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Home My WebLink AboutBuilding Permit #799 - 19 ACUSHNET STREET 5/4/2012BUILDING PERMIT TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received_ 2_ Date Issued: VY11-2— C LIS IMPORTANT: Applicant must complete all items on this nage -TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more. family � Industrial Alteration No. of units: Commercial Others: Repair, replacement- Assessory Bldg Demolition Other 5 -0 @M 3A7114 47 ON . M �?g Vw �7 m mv pq� MOM -b' Numb YA DESCRIPTION ION OF WORK TO RF PRF=;ZnPUr_n- eFa k2Z2a, Identification Please Type or Print Clearly) OWNER: Narne:- Zo &tj Phone: (617) 0/0 2306 ARCHITECTIENGINEER Phone: Address: —Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000,00 OF THE TOTAL ESTIMATED COSTBASED ON $125.00 PER S.F. Total Project Cost: $ FEE: a -Z) Check No.: -Receipt No.: Q�2 6- S - NOTE: Persons contracting with unregistered contractors do not have access to the guaranty and Location' I CyS `'J No. I t Date 2 -- TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ 670 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 25265 1306ng'Inspector '� 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 hiVIV N1 1, 4 TS HEALTH Reviewed on Signature COMMENTS 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 e -DPW Town Engineer: Signature: EA * cd �rli O w° U) o U w° rZo U ww a W 00 xI w w o0'4 U) w O. p°4 w w w v r� o z cn v o cn �rli O c c m c m e •L v C. 00 r : c � O y ,i V E _ O ' V V �aa Go N C. c ev w C.) � cm :mc M CD C* = �rli O Y V m e •L v C. �o ,i V E _ p e d Q ?:oc m Go N C.) � cm O z .N 2 O O a) � O v z O CL O CO) D O cm CA I Q 0 M E m co 3.0 a� CD L o a CL v�4 c C_-+ G O W vCD J .O C -G3 CL V CO) C _R CL 0 uj y LLI Y/ W W 19 W 0 The Commonwealth ofMassachusetis - Department oflndustrird Accidents Office of Investigations 600 Washington Street Roston, MA 02.111 www.massgov/dia Workers' Compensation Insurance Affidavit: BuUderslContractorsfElectrician,s]Plumbers ,Applicant Information Please Print Ledbly Name City/State/Zip l _ f��oT 2 % y�/ 9�. Phone #:�%� 5Fe Are you an employer? Check the appropriate box: Type of project (required): 1. [� I am a employer with 4. ❑ I am a general contractor and I 6. [] New construction ^ loyees (full aud/orpart-time) * have Hired the sub -contractors '1• remodeling 2. L► lam a sole proprietor or partner- listed on the attached sheet. x ship and'have no employees These sub -contractors have 8. ❑ Demolition working forme in any capacity. workers' comp. insurance. 9. El Building addition [No workers' comp. insurance 5. El We are a corporation and its 10.[] Electrical repairs or additions required.] officers have exercised their 3. ❑ I am a homeowner .doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself- [No workers' comp. c.152, §1(4), and we, have no 12.[]Roofrepairs insurance required.] employees. [No workers' 13.[] Other comp, insurance required.] ?Any applicant that checks box41 must also fill outthe section below showingtheir workers' compensation policy information. f Homeowners who submit this affidavit indicatingthey $ie doing all worlcand then hire outside contractors must submit anew 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 employee that is providing workers' compensation insurance for my employees ,,below is the policy and job site information. Insurance Policy 4 or S elf -ins. MG. #: Expiration Job Site Address: 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 requiredunder Section 25A o£MGL o. 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 ofup to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby cern er tli ain andpenalties ofperjury that the informationprovideldaabove is true andcorrect. - Signature Date: f 7a 6 C,),/) JD, Official use only. Do not write in flits area, to he 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 S. PIumbing Inspector 6. Other - - - Contact Person: Phone M - Information and Instruction's Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employeeis defined as ",..every person in the service of another under any contract ofhire,- 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 orpermit 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 ofits 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 certificates) 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 advisedthat this affidavit maybe Bubmittedto the Department of Industrial Accidents fox confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affiidavit 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 Ike. ' 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 permit1license 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 ormarked 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. Anew 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 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: The CQmMu wealth of Wssav usetts Tieparirxte,.t ofJ,dustrzal Accidents MOO of "estigatiou 6.00 WasbingtovL Street Boston, MA_ 02111 c1, # 617-7-274900 ort 406 or 1-877:MAS Revised 5-26-05 Fax # 617-727-7749 wwW.zx us,gov/dia �--.�•�UC7/��CO �j //.�if� UI9D� WORK PERFORMED AT: CONTRACTORS INVOICE E / DATE YOUR WORKORDER NO. OUR BID NO: s 0 • 0 ' • ' 1 �aY, , <12rv,'7oc oz/) �it5hi/% �a��'�,t �� 1 :��-%iirl/l cls !t/.