HomeMy WebLinkAboutBuilding Permit #830-2016 - 20 JOHNSON STREET 1/21/2016BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
1�1
Ile
Permit Nog. Date Received
Date Issued: ( 1 -2-k t I -
INTORTANT: Applicant must complete all items on this page
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
0 New Building
11 One family
11 Addition
11 Two or more family
11 Industrial
i?�Iteration
No. of units:
11 Commercial
e"Repair, replacement
0 Assessory Bldg
11 Others:
0 Demolition
11 Other
0S t* 0 Wel—I
pp 1C
0 Floodplain EIW6'tlan-d--s--------------El
W atershed District
Ovatertsewer
D
3TIO� OF WORK TO BE PERF-ORMEEN-
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Identification - Please Type or Print Clearly
OWNER: Name: /1a*t17ee_ Pe4,t1Y,1!VS+ P h o n e: Svof
Address: P. 05>. 19&x
Contractor Name
0
Address: 67? 4,�0,4, 010� Ox-�Yt
Supervisor's Construction License: 0,74�30 11 Exp.-- Dat'
e .
Home Improvement License:
Exp.' Date.
ARCH ITECT/ENGI NEER 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: $ LO 4pp FEE: $— /6.)-0
Check No.: 9,110 Receipt No. - � 41dr
: 'r
Plans Submitted El
I/
Plans Waived D Certified Plot Plan 11 Stamped Plans El
DISPOSAL
I! 0_�'
FypF_,6F
�] w:WERAGE
-T
I ic Sel
"6 ji
Tanning/N4assage/Body Art
Swinuning Pools El
well
Tobacco Sales El
Food Packaging/Sales [I
Private (septic tank, etc.
Permanent Dumpster on Site El
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On Signature
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: --Zoning Decisionlreceipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date DrivewaV Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
F1147EbEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signatureldate
COMMENTS
Dimension
Number of Stories: Total square feet of floor area, based on E�x't4rior�-,dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires.l.approvall 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)
U Notified for pickup Call Email
Date Time Contact Name
Doc.Building Pennit Revised 2014
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
ZBuilding Permit Application
Li 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/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (if Applicable)
• Mass check Energy Compliance Report (If Applicable)
Lj 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)
u Building Permit Application
L3 Certified Proposed Plot Plan
o Photo of H.I.C. And C.S.L. Licenses
Ei Workers Comp Affidavit
ci� 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
ci 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 2014
Location
No. 2,C) Date
Check # 1� /M
TOWN OF NORTH ANDOVER
Certificate of Occupancy $—
Building/Frame Permit Fee s-6—)ZL—
Foundation Permit Fee $
Other Permit Fee $
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Ae Commonwealth of Massar.chusefts
fIndustrialAccidents
Department o
I Congress Street, Suite 100
-2017
Boston, MA 02114.
www.mass-govldia
Workers, Compensation insurance Affidavit: Buffders/Contractors/FIqctyielansIPlumbers-
TO BE F"D WITH THE PEP2&TTING AUT"OPJTY' Please Pint Le*bl-
Ap-plicant
NaMe (B-Lisiness/Orgailization&divid'Llal):
Address:
Oilv/�Iqfnfe/zi-n:
Are you an employer? Cliec'ktheapRopriate box;
Phone #:
1.[] 1 am a employer with ___�_�PIOYCe3 (fall and/Or Par"'ma).t.
I am a sole proprietor or Partnership and have no employees Working for me in
any capacity. (No workers, comp. insurance r ' equired.]
3.0 1 am. a homeowner doing all work myself pTo workers, comp. insurance required.]
4. Al 'am a W owner d WEI be hiring contractors to conduct all work on my propertY. IWill
ensure thaEePont,11tors either have workers' compensation insurance or are sole
S. rl I am a general contractor and I have hired the sub-coiitractors: listed on the attached sheet.
'fhesb s�b-contractors&�e em"ployees and have workers' cor�p. insuranco�
6.E] we are a corporation and its offlqers have exercised their right of 'exemption per MG1, c.
