HomeMy WebLinkAboutBuilding Permit #56 - 175 WEYLAND CIRCLE 7/25/2007 pORTH
BUILDING PERMIT ?c��t�■� �tio
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit N0: Date Received 7 , , D
�SSACNuso'
Date Issued: �- �} �
IMPORTANT: Applicant must complete all items on this page
x � �
as.
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TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building A One family
❑ Addition ❑ Two or more family ❑ Industrial
❑ Alteration No. of units: ❑ Commercial
`Repair, replacement ❑ Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
a Will
5
DESCRIPTION OF WORK TO BE PREF RME
Re,oAcem G- /(V w Dm/.
D �
0 ,4*r slot S " l� ft OF f
l'N fit I s �e slwF -- rE Afi,i
Identification Please ype or Print C early)
OWNER: Name: er'� icc�. �, , Phone:
Address: l t'( /�
' 5"1 am e",
MIN. t.
5
REAyY 5
r,..
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: $ X Z
Check No.: r Receipt No.: �� 3
NOTE: Persons contracting with unregistered contractors do not have access to the guarantv fund
Signature of Agent/O r Signature of contracto
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF-U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
DATE REJECTED DATE APPROVED
CONSERVATION Fl—
COMMENTS COMMENTS
DATE REJECTED DATE APPROVED
HEALTH ❑ ❑
COMMENTS
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 ❑
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
Located at 384 Osgood Street
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gpr
4y 9 Y
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
vt �'�t c�r/�-- G G✓rt 7�M•e
❑ Notified for pickup - Date
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
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✓
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
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 2.2007
Location
No. Date S 'o
NOR,h TOWN OF NORTH ANDOVER
F p
Certificate of Occupancy $
��J'••'° E<� Building/Frame Permit Fee $
�cwus
Foundation Permit Fee $ `
Other Permit Fee $
TOTAL $
Check # /c
2041o4
V Building Inspector
NORTiy
Town of
0%
No. 194
0o , �` dover, Mass., 7•et �' O.�
COCMIC.e.CK
SRATED p5
BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
O`er BUILDING INSPECTOR
THIS CERTIFIES THAT......j.a/".� S � � ..`..... ............................................. Foundation
has permission to erect........................................ buildings onI ............... ... .............' .... Rough
to be occupied as./40..... 0 .... ..0.................................................. Chimney
.. A. .. ILIO ........ ... ..... ..
provided that the person accepting this permit shall in eve res ect con of rm to a terms of the application on file in
P P P g P ry P PP 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
b Jamm- PERMIT EXPIRES IN 6M THS
ELECTRICAL INSPECTOR
UNLESS CONSTRU ARTS Rough
....................................................................................... Service
BUILDING INSPECTOR
Final
Occupancy Permit 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 BeDone FIRE DEPARTMENT
Until Inspected and Approved by-the Building Inspector. Burner
Street No.
SEE REVERSE SIDE Smoke Det.
The 'CO mmonwe'alth of Massachusetts
'.' DepartMent a#Fire Seiv" '.
o
Ofce Wthe State.Fire Marshal "
P DA ox IMS S4itc Road,Stow,btA 01775
APPLICATION FOR PERMIT,
Date. �•-20 1
': •„ : N''•
Aft r.; .k'eitalt:NQ
(C .)...' (TIApplicabie) Dig safe '
In m mt6=%*h_6e.prbiisioas of M t-r L. .CGaptrr k 0 a4
pro?idrd io Scxioa'. 52 7 C M'R. 3 4' appliacoion it ltercby made Sun Aim
(Furl nfthb of"
. persoq.I+itnias Co
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':�: ::pucliarafor.
r" (S cttorp.O:Box atyw7oww
.•'paliiclt pt>x�t..For�„ion•to ' �o'ca a:.e� _
`ts "; dutn s'ter 'for
9' d:. c s z o
>rz1i' a:
CO
stEr ''must'.- b'e .2.S'' from structure or Gov' e
(CAve:locatioa b3'secc f'arnd'rta,ar descnbc is sues Aiaana al to Ovied edapsge idtnti m6ca of locadc }
Name of C=pcn=rolxratorCeti No..
([fApombie) -" -/4 -_
•... � � -ter'of.�l�&caac)
Thm ofcxpimcioa e' 0 50.00The
O. aoa. alLh of Mass achuse <
--Depa`gmbnt'of Fire services
..
ifce.o,f t,�e State Fire 'Marsha,1
P.0.8ox,102s.Staic Saad:Sto v,MA 01773
PERMIT '
North 'Andover, PertaiatTo . Date:
,. {'C;t�.o[ a�pr,) (tfAppfieablc)' Diig Saaevum er
eccoidntioe:with�heTrim'ioni of t+ii'G;Z 14 8 C6gtex_ jZ.�.piwidccl is soedon M� 3
_ ::•ShIn?Cr v u grined to:. tn') start Dace .
F6 f'natme.of
person,rim or Corporation
-.:.
