HomeMy WebLinkAboutBuilding Permit #500 - 178 STONECLEAVE ROAD 12/22/2011TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit N0: 4-0c) Date Received
Date Issued: 12129 i
ORTANT- Annlicant must complete all items Qn this page
Print
PROPERTY OWNER fi NO Y O U E (3,21,4-- Unit #
Print
MAP NO:� V ARCEL: A01 ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
100 year-old structure 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
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DESCRIPTION OF WORK TO BE PEKr'URAIED:
lOK °° J
(Identification Please Type or Print Clearly)
OWNER: Name: A 4�% EY �/ � Phone:
Address: A V D I, g, 0/�1%/�
CONTRACTOR Name:
Address:��j D
Supervisor's Construction License: �� /2 ZZ Exp. Date: 4-17 – 2 d /3
Home Improvement License: !° 3 Exp. Date:
ARCHITECT/ENGINEER Phon
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT: $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COSTBASED ON $125.00 PER S.F.
Total Project Cost: $C>f) ° FEE: $ ��
Check No.: 91 / Receipt No.: e
C`
NOTE: Persons contracting with unregistered contractors do not have access to
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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
PLANNING & DEVELOPMENT ❑
COMMENTS
CONSERVATION
COMMENTS
HEALTH
r r .
COMMS -NTS
DATE APPROVED
Reviewed on Signature
Reviewed on Siqnature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
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 2011 June/mi
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
o 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
o 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: Doc.Building Permit Revised 2008mi
Location —%%� `'��yl- c%G✓f f �i�'
00 �% �- Date . Z`7' /
No. J/
TOWN OF NORTH ANDOVER
Certificate of Occupancy $ r
Building/Frame Permit Fee $ 6�
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
�Z
2 j{ Q G 7 / uilding Inspector
e
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Wood & Associates
Insurance Agency, Inc.
32 South Common Street
Lynn MA 01902
i
FAX r'_nVER SHEET
Tele (781) 581-5900
Fax (781)593-0776
COMPANY: l 11 7- ,
DATE: Q Z—/
PA(
MESSAGE:
Insurance
Insurance Professionals Since 1954
www.woodinsurance.net
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
ky 600 Washington Street
Boston, MA 02111
www mass.gov/dia
Workers' Compensation Insurance davit: Builders/Contractors/Electricians/Plumbers
Name (Business/Organization/Individual):
Address:
City/State/Zip:
Phone #: //7������
Are you an employer? Check the appropriate box:
1. 0 I am a employer with _/
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet. I
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ 1 am a homeowner doing all work
right of exemption per MGL
myself. [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. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12. W Roof repairs
13.[" Other & //�
*Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. v
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.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. 1
Insurance Company Name:_
Policy # or Self -ins. Lic. #: � � � './ Expiration Date:
Job Site Address: ���C� ��/O�('/�� �U City/State/Zip;/ / G�
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.
I do hereby cert' mJer he pains and penalties of perjury that the information provided above is true and correct
.;3, ASSOCIATES
LYNN MA 01902
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 #:
ISSUED BY THE STOCK4111ItJSURANFIRM MPANY HEREIN CALLED THE COf:1PANY
COMPANYGRANITE STATE INSURANCE
1
AGENT NUfv13ER POLICY NUMBER
0071183-00 wc oog-94-7874
--
013-66-1111-00
if indicated below, Interim adjustments of premium shall be made:
Semi -Annually Quarterly Monthly DEPOSIT PREMNM
12/02/11 ASSIGNED RISK 66
issue Date issuing Office
3097 (Revd 04/08)
Authorized Representative WC 00 00 01A
GEORGE ORFANOS & PAUL ORFANOS C M A RT I.5
37 CHILDS ST
LYNN, MA 01905-0000
A Chards company
EXECUTIVE OFFICES:
SEE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE - WC990610 175 Water Street
New York, NY 10038
LO#OdA 1U1# -
WOOD S ASSOCIATES
WORKERS COMPENSATION AND EMPLOYERS 32 S COMMON ST
LIABILITY POLICY INFORMATION PAGE LYNN, MA 01902-4433
INSURED IS PREVIOUS POLICY NUMBER
E
PARTNERSHIP
OTHER WORKPLACES NOT SHOWN ABOVE: SEE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE - WC990610
MEM 2 POLICY PERIOD 12:Ot AM. standardtime at the Insured's
mailing address 11/05/11 TO 11/05/12
FROM
ITEM 3
A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed
here:
