HomeMy WebLinkAboutBuilding Permit #662 - 184 MIDDLESEX STREET 4/12/2007rs
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATIO7112
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Permit NO:6�Date Received lz�
Date Issued:
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TYPE OF IMPROVEMENT
IMPORTANT: Applicant must complete all items on this page
LOCA 1 ON
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Non- Residential
❑ New Building
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PROPERTYOWNER. C
Rrin
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No. of units: 3
0 Commercial
k Repair, replacement
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MAS' NU:
t rPARCEL �A ,
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ZONING DISTRICT. Y
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HISTOR16 DISTtZICT ves, nc� =
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
0 One family
❑ Addition
Two or more family
❑ Industrial
0 Alteration
No. of units: 3
0 Commercial
k Repair, replacement
❑ Assessory Bldg
0 Others:
0 Demolition
❑ Other
0 peptic C} ll/11
i Flraldplain i lflfelads,
C] ,'Watershed C7�srt'
UaferlSewer
v yAp
jj lI Ut5(:KIP I ION OF WORK TO BE PREFORMED:
JV�� IA
1(kcp M eS:), (hUiS fn., IMP,71A IAn(J1P r'IAII or.vn.
(4tAA SEK, WiVlu 0w3
Identification Please Jype or Print Clearly)
OWNER: Name: C_k_�_ ,, ---N- V--, Phone:
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: $ 30, J�c3 C� FEE: $
Check No.: Receipt No.:
`� �o//--
C S�
NOTE: Persons contracting with unregistered contractors do not have acc ss to the guaranty fund
Signature of Agent/Owner Signature of contractor,
9
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
DATE REJECTED
CONSERVATION11
COMMENTS
DATE REJECTED
HEALTH
COMMENTS
DATE APPROVED
DATE APPROVED
11
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Water & Sewer Connection/s
Located at 384 Osgood Street
Comments _
Comments _
FIRE, DEPARTMENT -Temp Dumpster . n,Fsit_. .: yes
Located at 124 -*Main Street ..a
Fire Department s gnatureldate
COMMENTSa
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 2007
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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2007
Locaflon LOW Awk
No. &1� Date
40RTh TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ --Ye2601
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check q�-D /& —
201 17
Building Inspector
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
`� www mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information - Please Print Legibly
1
Name (Business/Organization/individual): R( k e COV, S ty UQ I1 U " ( 6 1�, (
Address:
City/State/Zip: �o IduyPiv AIN M16 Phone #: ��} �� R Z- IM z
Are you an employer? Check the appropriate box:
1. I am a employer with 3 4. EI '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.
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. ❑ I 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
10.0 Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.0 Roof repairs
13.❑ Other
Tony applicant tnat checks box #I must also till 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 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. i i
Insurance Company Name: SS Q (I (/lA e a ,r� 1 {Yi tDC 6 M A /(/l ) o ff L C v kg ye (0.
Policy # or Self -ins. Lic. #: V UI / ((3 p C1 `�D 0 0 [ 1 OQ G Expiration Date: l0 / 6 / jjo7
Job Site Address: 1%1 /1111 I e�(eA Je S e X SS City/State/Zip: Ala Y LA, 1U aoP,Y Art 011
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.
r
I do hereby cert' nder the pains and penalties of perjury that the information provided above is true and correct.
e(
Phone #: " - V M(— (— 6 —yq k
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 #:
This warranty gives the owner specific legal rights, and owner may also have other
rights which vary from state to state under Massachusetts law, sales of goods carry
an implied warranty of merchantability and fitness for a particular purpose.
XII. COMPLETENESS OF AGREEMENT FOR EXECUTION
The owner is hereby advised that he should not sign this Agreement unless and
until all blank sections have been filled in or marked as void, deleted or not
applicable, and until all exhibits or referenced documents that are incorporated
herein are attached hereto.
XIII. COPY OF AGREEMENT TO BE GIVEN TO OWNER
This Agreement is governed by the Laws of Massachusetts. It must be executed in
duplicate, and an original signed copy hereof given to the Owner at the time of
execution. No work under the Agreement shall begin prior to the signing of the
Agreement and transmittal.
RIGHTS TO CANCEL
The Owner may cancel this agreement if it has been signed by the Owner at a
place other than an address of the Contractor which may be his main office or
branch thereof, provided that the Owner notifies the Contractor in writing at
his main office or branch by ordinary mail posted, by telegram sent or by
delivery, not later than midnight of the third business day following the
signing of this Agreement. See attached Notice of Cancellation.
Note: This proposal may be withdrawn by us if not accepted within 30 days.
HOMEOWNER: DO NOT SIGN THIS CONTRACT IF THERE ARE ANY
BLANK SPACES.
Owner's Signature +, /�. t'�-. ' !`;_ Date Signed
Owner's Signature':11 `';�. ` .a Date Signed.
Contractor's Signature ! Lil`i ��%4" Date Signed 2
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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Industries of Massachusetts Mutual Insurance Company
Burlington, Massachusetts NCCI NO 26158
(800) 876-2765
ITEM
1 The Insured Ratte Construction Co
Mailing Address: 10 Main St FI 2
(No. Street
❑ individual ❑ Partnership ® Corporation ❑ Other
Other workplaces not shown above:
POLICY N0. I VWC 6004550012006
PRIOR NO. I VWC 6004550012005
North Andover MA 01845
Town or City County State Zip Code
FEIN 04-3247039
2. The policy period is from10/06/2006 to 10/06/2007 12:01 a.m. standard time at the insured's mailing address.
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 work in each state listed in item 3.A.
The limits of our liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident
Bodily Injury byDisease $ 500,000 policylimit
Bodily Injury byDisease $ 100,000 eachemployee
C. Other States Insurance: Coverage Replaced By Endorsement WC 20 03 06A
D. This policy includes these endorsements and schedules: SEE SCHEDULE
4. 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 change by audit.
Classifications Premium Basis Rates
GOV
CLASS
Estimated
Per $100
Estimated
Code
Total Annual
of
Annual
No.
Remuneration
Remuneration
Premium
INTRA 177476
SEE EXT
NSION OF INFOR
ATION PAGE
Minimum premium $ 500.00 Total Estimated Annual Premium $ 7,002.00
As indicated, interim adjustments of premium shall be made: Deposit Premium $ 5,462.00
❑ Annually ® Semi Annually ❑ Quarterly ❑ Monthly
MA Assessment Chg.
$6,682.00 x 4.1920% $280.00
This policy, including all endorsements, is hereby countersigned by Q?,6 &W, 09/15/2006
Authorized Signature Date
GOV
STATE
GOV
CLASS
KIND
AUDIT
PLACING
OFFICE
CLAIM
OFFICE
NAME
CHECK
SAFETY
GROUP
MA
5645
6
605
WC 00 00 01 A (11-88)
Includes copyrighted material of the National Council on Compensation Insurance,
used with its permission.
MacDonald & Pangione Ins Agcy
P O Box 428
No Andover, MA 01845