? Lwinlocate dutngs.t-er': f61� construction/renovatzonj•demolition o,f bui]ding,
dumPster must . be. 25 '. from' structure zf unableCo place vrth „lrenuired
dO"'lclear.ancc dumpst.er mutt :he covered
with p1 wood or tarn en of work •dray
ot. z 7 CLcJ
('Game locaton by street
b1`
to sue saa o provi a idgc_ titin of locatioa)
P'oid F S 0.00' _�'lt/ ��EiE(�+v
.o'er � 're Chief
xltiS+�arttlit willtapirs —a�6—o (Signanut
Of n gia.;w,g permit) ofacal graalingpbrrtvt (Ticic)
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 046124
Birthdate: 10/08/1960
Expires: 10/08/2008 Tr.no: 3934.0
Restricted: 1 G
ANTHONY M SANCHEZ
15 BOARDMAN LN
HAMILTON, MA 01982 — '
Commissioner
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
-
600 Washington Street
Boston, MA 02111
www.mass.g ov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
jVName (Business/Organization/Individual): 801U61V0 6j O 1VLLG
Address: Y11 1 6 Cydou -
City/State/Zip:& 4ti.0oye y� 61&Phone #: �� ��,5� �0 00
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. it I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.E] I am a sole proprietor or partner- listed on the attached sheet. E] Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
officers have exercised their 10.0 Electrical repairs or additions
required.] of
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof Zairsinsurance required.] t employees. [No workers' 13-11Othere rY`
comp. insurance required.]
*Any applicant that checks boz#1 must also fill out the section below showing their workers'compensation pol icy 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.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. �r
Insurance Company Name: 6;e,T
Policy#or Self-ins. Lic. #: CP�UUNG,0/O Expiration Date:
Job Site Addressl,27 Wr,-4 !,:r, City/State/Zip: y- f4A dc,,le�, {�/� X01_
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.
/do hereby certify under the pains and enalties of perjury that the information provided above is true and correct.
Si nature• Date: 7 �S� 6
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
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 pen-nit/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
Fax#617-727-7749
Revised 5-26-05
www.mass.govldia
07/25/2007 10:12 FAX 9788971553 THE GETCHELL COMPANIES 0001
AAQ , CERTIFICATE OF LIABILITY INSURANCE 07 5 ZO07
Pmmmm (978)897-7773 FAX (978)897-1SS3 THIS CERTIFICATE 18 ISSUED AS A MATTER OF INFORMATION
The Getchell Companies Insurance Services, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
873 Great Road, Suite 102 HOLDER-THIN CERTIFICATU DOES NOT AMEND.EXTEND OR
ALTER THE CQVFRAGE AFFORDED BY THE ORJCIE
PO BOX 844
Stow, NA 01775 INSURERS AFFORDING COVERAGE NAIC O
namD Boston North Holding, LLC INSUREf k Acadia Insuranca
4S1 Andover Street USURER&
North Andover, MA 01845-0000 LNILLa
IrvsuRc-Ra.
LruuRLae L;:
THE POUGES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE ROM NAMED ABOVE FOR THE POLJ,I/PERIOD INDICATED.NOTWffHSTANDM
ANY REOUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OT-IER DOCUMENT WLTH RESPECT TO WHICH•-tics CERT wKA* TE MAY Be ISSUED OR
MAY PERTAIN.THE INSURANCE AFFORDED BY THE ROUGES DESCRIEED HEREIN IS SUSJWt TO ALL THE TMO EXCLUSN)NS AND CONDITIONS OF SUCH
ROUGES.AGGREGATE LIMITS SHOWN MAY HAVE BEp+i REDUCED In'PND CLAIM&
WRTYPE OF INSURANCE POLICR MIYBER '� LITS
GQI M UADIL.NT'Y CPAWSUILD-15 01/06/2007 0 /2008 E tiCh oN: mwmm a 1,000,0001
XCOMMERCAL GDEML lM{61UTY O•LFMGTs� i 300
CLAIMS MADEXX OOCUR M 91 EV(My mr Pr's+) S S
.0001
A P IMNAL O ADV INAW S 1 000
01!WAALAd'&WM'a $ 2.000
1000
NKAOOREMYELMrrA"IJE.SPIR NS+ODUCT6-COMP1bPAGs i 2,O00,
PoucY M.aT El Loc
AUTOMOBLE UAIRM O)MISMS94GLIMMIT f
ANY AUTO %3 Y dd 0
ALL OWNED AUTOS W HOLY INJURY
SCHEOULEDAUTOS IF�rAraon) S
toRwm OS o OLYWAM
f
NON•OWPO
hEDAUS (Peraa9neN)
PI.OPEMOAMAGE t
(P•!r acditQ
QARAMUAML" ALTOONLY-GAAGCIDWIT i
ANY AUTO Cr NER TIMI EA ACC S
Al TOOLVLY AGa S
690EsanN Aa I A LLaI I JTY EaCt O= $
OCCUR r7 CLAIMS MADE At WMAYE 8
s
DEDUCTIBLE i
RETENTION E s
WORKOW COMP6NZATION AND WANNS06.14 01/06/2007 01/06/2008
EMPLOYERS'LJAIILRY
A EJ.EACH ACCE80 i 500■
0"eEKA�exeLu� EJ.DLIEAL+'E-FJ QVLOY S 500
CLd ->oLcv wLrs $ Soo
OYRIR
DacmvrmN OF OPIRATmNs i LOGTmm ivmocI m/Dmunum AODM IY Emmoamw i I/EGAL Pnftd Orb
e: 175 Weyland Circle, North Andover, MA
F
pig"my OF TRU awn DBCRIi ID Poul R CWMML M MORM THE
L;NPIRAYION MW THSIMP,TIA*W14 INSIAM WIL DMAYOR TO WK
10 DAYS WP6YM NOM YO YNn CWMMCATI NW ML NAIM TO THE LIPT,
LWTFALL MCTO MAL3UCN NOTICES LILL.ITrro70 NO0MAAYION OR MAN LIrY
Town of North Andover OF ANY Law UPON THE R5,4511:OR RlINIMMATTViS,
Attn: Building Departwnt FrATMI
ACORD 25(2001/08) I ACORD CORPONTION 1988