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Home My WebLink AboutBuilding Permit #148-2016 - 19 SECOND STREET 8/3/2015 BUILDING PERMIT o� NORTH q+w- 16 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION y0 Permit No#: ^` Date Received ,S7eu�Pa45 �SSgCHus�< Date Issued: U I [J�5 IMPORTANT: Applicant must complete all items on this page Bern. skrsS LOCATION S / � A Print PROPERTY OWNER J�✓� Ccs /� Print 100 Year Structure yes no MAPDI2D PARCELD� ZONING DISTRICT: Historic District yes no Machine Shop Village 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 ❑ Septic ❑Well ❑ Floodplain. ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: I �J Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: L(c ` o�'yy I Contractor Name: Pfio Email: o 'Soo .z,ci, Address: ^ ro r'J 11M, 6 3 o 7 Supervisor's Construction License: Exp. Date: r Home Improvement License: 9 Exp. Date: �� i ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.-00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$,2 . Total Project Cost: $ �'/`OuU� FEE: $ Check No.: , 3yS Receipt No.: ( � NOTE: Persons contracting with unregistered contractors do not have accessto e guaranty f Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ F E OF SEVJERz�,GE DISPOSALlic Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dempster on Site ❑ i THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF e U FORM I PLANNING & DEVELOPMENT Reviewed On Signature_ I COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments fr r Conservation Decision: Comments ` Water& Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIREIDEP.ARxTMENT -.TempADumpster.on.�site :yes: _tno� Located}at,12�AtMainrStreet: - _ FiretDepartmentaignature/date COMMENTS _ i 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.$10o-$1000 fine NOTES and DATA— (For department use) i LJ I r Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 i 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 OTE: 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 4, Copy Of Contract Floor/Cross Section/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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Permit � Building P 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 2012 I ECC Energy code Engineering Affidavits for Engineered products OTE: 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 2014 Location l —x , No. Date • - TOWN OF NORTH ANDOVER • r ,tCertificate of Occupancy $ r; H Building/Frame Permit Fee $ :V�7 Foundation Permit Fee $ y Other Permit Fee $ 3 , TOTAL $ r 0 Check# t� IBuilding Inspector r , NORTH . ( ver 0 J_ _n No. ,� 1 � o h ver, Mass, 2.o i sJ A- COC NIC MI WICK �1� 7d ADRgTED I"P�,`'�5 1S � - BOARD OF HEALTH- Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ........ !. ... �..... ^ . BUILDING INSPECTOR ..... . ..... Foundation has permission to erect .......................... buildings on .... .�1'., ... �C ......... ...�..... ....... 0 _"r� Rough to be occupied as .. .. . .. ....�4�.IF1.N�?.... .... �1.... .IIM .��,�.................. Chimney provided that the person accepting this permit shall in every laect conform to the terms of the application Final on file in 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 CONSTRUCTION STARTS Rough Service ................................................................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. Smoke Det. Propoat Page# of pag( I -�C) luso. -- % ca4a HOYT MASONRY PO a0X 1136 NYMOND NH 03077 U 978*390*3456 i PROPOSAL SUBMITTED TO: JOB NAM�.� JOB# ADDRESS JOB LOCATION DATEDATE� f �-f- DATE OF PLANS, - / _,s- PHONE# r FAX# n 7 P - 6 S�� ARCHITECT Ix�e L-1 0/ hereby submit specifications and estimates for: /1 �,�r tis kr�?}�yS. . qi t. . . 7..EAlE - �t��► �� G.�/�,,. _ 77ye prop a hereby to furniV material and labor-complete in accordance with the above specifications for the sum of: $ A-11C Vvf J� , av Dollz with payments to be made as follows: Any alteration or deviation from above specifications involving extra costs ! Respectfully will be executed only upon written order,and will become an extra charge ��+++ Submitted over and above the estimate. All agreements contingent upon strikes, / I accidents,or delays beyond our control. p /e x V Note—this proposal may be withdrawnus if not accepted within _days. Rcceptance of i3ropoWd The above prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payments wilt be made as outlined above. Signature Date of Acceptance + 2=2 - ) -5-- Signature A-NC3819/T-3650 09-11 The Commonwealth of Massa chusetts z . Department of IndustrialAccidents = d 1 Congress Street, Suite 100 Boston,MA 02114-2017 www mass.go v/dia SJ• Workers'Compensation Insuranice Affidavit:Builders/Contractors/EIectricians/Plumbers. TO BE PILED WITH THE PERMITTING AUTHORITY. AvOicant information Please Print Ledb Name(Business/Organization/Individual): ,jU✓I _ Address: O f' o City/State/Zip: -- -.4 14 cl 7 2. Phone Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction IF]I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capac ty.