HomeMy WebLinkAboutBuilding Permit #703 - 171 PLEASANT STREET 6/16/2009BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: U Date Received
Date Issued: G
IMPORTANT: Applicant must complete a(l'll items on this page
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LOCATION'- 1 -11 - (1 �- e I -e/, > / V .i 1 [
PROPERTY OWNER
MAP NO: 0—PARCEL:
Print
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ZONING DISTRICT: Historic District yes no
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:
ntification lease Typg or Print Clearly)
OWNER: Name: ��a 9 Phone: 6' 6 Z
Address:
fog
CONTRACTOR NamePhone:
ru�ai �J. !226 V v' / fief V L
Supervisor's Construction License: (:) (0 1 1 Exp. Date: /Z 0 t O O
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Phone:
Address:_ ZZA 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: $ Z m ®d r.'ev FEE: $ �—
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner ,
" Signature of contractor
�J
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
COMKENTS
A
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
a
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
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
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 Arid
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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2008
Location/ -)/-/22 7'
No. O Date 6
NORTH TOWN OF NORTH ANDOVER
i • OL
9
Certificate of Occupancy $ `
'7g''••°''t�'
Building/Frame Permit Fee $
swcMust
•
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
22
Building Inspector
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 *aashington Street
Boston, M4 02111
c I www massgov/dia .
Workers' Compensation Insidtrance Affidavit: Builders/Contractors/Electricians/Plumbers
Eli cant Information PiPs,ap 14..:..4 r -11..
Name (Business/Orbwiration/lndividual):
Address: 2 " l��
City/State/Zip: (/fe-�[M
N
IN
Phone #:_. qV -C/7- �S 3
Are you an employer? Check the appropriate box:
11K
I ars► a employer with
4. [3I am a general contractor and I
employees (full an _time).*
2. ❑ I am .a.sole proprietor or
have hired the sub -contractors
listed
partner_
ship and have no employees
on the attached sheet i
These StL&contractnts have
working for me in any capacity.
[No workers' comp, insurance
workers' comp. insurance.
5. ❑ We are a corporation and its
required.]
3.0 1 ain a homeowner doing
officers have exercised their
all work
right of exemption per MGL
mysel£ [No•workers' comp,
c. 152, § 1(4), and we have no
insurance required.] t
.employees. [No workers'
comp. insurance required_)
Type of project (required):
6. ❑ New construction
7. 0 Remodeling
S. Q Demolition
9. E3Building addition
10.0 Electrical repairs or additions
I I .Q Plumbing repairs or additions
12.Q Roof repairs
I3.Q.Other P,&06 C.
•An licartthat i .. el r
Y aPP checks bob # 1 mutt also fill out the section below ahow.ing their workers' compensation Podtcy mformatiot6 f
7 homeowners who submit this affidavit indicating they are doing an work and then hila outside contractors
4Contraetors that check this box_ mush an additeotml shea showingthe name of the sub
must submit a new affidavit indiaatios such
-
cwftctm and their workers' ca—
arr.
Gr eriploYer thars{rot g workers'comP"
is
fnmateon
informatnrt pensadoncnsuranceforcryeM10YeeBelow is hePoy mrdjob site e
Insurance Company Name:_WSL %nn' //4
Policy # or Self -ins. Lie. #:� p (� �� 0 /9 I L( d:
w�/p�3�Sgo�vo 8 — �i / 2,vla-
Job Site Address: i f' I 3 � Zrw t
C �__�5�9'nvi 1 /v Z '�
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 im osition of criminal
fine up to $1,500,00 and/or one-year imprisonment; as weil 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.
1 do hereby cern under the p �and�makies�affpo erjury that the information provided above is true and correct
Sr tore:
i Date: �/ �0
Of,]`Ictal use only. Do not write in this area, to be completed by Cfty or town offuza[
City or Town: Permit/License #
Issuing Authority (circle one):
I. Board of Health 2. guilding Department 3. City/Town Clerk 4. Electrical Inspector
6. Other 5. Plumbing Inspector
Contact Person• Phone #
Information a. lid Instructions
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 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'fbmgoing engaged in a joint enterprise, and including the legal representatives of a deccased employer, or the
receiver ortrustee of an individual, partnership, association or other legal entity, employing employees. 'However the
owner of a dwelling house having not more than dyer 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 *o construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence.of compliance with the insurance' coverage required"
Additionally, MOL 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
requi =n=ts of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation• affidavit compierteiy, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es).aond phone numbers) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or pmtners, 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 num. ber listed below. Self-insured con paniess should enter their
self-insurance-Iicense number on ti='appropfiate Tine.
