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HomeMy WebLinkAboutBuilding Permit #774 - 20 COMMONWEALTH AVENUE 5/15/2013TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: Date Received Date Issued: S � �) (� IMPORTANT: Applicant must complete all items on this page LOCATION Mrvv04 c4 ��� v� PROPERTY OWNER Q ..�n� .n In C- ri 190 MAP NO: ft2-. PARCEL: Print 100 Year Old Structure yesno ZONING DISTRICT: - Historic District yes no Machine Shop Villacle yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition YTwo or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial !'Repair, replacement ❑ Assessory Bldg ❑ Others: Cbemolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer DESCRIPTION ©ooq_, , WA tL,(,nd-DwS - OWNER: Name:-� AAArcee- CONTRACTOR Name:6t—_ Address: bh NtK1-UKmtU: g lea --1 � (4C- r Pl_A:5J\ o� int Clearly) L14"49e,4 , Phone: 4 �A 0/S-9 6 Supervisor's Construction License: CS °ra2H Exp. Date:f Home Improvement License: 131 � 5_6P Exp. Date: 1 / % ARCHITECT/ENGINEER Phone: Address: Reg. No FEE SCHEDULE: BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ 3s() 0 FEE: $ 4 Z Check No.: C Receipt No.: 40 �- NOTE: Persons contract *n w'th unregistered contractors do not have access to a guaranty fund Signature of Agent/Owner Signature of contractor Plans Submitted ❑ Plans aived ❑ Certified Plot Plan ❑ Stamped Plans It 1 Location^_( No.7) 4-:-G Check #�� 26402 Date 1S TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Building 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 COMMENTS HEALTH COMMENTS Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes_.. Planning Board Decision: Conservation Decision: Comm Comments Water & Sewer Connection/Signature & Date Driveway Permit c DPW T owo ]Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMi_f-T -Temp Dumpster on site yes no Located at 124 Main Street Fire Departiner gignature/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 MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA — (For department use B Notified for pickup - Date Doc.Building Permit Revised 2010 No 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 o Building Permit Application o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract o Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Crossection/Elevation Pian Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Li Mass check Energy Compliance Report (If Applicable) o 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) o Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses a Workers Comp Affidavit a Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o Mass check Energy Compliance Report o 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 app, al 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 2012 5/15/2013 12:99 PM FROM: Risman Byette Insurance Agency Inc TO: +1 (978) 688-9542 PAGE: 002 OF 002 ACORD0CERTIFICATE OF LIABILITY INSURANCE �./ DATE(MMIDDIY 2/19/20133 THIS 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 policy(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 rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Commercial Lines NAME: Byette Insurance Agency, Inc. A)�NN E (978)851-6678 AIC No: (978)851-0106 853 Main St. E-MAIL INSURERS AFFORDING COVERAGE NAIC # EACH OCCURRENCE $ 1,000,000 INSURER -National Grange Mutual Ins Co 14788 Tewksbury MA 01876 INSURED INSURER B : INSURERC: Jay Stamp, DBA: West Tewksbury Contractors 79 James Avenue INSURER D : INSURER E : -- INSURERF: Tewksbury MA 01876 CUVFFIAGFS CFRTIFICATF NIIMRFR•L:1LV Or Lowest RF\/I CIf1N NII11lIR1I=0- 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 MAYHAVE BEEN REDUCED BY PAID CLAIMS. I TR TYPE OF INSURANCE INSR ADDL WVQSUBI POLICY NUMBER MMIDPOLDIYYYY POLICY EXP MMIDDIYYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FOOCCUR HPO13913 /10/2012 /10/2013 EACH OCCURRENCE $ 1,000,000 IJAMAGE 1=17= PREMISES Ea occurrence $ 5,000 MED EXP (Any one person) $ 500,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY M PR& LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ A AUTOMOBILE X LIABILITY ANY AUTO ALL OWNED X SCHEDULED AUTOS AUTOS HIRED AUTOS X AUTOS ED 9013913 0/1/2012 0/1/2013 OBINEDtSINGLE LIMIT 500,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ Perracciden tPROPERTY DAMAGE $ Underinsured motorist $ UMBRELLA LIAB EXCESS LIAB Ft OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATIONV� AND EMPLOYERS' LIABILITY Y / N ANY PRO FIR IETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED9 (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A STATU- OTH- TORY'IMII ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) ..�r�irrr •.r�i nvw�n t.ANt-tLLAIIUN (978)688-9542 North Andover Building Dept 1600 Osgood Street Bldg 20, Suite 2-36 North Andover, MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Lamarche/SHAWNA AI.UKU Lo (LU7UIUo) © 1988-2010 ACORD CORPORATION. All rights reserved. INS025 (201005).01 The ACORD name and logo are registered marks of ACORD el rA JOU _ LL O m - L aV_+ -- O O LL ..i E a0+ N U Q_ U1 N N Z Z m C .2 'O 7 O LL L O O OC > C E L U C LL H Z Z co J d L 7 O d' R C LL H Z U ~ W W L 0to O d' U N N m C LL oc O LU0 Ln Z C7 :3 O O' m C LL Z oc a CL W 0 ui Ll. 7 m Z v0 N D E N O R � R O � as N O � Q r y N R y ?.dV: _ • 0- 0 w •' V 3 N R �E � d L >�Ceh i>-% L N > c CD R w o �o� 0 ; 0 Q c U) o s Eoo a d z CL c t mn 3 �> o �c c O N CL (D 0 c c c a L L R "a O N V m R N W -0— O O " u - LULL 'y d N C O 'Q.