152,§I(4).an� "have ' "' ' �s. Vo wor�ers' comp. insurance required.]
'We not,"
t Yloye
Type of project (muired):
7. E] New construction
8. EA Remodelhig
9. El Demolition
10 F1 Buil4ing addition
I J.FJ Electrical repairs or additions
13.E] Roof repairs
14.El Other
1noll information.
*Any applicaritthat checks UoX#1 must also tM OUM10 SeCTIOR UMUW "511UW.Mr, — n—
t s afA y are doing aa work andthenhire outside contractors must submit anew affidavit indicating such.
I Homeowners who sob�fit U davit indicatiAg the
Tcootraj�tors that check this �ox rt�ust-attacfied an additional sheet showing thp name of the sub -contractors and state whether or not. those entities have
employees. If the sub-c6fi6cf6rs fia�� emplojeeg, le� ifiuft provido their workers' comp. policy number.
y emplbyees.' Below ls'thepoficy andjoh site
I am an employer that ispiavidingworNys' compensation insurancefor m
information.
Insurance Company
Policy # or Self -ins, Lio. #* ExpirationDate:
fob Site Address: 2o \ e) A CitylState&ip: k14 /'�S "��
Attach a copy of the Workers' cbinipeWation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under MCYL o. 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 fme 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. Is ir e and correct.
I do hereby cerdfy under thepains and t1za V1 e
t the informationpro U, d b 740
X�(-:-=1,7 Date: M�l —
Ofjlelal use only. Do not write in this area, to be cOMPleted bY city Or town official
City or Town:
Permit/License 0
Issuing Authority (circle one): i
1. Board of E(ealth 2. Building Department 3. CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: — phone#:
Massachusetts General Laws chapter 152 requires all employers to provide workers, compensation for their employees.
A '-N
Pursuant to this statute, an employee is deflned as " ... every Person in the service of another under any contract of flike,
expres� or implied, oral or written.', I
Aix employer is define d as "an ind&i dual, partuersWp, as s o ciatio�n, corp oTation or other legal entity, or' any two or more
of the foregoing engaged in ajoint cnf��riso, and including the legal representatives of a deceased employer, or the
receiver or truAeo of an individual, partnership, association or other legal entity, employing employees. Huv�cver the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant ofthe
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 b6 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 covera*'g*e required."
Additionally, MOL chapter 152, §25C(7) states "Neither the commonwealth nor any of its 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 contiacting authority."
Applica
Please fill'out the -workers' compensation affidavit completely, by checking !h6boxes that apply to your situation and, if
necessary, supply sub-'contractoi(s) name(s), address(es) and -phone number(s) along with their cortificate(s) of
—insurance.—L-imite&L-iabilibr-C-ompanies-(LL-1a)-or-L-imited-L-iabtitTPatmrsFh-ip—s(LLP),—with-n-o—empi,oydeso erthantho
members or partners, are not required to can'y workers' compensation insurance. 1fanLLCorLLPdo . es have
employees, a policy is required. Be advised that this affidavit may be submitted to the Depattment. of 1dustrial
Accidents fbi confirmation ofinsurance, coverage. Also be sure to sign and date the aifidavit. Theaffidavit'should
be retai-ned to the city or town that the application for the permit or license is being requz�,stod, noi the De�artment of
ThdustrialAccidenis. �hould you have any questions regarding the law or ifyou'are r6q�#e� to obtain a workers'
compensatioA polfc;�, please call the Department. at the number listed below. Self-iiisur6d companies sh.puld'entor-their -
self -insuran'c'e 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, mirabor which will be used as a reference number. Th addition, an applicant