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 tine 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 ".lob Site Address" the applicant should write "all locations in (city or
town)." A copy of -the affidavit that has been.officiaily 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 lnvestigpations 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 CommonweaLlth of Massachusetts
Departinent of lndustiial Accidents
Office of Investigations
600 Washington Street
Boston, IviA 02111
TeL # 617-7274900 6= 406 or 1-8.77-MASSAFE
Fax ## 617-727-7744
Revised 5-26-05 www.mass_gov/dia
06/15/2009 16:06 FAX 78127273lu
♦i;t>..�rhu.ctt.. Llri►atZntrnt „i Puhli': Nalel%
Board of Buildime Re-ul;Ni,eu.:►nd Stuntl:ud�
Construction Supervisor License
License: CS 28898
2estricted lo: 00
3REGORY S GREEN
3 FOUR ACRE DR
3URLINGTON. MA 01803
�JL
expiration: 5J25W10
Tr 2W51
Licaw or registration vaiid for indmdui use ody
before the expiration gu Regulations and Standards
$card of Building Rego
One Ashburton Place Rm 1301
Boston, Ms. 02108
Not valid without signature
`J s
G
ar
Aao/oris*tng 1 Boa
1301
One Ashburton Place
Boston. Massahusetts 02108
Home Improvement Contractor RejZistrattiion�zr�
Re iWiS
Type; DBA Trp 271006
Expiration: 72010
G & G ROOFING CO -
Gregory Green
8 Four Acre Dr
Burlington, MA 01803
0114AI 6 SAij-W07-W-""
narra nrd. M> reason for change -
Update Address
Addrt�s ..-J mews! 1 °st Cud
610537
6l 10/Luua 1:lJ.Lz ra.
I n 1DATE (MNIIDIXYYYY)
AC_ORD. CERTIFICATE OF LIABILITY INSURANCE 0611olo9
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
PRODUCER ONLY AND CONFERS NO RIGHTS UPON'THE CERTIFICATE
USI Ins Serv., of MA Inc. aiOLDEt. THE CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW
12 Gill St, Suit* 5500.
P O Box 403 INSURERS AFFORDING COVERAGE MAIC /
Woburn, MA 01888
INBI>RERa Penn-Amd'fca Insurance Compan 32859
INSURED
G 6 G Roofing Company INSURER&
Gregory S. Grwn dlbla INSURER C:
8 Four Acre OrNe *MIXER Lr.
Burlington, MA 01803-1921 INSURER I>_
COVERAGES COVERAGES AS OF OVIO109
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 WTTII 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, ELUSIONS AND CONDITIONS OF SUCH
POLICES. AWREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIIMS.S ve pOLIOYExPIRATIQN LEM
A aEXERAL LIABLITY
X COMMERCIAL GENERAL LIABILITY
CLAMS MADE a OCCUR
X 811130 Ded:1114
GEHi AGGREGATE LIMIT APPLIES PER.
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUMS
NONAYMNEOALITOS
ANY WTO
Occm "CLAMS MADE
DEDUC71BLE
WOWJM COMPENSATION AND
MPLOVEW LMBI.ITY
ANY PROPRIETORIPARINEWE%ECUTIVE
OFRCERAAEMBEL EXCWDED7
I(yO� doac(Ao under
SPECIAL PROVISIONSbelow
OTHER
01/31/09 101131110
DESgIPTION OF OPERATIONS I LOCATIONS I VEHICLES I E=LtWMS ADDED BY ENDORSEMENT SPECIAL PROVISIONS
Evidence of General Liability Insurance
Workers Compensation Certificate will be forwarded directly by carrier.
COMBINED SINGLE LIMIT $
(Es "O dad)
BOOILYNJURY S
(Po( peon)
BODILY INJURY $
(Persocdonq
PRO
Iftf ���DAMAGE $
OTHER THAN EAACC S
AUTOONLY: ADD S
EACH OCCURRENCE S
AClRFr.ATE is
EL.