[No workers'comp.insurance required.] 9. ❑Demolition I❑I am a homeowner doing all work myself,[No workers'comp.insurance required.]t 10 []Building addition 4.❑I amla homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.[]Electrical repairs or additions proprietors with no employees. '' 12.0 Plumbing repairs or additions 5.`0�I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.[��R/oof repairs `C�These sub-contractors have employees and have workers'comp.insurance. 6.Q We are a corporation and its officers have exercised their right of'exemption per MGL c. 14. Other p 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] *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 a new affidavit indicating such. TContractors that check this box must-attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-conlraciors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees.',below is the policy and job site information. t Insurance Company Name: C1 I '-1 �J-�Pwcle 1/7 17 Policy#or Self-ins.Lie.#: U13 0& go 2 Expiration Date: JL/)-/ —7 2oi L Job Site Address: Ci�/State/Zip� AJover,:MA. Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert' under the pains ndpenalties ofperjury that the information provided above is true and correct. Sim e: � / Date: 3— Phone 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#: i 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 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 Iocal 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 foi•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 reference number. In addition,an applicant that must submit multiple permittlicense applications in any given year,need only submit one affidavit indicating current poll' 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 bum leaves etc)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia L0110312015 08:45 Stewart Ltdiinsurance Managment TAX) P.0011001 R1CERTIFICATE OF LIABILITY INSURANCE e%3i`2015Y) CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT 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 INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the polloy(les)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 lights to me cortlflcato holder In lieu of such'endoreement(e). PRODUCER STEWART LTD/INSURANCE Mt;1RT PN rEie (603) 895-2200 (603)8 5-6761 10 Fraetotrrri Rd AODRE :brant@w'stewartinsurance.com Raymond, NH 03077 IN$URER(0) ARrORDINO OOVORAON NAIL/ INSURER A:Pe®r1®Ss 1naurance INSURED Hoyt Masonry LLC INSURER 8,Cincinnati. insurance Sean Hoyt INSURER C; PO BOX 1136 INSURER D! Raymond NH 03077 INSURER E: SURER F; COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. f�TR TYPE OF INSURANCE piao WVD POLICY NUMBER M D M LIMBS X COMMERCIAL OQNERAL LIABILITY EACH OCCURRENCE s 1 000j000 000 CLAIMS-MADE D OCCUR PREMISES Ea o=Urrencel $ 300,000 MED EXP(AnX oneperson) $ 15,000 A BKS55460465 04/21/15 04/21/16 PERSONAL&ADI/INJURY s 1,000,000 . GEN'L AGOREOATE LIMIT APPLIES PER: GENERAL. AGGREGATE $ 2,000,000 POLICY E]JELOC PRODUCTS-COMP/0P AGO s 2r000,000 OTHER! & AUTOMOBILE LIABILITY e $ 1 000 000 ANYAUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BKS55460465 04/21/15 04/21/16 A AUTOS AUTOS BODILY INJURY(Per aeoldenl) $ X HIRED AUTOS X NON-OWNED $ AUTOS Per accident s x UMBRELLA LIAR' X OCCURCU60020697 07/07/15 07/07/16 EACH OCCURRENCE s 1,000,000 ARD, EXCESS LIAR CLAIMS-MADE AGGREGATE $ 1,000,000 D RETENTIONS 10 000 $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETDR/PARTNERfWCVTIVE v!N UBOG14039 07/07/15 07/07/16 E.L.EACH ACCIDENT 6 100 000 OFFICEWMEMSER EXCLUDED? a NIA (Mandatory[it NH) E.L.DISEASE-EA EMPLOYE,$ 100,000 If Yyeea deacribp undel' OESGtRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT s 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached N more specs Is required) CERTIFICATE HOLDER CANCELLATION Evidence of Insurance SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE North Andover MA THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS- , AUTHORIZED REPRESENTATIVE I _ ®1988-2013 ACORD CORPORATION- All rights resolved. ACORD25(2013/04) The ACORD name and logo are registered marks of ACORD G.. / 9 q --P T-7y -;�—