�-,Fhi-�� • 45�/ C� Sr 2 /z7// 7"U 771-5b// IUfCU !mown/A' � chl FA/ ,9 'eJal it/ir ria u� r x/1/0 �upr% �/% x �,F-s 74 A-5 , ,Gl/Jf1 dllGli � . !7i r !7 � /7�F�/rl/✓ < <'C>/j � /�%i Ir l r� z � v All Material is guaranteed to be as specified, and the above work was performed in accordance with the drawings and specifications provided for he above work, and was completed in a substantial workmanlike manner f o ragreed sum of This is a ❑ Partial ❑ Full invoice due and payable by: Month In accordance with our ❑ Agreement U Prs'osa Dated TC8122 4 _C-ONTRAC ORS INVOICE Day Year Month Day Year �a y /Iu�n�ahPFcJ v�f WORK PERFORMED AT: CONTRACTORS INVOICE DATE YOUF3i WORK ORDER NO, OUR BIO NO. /lly6/N /DDG �!o 17 .333 3.3 5-00 ?& 7X33 I 5 7) lis — �rxrl .5��'G�t f/N 9 �� /f7 f-fr �. ✓Y� ,500 1300 a?� D .39� /00 fs3 tas'"d 33.3 0200 117 ,Y1/ ��, �� -Fd�� /�f ��.� ,�n-.. oo /00 a oo ~� c ya00 /,Yo 0 c? S-00 All Material is guaranteed to be as sp prov eV-f-o-+r� the aboork, and was \off i 117 , and the ete m a vork was performed in accordance with the drawings and specifications ntial workmanlike manner for the agreed sum of Dollars ($ ). This is a ❑ Partial ❑ Full invoice due and payable by: Month Day Year In accordance with our ❑ Agreement ❑ Proposal No. Dated Month Day Year TC8122 CONTRACTORS INVOICE Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS -095935 s`s�,`.� DANIEL H OLD • - - �.� 204 HUMPHR&YiSTREET SWAMPSCI TT MA 01907` Expiration Commissioner 03/20/2014 Office o ousumer airs mess ego ahoo HOME IMPROVEMENT CONTRACTOR a Registration: x154816 Type: Expiration: .4/10 12 013 Individual �y { i D REINOLDj l , DANIEL REINOLD , #r' 204 HUMPHREY ST El a SWAMPSCOTT, MA 01!Y07. Undersecretary i Dimension Number of Stories: Totals square e 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 Doc.Building Permit Revised 2010 Building Department The following is a fist 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 u Building Permit Application ❑ Certified Surveyed Plot Plan o 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) ❑ "ass 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 -.,.u:-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: Building Permit Revised 2008 Date. %1...`.. `........ . Of NORTH oZ. ? TOWN OF NORTH ANDOVER D PERMIT FOR GAS INSTALLATION ° 11,SSACNUSEt�y This certifies that .A . t, u. r /'` .. / . ,. 't/ ...... . has permission for gas installation . in the buildings of .. ? 1r .f -I? ii: ........................ . at ............ North Andover, Mass. Fee. 3> .1... Lic. No.'' 5.1..... ........ �.�.`. ? ....... . GAS INSPECTOR Check # ? z r. � N -- A4SSACHUSETTS L1NIFORM aPPLICATON FOR PERMIT TO DO GAS FITTING Type or print) Date NORTH ANDOVER, MASSACHUSETTS Building Locations Permits Amount S New ❑ Renovation ❑ Owner's Mame Replacement ❑ 5ric ?)c�KerM(A4 11Plans Submitted 3-5 _ (Print or type) Check ne: Certificate Installing Company Name flnLye-c pkv][ / H��I• (.o-. Corp. ��22 Name of Licensed Plumber or Gas Fitter CJQU[ti12 LURc�S ❑ Parmer. ❑ Firm/Co. INSURANCE COVERAGE Check one I have a current liability Insurance policy or it's substantial equivalent_ Yes No ❑ If you have checked ves, please in ate the type coverage by checking the appropriate box. Liability insurance policyOther type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter I42- of the Mass. General Laws. and that my signature an this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ ,-kaent ❑ herebv certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations pertormed under Permit Issued for this application will be in compliance with all pertinent provisions of the :Massachusetts State Gas, and Chapter 142 of the General Laws. By: Title C i tyi Town APPROVED it)Fric:; usF t)rNi_Y) Signature of dPlumber ❑ Gas Fitter �tilaste7 r—i Journeyman Plumber Or Gas Finer C\ck 53 tcense ivumoer 10h12v0s0b3T Advantage Claim Services 2100 Lakeview Ave. Dracut, MA 01826 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws, Ch. 139, Sec 3B To: Building Commissioner or Inspector of Buildings Town Hall address North Andover, MA 01845 01845 Re: Insured: Jeanne Savage Property address: 19 Acushnet St. Board of Health or Board of Selectmen North Andover, MA 01845 Policy #: HP2356076 Loss of: 05/01/04 File or Claim No. AD 7030 Town Hall North Andover, MA Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws Chapter 143, Section -6 to be applicable. If any notice under Mass Gen Laws, Ch 139 Sec. 3B is appropriate please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Glenn aua_rente Title: Adjuster On this date, I caused copies of this notice to be sent to the persons named at the addresses indicated above by first class mail. sOb3T Advantage Claim Services 2100 Lakeview Ave. Dracut, MA 01826 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws Ch. 139 Sec. 3B To: Building Commissioner or"/ Board of Health or Inspector of Buildings Board of Selectmen Town Hall address Town Hall 01845 North Andover, MA 01845 North Andover, MA Re: Insured: 19-21 Acushnet St Condo Trust Property address: 19 Acushnet St. North Andover, MA 01845 Policy #: SBP1978844 Loss of: 05/01/04 File or Claim No. AD 7031 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chanter 143, Section_6 to be applicable. If any notice under Mass Gen Laws, Ch. 139_Sec. _3B is appropriate please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Glenn Guarer_te Title: Adjuster On this date, I caused copies of this notice to be sent to the persons named at the addresses indicated above by first class mail. r -moW. i✓ `Pq . /'� ! / /