CERWICATE HOLDER EL.LATIUM
T>
SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFIDRE THE EXPIRATION
North Andover Building Dept DATE THEREOF, THE MUM INS11RERWILLENDEAVOR TOM to DAYSwtffM
384 Osgood Street NOTICE TOTHE CERTIRCATE HOLDER NAMED TOTHE LEFT, BUT FAILURE TO 00 SO SHALL
North Andover, MA 01845 HUME NO OBLIGATION OR LIABXI YOF ANY OND UPON THE WWRER, ITS AGENTS OR
I-- I
.� ..-^an f-^=w%OATIflM 40M
ACORD 25 (2001108)1 012 #3878588
Proposal-----------------------------------------------------
G & G Roofing (978) 807-5934
Residential Specialists since 1980 Licensed and Fully Insured
8 Four Acre Dr. Burlington, MA 01803. MA-HIC #106222 MA CS # 026698
We hereby propose to providelabor and materials necessary for satisfactory completion
of work at:
NAME �Ttw e- lxq i S
ADD
rIVA
PHONE
WORK TO BE PERFORMED:
0 i • ,40 t i► i
. t 0 M.`—� -
CELL #
ALL WORK AND MATE S GUARANTEED AS SPECIFIED AB
�
THE SUM OF: Doll
Payments to be made as follows: ,/a-(/, GL/z"
dy
6-
FOR
��6t)2/,
ACCEPTANCE OF PROPOSAL
Date: O
�
o
Signature: C 8 09 a G%
Signature:
06/12/2009 09:43 FAX 7812727310
...............
4 W
ISSM DATE 0611012009
-4 ONLY -AND
MATTER OF INFORMATION It
fM(:LFLTfflCATEISIsr
ISSUED, AS A
0DUCFR UPON THE T ATE
,CF
CERTIFICATE HOl.DM THIS CERTIFIC
r :Mr
L
,OV�
ERA
CONYERS NO WIM FR THE covERAGE AFFORDM By T11E
SI bmmmrc Scrvicm of )OE,�q NOT afr
,ND, F -MND OR ALT
pL
amachusem Inc POLICIES BELOW.
COMPANIES AFFORDING COVERAGE
Gill Satcl. Ste 5500 779==
obum.MA 0I R01
lu
egory S Gwen COMPANY
PANY A AIM- Mul" lnsurJI= Co
ba G & 0 Roofing L&MR
Four Acre Drive
lalis7o`tcm►,MA 01903 zft
POLICY
Wow) AwvE. FOR TIM
HAVE M To THE INSURED'
-)W __AE �XISRU, -S
SIR TH6TTJJEFOLlV,
r DmON OF CRIBED HMIN IS SUBIECT
PERIOD C NOT ST ANCt Ar
OR MAY rERTAIN.,fHE INStTp rOrtDM-BYTHErOLJ0ESDES �YPAJI)CIADA&
PLCT
Tow"i Ifils C 2TIFICATE MAY BE ISSUED UMrrS SHOWN MAy HA vg BM REDUCED 10
TO ALLTHE TERMS. ExCLMONS AND 00 M(OYNSOFSU POLICIES. L24EU
CO ljv.4l0flrAWhAMK
LTN GOWERAL ADOKWaTE
GENERAL /MAILRV PRODU
ACOA MOCIAL 00MAL LLO-RUTY POMNAL A ADV. rMlMy
C= ==.VMS MADur—looculL EACHOCCURRENCE
r—lowwu%mCowm.mwSmol. FRIT OHMAGE (AAY0ft*-)
MED. LXP2K3SlA"P* #'M')
CORIMINW wt.,QLH
AUTOMOBILE LIABILT" mmtr
u0mv INUAY
ANY AUTO (?A PKWO
ALL OWNED AUTOS
SCHWL"OlAvit" gamy Imutv
If= Ainus owmam
V0)#.*WM AUTO.'
GARAGE LUIURRY
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A cimim nVE 10/25/2U09 E.LDISSAM-poucYLUT 500'. 000
70:034U89:012008 10/2,5/200S j:LWS6ZMJ'��- _ALH. l0000() -
EMPLOYEE
JCOMMAMrSi DESCREMON UP OPERATIONS ou LoCATIONS-
Irmirox-jity s num is NOT covERED BY ME %vottg#rjLvC:oMPEN9ATIW POLICY.
12 CAVC8UED W"MN DATE
OR)tWAVYOETaAWVPDESCRM)MIICU�,7- T"t
n=BW.VaLUUnMCOWANYVM,LMMgAVOR-rOMAZLI—SVAUTMNOTIa'TIOTMCEILTWI�
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R LLBn.,Ty OF AMyjM UPON jtjg LomlPANY. MACOM ORRWRE�'TATr*'ES•
OSGOOD STREET
ANDOVER. MA 0124"