HomeMy WebLinkAboutBuilding Permit #63 - 2 PERRY STREET 7/25/2008Permit NO:
Date Issued
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
IMPO-RTANT: Ap:
LOCATION t
PROPERTY{
MAP"N0
Date Received
icant must
iplete all items on this page
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PROPOSED USE
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PARCEL:. ZONING DISTRICT Historic District yes
Machine Shop 'Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One family
Addition
Two mre 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 PREFORMED: "
-3/V 9A71+I A-PPRox D ),2-x' s
IdentificationPlease Type or P' t Clearly)
OWNER: Name: AA LbUE C -..t T A-AJu'� NP61�rA
Address: 1, F['12�p-t tJ"41/b6vC l;
.CONTRACTOR Name: Cc�6 EAntes . ktr Y&,Phone:
Address:J- , � K L�o')"tom "
Su ervisor's Construction License: �7l � Ex . Date � � b
M �
Home lmprovemen# License: Exp. Dale: / �P / 6
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERPIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ 9y FEE: $ 3�
Check No.: / C� d dO r/6,�Z Receipt No.: 13
NOTE: Persons contracting with unregistered contractors do not have access, to ghegyargnty fund
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 2.2008
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
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
4
COMMENTS
HEALTH
COMMENTS
DATE REJECTED DATE APPROVED
Reviewed on Signature
Reviewed on Signature
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 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.$100-$1000 fine
NOTES and DATA — For department use
❑ Notified for pickup - Date
................. _....................... __......... _......................... __............................. ---.................. _... __._........................ ---................................. _....................... _.... __._......................... ............................ __......................... _................................... __............................... _....................................
Doc.Building Permit Revised 2008
Location C? A�!�e
No. Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy, $
B uilding/Frame Permi
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # Id 0,4 0 (/,-?o�/
2 ; 3 5 7 ",j Building inspector
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Massachusetts - Department'Of Public Safety
Beard of Building R6�0ula&ifis`and Standards
Construction Supervisor License
License: CS 52493
Restricted to: 00
PETER M WALDEN
15 FORTUNE RD
WOBURN, MA 01801!
Expiration: 81812009
Tr##: 973
('mmissiuncr
R
,r
Acadia Insurance@
1. The Insured:
Acadia Insurance Company
Administered by Berkley Risk Administrators Company, LLC
P.O. Box 939, Pierre, SD 57501-0939 2510 E. Irwin, Pierre, SD 57501
Phone (605) 945-2144 Fax (605) 945-2048 Toll Free (800) 634-4589
NCCI Carrier Code 33391
Mathew Previte
dba: Ace Home Medics
57 Harold Parker Road
Andover, MA 01810
CERTIFICATE OF INSURANCE
WCIP
Policy Number: WC -20-20-000854-00
Risk ID: 0746866
Tax I D#: F 562616033
Policy Period: From: 9/29/2007
To: 9/29/2008
Date of Mailing: 5/812008
The Certificate is issued as a matter of information only and confers no rights upon the Certificate Holder.
This Certificate does not amend, extend or alter the coverage afforded by the Policy listed below.
This is to certify that the Policy of Insurance described herein has 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 Policy described
herein is subject to all the terms, exclusions and conditions of such Policy.
A
F uliF y y
'
Part One
Workers' Compensation
Statutory
Part Two
Bodily Injury by Accident $100,000
each accident.
Employers' Liability
Bodily Injury by Disease $500,000
policy limit.
Bodily Injury by Disease $100,000
each employee.
Should the above Policy be canceled before the expiration date thereof, the Company
will endeavor to mail 10 days written notice to the below named Certificate Holder, but
failure to mail such notice shall impose no obligation or liability of any kind upon the Company.
Certificate Holder's Name and Address:
Town of North Andover
384 Osgood Street
North Andover, MA 01845
Agency Name and Address
Durso Samuel J Insurance Agency
198 Massachusetts Ave
Andover, MA 01845
SOLE PROPRIETOR NOT COVERED.