MA
B. Employers Liability Insurance: Part Two of the policy applies to the work in each state listed in item 3.A.
The limits of our liability under Part Two are Bodily Injury by Accident f 100,000
each accident
Bodily Injury by Disease $ 500.000
policy limit
Bodily Injury by Disease $ 100.000
each employee .
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
SEE ENDORSEMENT — WC2003o6A
D. This policy includes these endorsements and schedules:
SEE EXTENSION OF ITEM 3.0. OF THE INFORMATION PAGE - WC990612
ITEM a
The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans.
All information required below is subject to verification and fhuatge by audit.
Code Number
Premium Basis
Total Remuneration
Rsta.Per
$100 OF Re-
Estimated
Premium
gasslfiatlons
® Annual 3 Year
munerstlon
Annual 3 Year
SEE EXTENSION OF ITEM 4. OF THE INFORMATION PAGE - WC7754
EXPENSE CONSTANT (EXCEPT WHERE APPLICABLE By STATE) V159 MA
_
....... ��..••w�e.�wuuue
DCFYtl1Y
S478
if indicated below, Interim adjustments of premium shall be made:
Semi -Annually Quarterly Monthly DEPOSIT PREMNM
12/02/11 ASSIGNED RISK 66
issue Date issuing Office
3097 (Revd 04/08)
Authorized Representative WC 00 00 01A
EXTENSION OF ITEM ID. OF THE INFORMATION PAGE
Policy Number: WC 009-94-7874
WC000402
WC000414
WCOFAC
107437
WC58509A
WC200101
WC200301
WC200302A
WC200303C
WC200306A
WC200307
WC2oo4O3
WC200601A
WC200604
WC992002
WC990610
WC990612
(Ed. 1/97) (Rev'd 04/08)
Effective Date: 11/05/2011
ANNIVERSARY RATING DATE ENDORSEMENT
NOTIFICATION OF CHANGE IN OWNERSHIP ENDT
NOTICE REG OFFICE OF FOREIGN ASSET CTRL
PRIVACY POLICY
WC - PREMIUM CREDIT APPLICATION
MA - TRIPRA ENDORSEMENT
MA LIMITS OF LIABILITY ENDORSEMENT
MA ASSESSMENT CHARGE
MA NOTICE TO POLICYHOLDER ENDORSEMENT
MA LIMITED OTHER STATES INS
MA ASSIGNED RISK POOL ELIGIBILITY ENDT
MA CONSTRUCTION CLASS PREMIUM ADJUSTMENT
MA CANCELLATION ENDORSEMENT
MA POLICY DEFINITION ENDT.
MASSACHUSETTS PREMIUM DUE DATE ENDT.
NAMED INSUREDS/ADDRESSES
wC 009-94-7874
Policy Prefix & No.
-------------------------
n,z_��,-ilii-no
Page 1 Of
EXTENSION OF ITEM 4. OF THE INFORMATION PAGE
MASSACHUSETTS
Sfteduie
GEORGE ORFANOS S PAUL ORFANOS
INTRAAr,dependertt State Risk ID
Item 4. Classification of Operations
Premium Basis
Rates
Estimated
Annual Premiums
Code
No.
