HomeMy WebLinkAboutBuilding Permit #492 - 188 SALEM STREET 12/20/2011Permit NO:
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
RIPTION OF WORK TO BE PREFORMED:
i� Identification Please Type or Print Clearly)
OWNER: Name: 4�2,1M mr rGvllp,l �
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED OST BASED ON $125.00 PER S.F.
Total Project Cost: $ 0.a �' FEE:
.a 7
Check No.: ��� Receipt No.:
NOTE: Persons contracting with unregistered contractors do not ha cess t the guaranty fund
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
DATE APPROVED
CONSERVATION Reviewed on Signature
COMMENTS
e
HEALTH Reviewed on Signature
COMMENTS
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 Usg000 Street
a 'tom �, .
Locat at 124 M Street . x s
Fire ¢DepmentMsignature/da77-77
te
art� . �
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.$10041000 fine
NOTES and DATA — (For department use
U 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 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 DEPARTMENTMFORM07
Revised 2.2008
Location
No. -I - Date // 0: 1
NORTH TOWN OF NORTH ANDOVER
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TOTAL $
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CERTIFICATE OF LIABILITY INSURANCE 10/25/2011 �
THIS CERTIFICATE IS ISSUED AS A NATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE
DOES HOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF
INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING IUSURER(S), AUTHORI29D REPRESENTATIVE OR PRODUCER, AND THE
CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. if SUBROGATION IS WAIVED, subject
to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not
confer rights to the certificate holder in lieu of such endorsement(s).
PNDDIICIM
CONTACT
MTM Insurance Associates LLC
575 Chickering Road
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PHONE YAx
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-MAIL
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North Andover MA 01895
ADDRESS:
PRIIDNMR
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North Andov r Building Corp
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Milton, MA 02186
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COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TU CERTIFY THAT TUE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TRE Z175URED NAMED ABOVE FOR TRE POLICY PERIOD INDICA7�D.
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 IS SUBJECT TO ALL THE 79BRITS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN
MAY HAVE REEK REDUCED BY PAID CLAIYIS. '
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TYPE, OF INSURANCE
POLICY NUMBER
POLICY EFF
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POLICY ERP
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EXECUTIVE t4TICERS RE
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11/11/2010
11/11/2011
F_L. DISEASE -PmarY L1H1T
$ 500,000
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$ 100, 000
CONHIMIS I Pi;SIIIAP11AN AT (IPF»AIJONS NR I.OVATINNS :-
CERTIFICATE HOLDER
CANCELLATION
Trim—
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EP.PIRATIOH DATE THEREOF, NOTICE WILL BE DELIVERED in ACCORDANCE 1-179 THE
POLICY PROVISIONS.
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- • Office of Consumervusi
Affairs andness Regulation
1 O Park Plazas Suite 5170
E6ton, Massachusetts 02116
c4
setts
Improvement Contx actor Registration
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Registration: .137552
Type: Private Corporation
Expiration: 11/26/2012 Tr# 205622
NORTH ANDOVER BUILDING CORP
JOHN LEEMAN E ---
P.O. BOX 132
N. ANDOVER, MA 01845
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Update Address and return card. Marls reason for change.
DP5•CA1 50M -04/04•G701216 F_I AddreSS�) Renewal L }umploynaQnf rLj Lost Card
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Construction Supervisor Lice6se ., s
License: CS. '82848
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Restricted to:. Oil
JOHN R LEEMAN JR
70 PILL®N ROAD
HT
MILTON, MA 02186
Expiration: 6/16/2012
t iiui�i >iuin•r . "
Tr#: 27-393
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The Commonwealth ofMassachusetts
Department ofludustrialAccidents
Office of Investigations
600 Washington Street
Boston, MA 02111
yv
www.massgovldia
Workelrs' Compensation Insurance Affidavit: Builders/ContractorslEleciricians/Plumbers
Applicant Information
Name (Business/organiiaiionllndividual):
Address: JPt 137_
City/State/Zip: IlU . Q 1 MC1 610 rPhone #:
Are you an employer? Chec the appropriate box:
1, �a employer with
4. ❑ I am a e
general contractor
Type of project (required):
2• ❑employees (full and/or part-time).*
i am a sole proprietor or
and I
have hired the sub -contractors
6. ❑ New construction
partner-
ship and have no employees
listed on the attached sh9et. 1
These sub -contractors have
7. ❑ Remodeling
working for me in any capacity.
[No workers' comp. insurance
F.
workers' comp. insurance.
5. ❑ We ato a corporation and its
8' ❑Demolition
9. El Building addition
required.]
3. I in a homeowner doing all
.officers have exercised their
10.❑Electrical repairs or additions
world
ys
myself. [No workers' comp.
right of exemption per MGL
c.152, §1(4), and we have
11. ❑ P1 b repairs
g p or o.dchtious
insurance required.] T
no
employees. [No workers'
12•❑ Roofrepairs
comp, insurance required.] 13.E l Other
*AHomeowners who submitthis
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation
policy information.
affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their wnrl -P,.,
y.
---T C"•• J +int—aL1V11.
oyer Matrsproviding workers' com
infopmation. pensation ins""""'fOrrny employees Below is tlzepolicy and job
site.
Insurance Company Name: Mal, 0 (/ r U
Policy # or Self -ins. Lic. #:
Mzz 3 (U 5 7% 1 ZU 10 Expiration Date:
Job Site Address:_ `f Dili�S ]"
City/State/Zip:
.Attach a copy of the workers' com ensation
p Policy declaration
licy
Failure to secure coverage as required under Section 25A ofMGL . 52 ge canolead to thewing the oimposition numbor and expiration date),
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER af criminal es of a
evesOf up to tions$250.0 a day against the violator. Be advised that a copy of Us statement may be forwarded to the Office of d a fine
Investigations of the DIA for insurance coverage verification.
r do Izereby .
nr�
unser tine paints and lties ofperjury that the information provided above is true and correct.
✓r «« use oncy..uo not Write in this area, to he completed by city or town offcial.
City or Town:
Issuing Authority (circle one): Permit/License
L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical inspector S. Plumbing g inspector
Contact Person:
Il 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 apartf rents 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 shallwithhold the issuance -or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for nny
applicant who has not produced acceptable evidence of compliance with the insurancd 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 ofpublic 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 -contractors) name(s), address(es) andphone 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 0 ice 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/liceiise applications in any given year, need only submit one affidavit indicating current
Policy information (ifnecessary) 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 marred 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 for any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOTrequired 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:
`J< Ie CoPkIMOWWealyth- o.i 1dassaeausetts
Department of Industrial .Accidents
®ice of Investigations
600 Washington StrWL
Boston; .A 02111
Tel. # 617-727-4800 ext 406 ox 1..877-M.SS.FE
Revised 5.-26-05 Fax # 617-727,7749
www.mass.;;ov/dia.