� O LW E O LW Q CD . F. V Q O -.0 Q m co N -0 c c OJ 2 R O L c o 1 i oU) CO Z U W CL x W C.1 H U) W CL Z w O F" V W CL N z CD z m ti •.v L7- -2 = 0 12 E I.L Z 0 .E L O V cc O V .N 0 cc _cc 1W The Commonwealth ofVlassachusetts Department of IndustrialAccWnts Office of Investigations 600 Washington Street Boston, MA OZIIX www.mass.gov1d1a Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrlicians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ���--�� Address: �4 ✓we S UE City/State/Zip: Phone #: %� Are you an employer? Check the appropriate box: - Type of project (required): 1. J3 I am a employer with 4. ❑ I am a general contractor and T 6. ❑ New construction employees (full and/or part-time).* 2. El am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. �• Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. Building addition [No workers' comp. insurance 5. F1 We are a corporation and its 10.❑ Electrical repairs or additions required.] 3. ❑ I am a homeowner, doing all work officers have exercised their right of exemption per MGL I L ] Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs insurance required.] employees. [No workers' 13.❑ Other comp. insurance required.] ?Any applicant that checks box#I must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they ire 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. 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. Lie. Expiration Date: 3 ! y Job Site Address: 10 CB -V .1 V-ts `1 /� 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 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 maybe forwarded to the Office of Investigations of the DTA for insurance coverage verification. I do hereby co t?ry un gr tli ains and penalties of perjury that the information provided aboveis true and correct. Sienature: \ Date:/ / 5/) / D V- DS,J Official use only. Do not write in this area, to be completed by city or town official. City or Town: PerniffMcense # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Pers Phone #: Information and nstructio rns 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 ofits 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) 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 maybe 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 (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 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 io bum 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 Gorl< onwealthofMaSs,gc _vsetts� Dopartiment ofIndustrial .A celdents Office gfI11VeStigaf14nS 600 Wasbiztpa Stxeet Roston? MA Q2 X Z Z TeX, # 617-727,4900 oxt 406 or 1-877, MASSAFR Revised 5-26-05 Fax# 617-727-7749 ^crnrrctr rnnnn n...=t.i.:.. WEST TEWKSBUR Y CONTRACTORS 79 James Ave. Tewksbury MA 01876 978-808-0599 Rudolph Cataldo 20 Commonwealth Ave. North Andover MA. . . [SATE 5/13/2013 /3 Date l CERTIFICATE OF LIABILITY INSURANCE ATE (MMIDD/YYYY)ACORD D05/14/2013 PRODUCER 781.729.8770 FAX 781.729.0053 John A. Pierce Insurance Agency, Inc 934 Main St. Winchester, MA 01890-1994 THIS 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 POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED Jay Stamp DBA: West Tewksbury Contractors 79 James Ave Tewksbury, MA 01876 INSURERA: Utica Mutual Ins Co 0019 INSURERB: 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 LTR DD' NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MM/DD/YYYY POLICY EXPIRATION DATE MMIDDIYYYY LIMBS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE T R NT D PREMISES Ea occurrence $ CLAIMS MADE 7 OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ POLICY PRO LOC JECT AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT $ (Ea accident) BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY $ (Per accident) HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE $ (Per accident) ' GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO AUTO ONLY: AGG $ EXCESS / UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE —] OFFICER/MEMBER EXCLUDED? 4611053 03/11/2013 03/11/2014 X TORY LIMITS ER E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE - EA EMPLOYEE $ 100,000 (Mandatory in NH) If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ S00,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS perations usual to interior carpentry. Jay Stamp has not elected coverage under the workers compensation policy. CERTIFICATE HOLDER CANCELLATION North Andover, Town of Attn Building Dept 1600 Osgood St North Andover, MA 01845 ACORD 25 (20091011 GAY • 072 GAA QCA7 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 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR AUTHORIZED REPRESENTATIVE Kevin Pierce (ci i9RR-20n9 ACORn CORPORATION All rinhfc racarvarl The ACORD name and logo are registered marks of ACORD ' ��-i000Y!//jtOI/.CC=PQLU� M. ✓(/�Q.ddCZCiLLLdQ�6 office of Consumer Affairs & Business Regulation HOME IMPROVEMENT CONTRACTOR I t Registration: 31756 Type: Expiration: 9/12014 DBA i W T TEWKSBURX_CONTRAGTORS ...........; Il JAY STAMP �. 79 JAMES AVE.r_,: ;;A+ TEWKSBURY,MAOi870;_r Undersecretary I i Massachusetts, Department of Public Safety t P Board of Builging Regulations and Standards Construction Supenicor r License: CS40224 j Al�c,(, JAY 'M STAMI � 79 JAMES AVE TEWKSBUO- M 01876 =, Commissioner Expiration 05/09/2014 t" f