Date Issued: 5/8/2008
BA3140
Fax: 978-475-6482
Cell: 978-604-5243
acehomemedies(a)Comeast.net
HIC License # 153165
Estimate/Agreement #:
167Permit
Estimate/Agreement Date
February 28, 2008
Now AccentinQ'Master Card & Visa
1-877-5 ODD JOB
Cost Estimate /Agreement for Services:
57 Harold Parker Road
Andover, MA 01810
Proposal Submitted To:
Miguel and Kerry Anne
Ezpeleta
2 Perry Street
North' Andover, MA 01845
Job Location:
2 Perry Street
North Andover
Bathroom Construction
Demolition,
Remove flooring & prep for tile with tile board, insulate & sheet -rock walls, install and case door, install double sink vanity & top,
3$00
Construction,
medicine cabinet, light bar over sink & shower. Construct wooden storage shelves or boxes with lids in the low comer of the room.
oordination and
Remove and replace window with vinyl, insulated, double -hung Harvey window with privacy glass. Tile the loor,;grout and seal
supervision
ile. Coordination and supervision of electrician and lumber. Obtain ernut.
Plumbing Allowance
Allowance for plumbing for installing new double sink and fixtures, new toilet ,& shower. Move radiator.
3450
Electrical Allowance
Allowance for electrical work to install new medicine cabinet lighting, GFI :outlet.and light/fan. Tins includes !the outlet and the
S600
light/fan unit. This will probably require three new circuits.
Materials
ix -panel solid pine door and basic brass hardware, mplacement vinyl dortble'hung insulated Haley window, insulation, filo,, and
870
all materials (except". the tile), wallboard suitable for gaster, er, wood for shdg�p and casin for winil,w and oor•
Disposal and Permit
175
Fees
]aster
Plaster installed on walls and ceiling
600
Total:
9,495
Hello Kerry Anne and Miguel,
Thank you for this opportunity. We greatly appreciate it and look forward to working for you to enhance your home. Just a few side notes regarding
this proposal. First, the allowances could be less than in thisproposaL Ifthingsgo a rell,and.ittakes less time than expected, you will be credited the
difference. For the plastering, we would recommend having this done, especially in a humid room Like a ,bath. Rut, please let nee kilow f t ou
jpillefe
to not have this done. We cm a¢ssistyouin choosing thefnllowing.items, double sink, varri t rjr1d ixtures, rnedidr e- abf,.c: rief 11 ;1,,�,
,,,.,
& hardware, :toilet ,& shower and tik - For:some of these items, w uu get d t., �r.. - r , �, :: alo,.. I
jif year
can be modifiedr n many ways to suityourr-needs and bud get Please let me knor� l.e f O ar ra' lar r l cat ga rratr . 11�E c.,,,raaa rz^e With a,. a I
week ofareg4anceand this should lake approx Iwo weeks to cotrTtete. T117i en y o a of a :!ha rr: r ... ,... �..... ;`�• r.
look orward to.speaking to ,you :soon
Regards,
Mat Previte
978-604-5243 (cell)
acehomemedics@comcast net
Prices are based on standard removal & installation. Additional work may be required due to conditions that we cannot see or predict. Additional costs will be conveyed to
you if/when we discover it to be necessary. Payment terms: 1/3 due upon start, 1/3 due when plumbing and electric is complete, 1/3 due upon completion.
Thank you for your consideration. We greatly appreciate your,business and look forward to providing you with exceptional clualil37, in
a professional, neat, timely and efficient manner. Our number,one is your comp sfrtifaction.
Accepted: The above prices, specifications and
conditions are satisfactory and are hereby accepted. Si tl3r
Bate
Horne Medics.is authorized to do the work as specified.
;Payment will be made as outlined above.
Signature Date
jl \ The Commonwealth of Massachusetts
Department of Industrial Accidents
�t t. i � Office of Investigations
:1 . u I
600 Washington Street
..� - . Boston MA 02111
www.mass.g ov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: t�IV D QV C� Phone #: Dq
Are u an employer? Check the appropriate box:
lam a employer with �_
4. ❑ I am a genera( contractor and I
111IIITTTTTT employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ 1 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
71emodeling
8. ❑ Demolition
9. ❑ Building addition
]0.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
*Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information.
t Homecwners -,0m submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indizating st:�;h.
$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.
Insurance Company Name:
Policy # or Self -ins. Lic. #: We ---ZD -Ito — 00015�— 0 0 Expiration Date:
Job Site Address: �. f2ez� �h� City/State/Zip: Nh OJ
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.
I do hereby cerci id r the Ins penalties of perjury that the information provided above is true andcorrect.correct.
Signature: ✓ Date: / r� Ii
Phone #: �/ — J ZN 3
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 #:
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 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-contractor(s) 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 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 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:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-7274900 ext 406 or 1-877-MASSAFE
Revised 5-26-05
Fax # 617-727-7749
www.mass.gov/dia
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