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HomeMy WebLinkAboutBuilding Permit #280-12 - 19 FERNCROFT CIRCLE 10/4/2012 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Aepo _ 2 Date Received Date Issued: �6 �� � L gIMPORTANT:Applicant must complete all items on this page LOCATION C L LF Print PROPERTY OWNER ��Z 1I /I/b 1-7, C�/L)Jnit# Print MAP NO: PARCEL: M�2 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 0 Industrial Iteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic, 0`Well ©1F1604plain ' 1041ands Watersfied►Disfrcf CTWater/Sewer . DESCRIPTION OF WORK TO BE PERFORMED: UP (YL c---r n4,- 11A L 4�,,e U M (Identifcati9 le� T pe r Print Clearly) OWNER: Name: � � / 7. /V Phone: Address: CONTRACTOR Name: (04q4` Mqtf I i --L) 0 Phone: �j �� �69 ~ 7 U Address: J�./�'' i C� ✓/ .a/ lJ �v Supervisor's Construction License: 6 Q v Exp. Date: l Home Improvement License: J Exp. Date: ARCHITECT/ENGINEER !��Cl Phone: / Address: / Reg. No. FEE SCHEDULE:BULDINff PERMIT.$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Tota! Project Cost: --7 6 0 C� FEE: $ ,33 'o 0 Check No.: Receipt No.: NOTE: eY on tracting with unregistered contractors do not have access to Athea my fund Sianature:.oRAgent/. caner :,.=: : _Siariatiare of,.. f contractor .: Location No. �� /Z Date MORTh TOWN OF NORTH ANDOVER O:�•�•n .•1ti0 F s M a y Certificate of Occupancy $ ISO-Must Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Y Check # 24653 wilding 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 COMMENTS HEALTH Reviewed on Signature COMMENTS { ` . Zoning Bo g and of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: 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.$10041000 fine NOTES and DATA-- For department use 13 Notified for pickup - Date Doc:.Building Penn it 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 ❑ 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 1 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 VOTE: 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 ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) TM 10/03/2011 PRODUCER 603.382.4600 FAX 603.382.2034 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Insurance Solutions Corporation ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 60 Westville Rd HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Plaistow, NH 03865 INSURERS AFFORDING COVERAGE NAIC# INSURED Gary Martino dba GDM Woodworks INSURERA: MMG Insurance Company 15997 7 Jasmine Dr INSURERB: Continental Casualty (AR) Atkinson, NH 03811-2253 INSURER C: INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.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 TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LTR NSR DATE MM/DD/YYYY DATE MM/DD/YYYY LIMITS GENERAL LIABILITY SC10950537 05/08/2011 05/08/2012 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES(Ea occurrence) $ 250,000 CLAIMS MADE OCCUR MED EXP(Any one person) $ 5,000 A PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO- JECT LOC AUTOMOBILE LIABILITY KA10950537 05/08/2011 05/08/2012 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY $ X SCHEDULED AUTOS (Per person) A X HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR F—I CLAIMSMADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION 6S59U64311P61410 07/17/2010 07/15/2011 X TORY L IT MS ER AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVELJ YD E.L.EACH ACCIDENT $ 500,000 B OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS K;ary Martino is excluded from the NH Workers Compensation & Employers Liability Policy CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Town of North Andover IMPOSE NO OBLIGATION OR LIABI OF ANY KIND UPON THE INSURE ,ITS AGENTS OR 1600 Osgood St REPRESENTATIVES. N Andover , MA 01845 AUTHORIZED REPRESENTATIV ACORD 25(2009/01) ©1988-2009 CORD COR R 10 All rights reserved. The ACORD name and logo are registered marks of AC RD NORTH Tomm of N_ 1 -_ , Andover. 0 �r o dover, 1VMass., /0'A // LAKE If, COCMICMEWICK s RATED BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System / BUILDING INSPECTOR THIS CERTIFIES THAT.......... � ........................'r�. ...... .... �!!r/d'���.................................................................... Foundation has permission to erect............::........................:. buildings on �/`........................ Rough .... ... ..... ....... .................. .................... � �c�� �j Chimney to be occupied as................ ...... ........................... .. ..�............ .........................................:.................................................. provided that the person accepting this permit shall in every respect conform to the terms of the application on file in 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 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO TARTS Rough a _ .. .... .......... ..................................... Service BUIL CTOR 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 Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner - Street No. SEE REVERSE SIDE Smoke Det. ' t ✓l� VO�/P7/I72MLC(��QG�L � CZCfLI(.OG'U4 Office of Consumer Affairs&B siness Regulation HOME IMPROVEMENT CONTRACTOR Registration:.-:107854 Type: sExpiration: _817!2012 Individual --------------------- • F.-:ter's:;:!'�._:;_ G D.MARTI11tC t..:.i Gary Martino - .,`., 7 Jasmine Drive Atkinson, NH 038111y':;, Undersecretary - Massachusetts- Department of Public Safety Board of Buildin- Re-ulations and Standards Construction Supervisor License License: CS 47257 Restricted to: 1G GARY D MARTINO 7 JASMINE DR ATKINSON, NH 03811 �--�-- Expiration: 10/29/2011 I ( nunissioncr Tr#: 10327 1 S - i The Commonwealth ofMassachusetts Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www.masx gov/d'ia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zi p��1. 1/L��) /d/!1 ����Phone#: Are you an employer?Check the appropriate box: _ 1.❑ I am a employer with 4, Type of project(required): ❑ I am a general contractor and I 2;employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction I am a sole proprietor or partner listed on the attached sheaet.t 7• emodeling '' ll shipi d have no employees These sub-contractors have S Demolition worg for me m any capacity. workers'comp.insurance. ❑[Norkers'comp.insurance 5. ❑ We are a corporation and its 9. ❑Building addition required.] officers have exercised their 10.❑Electrical repairs or additions 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 repairs insurance required.]t employees.[No workers' comp,insurance required.] 13.0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T Homeowners who submit this 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 workers'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: ' Policy#or Self-ias.Lic.#: Expiration Date: 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 required under Section 25A ofMGL 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 maybe forwarded to the Office of Investigations of the DIA.for insurance coverage verification. 71rdoher-7_e-bceri*1flte airs andpenalties ofperjury that the information provided abo Istr aandcorrect. Date: ?hone Officia7onaly- not write in this area,to becompleted by city or town offlcial City oPermit/LicenseIssuingcle one):I.Boarof 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 j oint 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-contractors)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 permit/license number which will be used as a referencd 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: Tie Commonwealth of Massachusetts Department of Tadustxlal Accidents O ce of InVestigatloiRS 600 Washington Street Boston;M-A 02111 Tel.#617-727,4900 ext 4406 ox 1-877-MASSAFE Revised 5-26-05 Fax#617,727-7749 Www.m.as�.Rovjdia