensation policy,please call the Department at the.numberr 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 bum leaves etc.)said person is NOT required to complete this affidavit
The Office of Investigations would like to than 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.fag.number._..
The Cornmonwealth cif Massachusetts.
DcPar tor=t Oflmdustrial Accidents
Office Gf Inrestiaat ons
600 washmgbn Street
Boston,M—A 02111
Tel. ' 617-72.7-4900 eZ 4.0.6 or 1-877-1VLASS_kFE
Revised 5-26-05
Fax TM 617-72.7-7749
urVM'.mass._gov/dia