Estimated Total
Annual Remuneraft
Per $100 of
Remuneration
RATING GROUP: 0001-01
PAINTING OR PAPERHANGING NOC S SHOP
5474
IF ANY
5.09
OPERATIONS, DRIVERS
STATE OF MASSACHUSETTS TOTALS
TOTAL CLASSIFICATION PREMIUM
SUBJECT PREMIUM
MODIFIED STANDARD PREMIUM
UNDISCOUNTED PREMIUM
50
LOSS CONSTANT
0032
0900
159
EXPENSE CONSTANT 0.
TERRORISM RISK INS ACT 2002 03
9740
0
269
POLICY MINIMUM DIFFERENCE
094 0
478
TOTAL ESTIMATED PREMIUM
478
TOTAL DUE
TOTAL PREMIUM FOR TERRORISM COVERAGE INCLUDED
IN TOTAL ESTIMATED PREMIUM $0
WC 7754 (Ed. 4-81) (Rev'd 04/08)
jv-0T--rl 01:42pm F rom-
T-241 P.001/002 F-966
�>,,:,._,,,,•,-.;;-,,,u,.,..:..:,a.M;::,�,,-,:�;::.,x;,,,,,,...,.�M.�.>._ - ._.�.._ D CONFERS NO RIGH 15 uYuN I n�
n.saT„ C>
IS CERTIFICATE 1S ISSUED AS A MATTER OF INFORMATION ONLY AN
EXTEND :RTIFICATE HOLDER. THIS CERTIFICATE DOES T AMEND
DOES NOT 000NSTT UTE ATHE oONTRACT BFETINE N
'THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCETHE
IE ISSUING INSURER S ,AUTHORIZED RE RESENTATIVE OR PRODL
T OVAL INSURED, the pol cy(ies) mup be endorsed./ If SUBROGATIOP
PORTANT: If the Certificate holder ►s an ADD
WAIVED, subject to the terms and conditions of the policy, certain policies may require and endorsement. A statement
this certificate does not confer li ht5 t0 the cerEficate holder in lieu of such endorsement.
Wood & Associates
23 S Common St
Lynn, MA 01902
George Orfanos & Paui Oftncs
DBA Orfanos Painting
37 Childs St
Lynn, MA 01905
COMPANIES AFFORUINta IMOUMI-' 1"11^
COMPANY A GRANITE STATE INSURANCE COMPANY
a -'ea. e•"'.--:ojy,,.o!:;i�,i�:�ip,....:.°Y..:d"Ge.d.,.g9wN ':�.:,..w.,.r.-.._... -. s....,....-._.. ._.... .
CIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE F4
11
THIS IS TO CERTIFY THAT THE POLI
ON OF ANY CONTRACT OR OTHE
THE POLICY PERIOD INDICATED, NOT WITHSTANDIN CERTIFICATE MAY BE ISSUED OR MAG ANY REUIREMENT, TERM QPEI
RTAIN, THE INSURANCE AFFORDED THER
DOCUMENT WrrH RESPECT TO WHICH THIS
POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN
MAY HAVE BEEN REDUCED BY PAID CLAIMS,
LTR
EMPLOYERS LIABILITY
LIMITS
PROPRIETOR!
TNERSIMCunvE
ICERS ARE tISFASE
RY LIMITS
0 EXCL ❑ 9947874 11 /05/2011 11 /05/2012
ER
:rage Applies is MA Operg— Only CIDENT
POLICY LIMIT
E: NO PARTNERS ARE COVERED BY THE WORKERS COMPENSATION POLICY.
CERTIFICATE HOLDER ANCELLATION
RANDALL BURSA
i
ULD ANY OF TFIEABOVE nescsuBED POUCaESBE cANc�LED e�aRe THE
178 STONECLEAVE RD MnoN DATETNEREOP. NOTICE WILL BE DELNERED IN ACCQROANCE
NORTH ANDOVER, MA 01845 m THE POLIO' PROVISIONS.
AUTHORIZED REPRESENTATIVE
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