that must submit multiple Pormit/liconso applications in any given year, need only submit one affidavit indicating current
Policy inform-atio-n (if necessary) and under "Job Site Address" the applicant should write "all locations in or
r arked by the city or town maybe provided to the
town)." A copy of the affidavit that has been officially stamped o in (city
applicant as proof that a valid affidavit is on file for fature permits orlicenses. Anew affidavit must be filled out each
Year. Whore 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 Department's address, telephone and fax -number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-AMSSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
NOTICE
TO
EMPLOYEES
NOTICE
TO
EMPLOYEES
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Street, Boston, Massachusetts 02111
617-727-4900 — http://www.mass.gov/dia
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that
I (we) have provided for 'payment to our injured employees under the above mentioned chapter by
insuring with:
THE TRAVELERS INSURANCE COMPANIES
NAME OF INSURANCE COMPANY
P.O. BOX 1450
MIDDLEBORO, MA 02344-1450
ADDRESS OF INSURANCE COMPANY
(IEUB-3F3G793-7-15) 02-10-15 TO 02-10-1G
POLICY NUMBER EFFECTIVE DATES
M P ROBERTS INS AGENCY 10GO OSGOOD ST
N ANDOVER MA 01845
NAME OF INSURANCE AGENT ADDRESS PHONE#
CENTER REALTY TR OF NO.ANDOVER 177 SALEM ST
NORTH ANDOVER
MA 01845
EMPLOYER ADDRESS
EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required 'in cases of personal injuries arising out of and in the course of
employment to furnish adequate and, reasonable hospital and medical services in accordance with the
provisions of the Workers' Compensation Act. A copy of the First Report of In'
jury must be given to the
injured employee. The employee may select his or her own physician. The reasonable cost of the services
provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably
connected to the work related injury. In cases requiring hospital attention, employees are hereby notified
that the insurer has arranged for such attention at the
NAME OF HOSPITAL
ADDRESS
003101 W20PIG02 TO BE POSTED BY EMPLOYER
T? Allk
'A'
'S
ONE TOWER SQUARE
HARTFORD, CT 06183
CLASSIFICATION SCHEDULE:
CLASSIFICATIONS
SIC -CODE: G512
AND
EMPLOYERS LIABILITY POLIC
TYPE v INFORMATION PAGE WC 00 00 ol ( )
POLICY NUMBER: (IEUB-3F36793-7-15)
PREMIUM BASIS
ESTIMATED
TOTAL ANNUAL
CODENO REMUNERATION
RATES
PER $100 OF
REMUNERATION
SEE EXTENSION OF INFORMATION PAGE - SCHEDULE(S)
NAICS: 531120
LSTIMATED
ANNUAL
PREMIUM
------------------------------------------------------------------------------------
STANDARD
TOTAL ESTIMATED ANNUAL STANDARD PREMIUM $ 582
PREMIUM DISCOUNT NONE
0900-20 EXPENSE CONSTANT 250
TERRORISM G
TOTAL ESTIMATED PREMIUM 838
TAXES AND SURCHARGES 31
DEPOSIT AMOUNT DUE 8G9
Minimum Premium: $ 272
EMPLOYERS LIABILITY MINIMUM: $50
DATEOFISSUE: 11-21-14 AA
OFFICE: SPRINGFIELD MA 354
PRODUCER: m P ROBERTS INS AGENCY CYV44
COUNTERSIGNED -AGENT
AObk
TRAVELERS
ONE TOWER SQUARE
HARTFORD, CT 06183
WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE V INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (IEUB-3F36793-7-15)
NEW -1 5
INSURER: THE TRAVELERS INDEMNITY COMPANY OF CONNECTICUT
I
INSURED:
CENTER REALTY TR OF NO.ANDOVER
PO BOX 876
NORTH ANDOVER MA 01845
Insured is TRUST
NCCI CO CODE: 12G37
PRODUCER:
M P ROBERTS INS AGENCY
1060 OSGOOD ST
N ANDOVER MA 01845
Other work places and identification numbers are shown in the schedule(s) attached.
2. The policy period is from 02-10-15 to 02-10-16 12:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in
item 3.A. . The limits of out liability under Part Two are:
Bodily Injury by Accident: $
Bodily Injury by Disease: $
Bodily Injury by Disease: $
500000 Each Accident
500000 Policy Limit
500000 Each Employee
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MD ME MI MN
MO MS MT NC NE NH NJ NM NV NY OK OR PA RI SC SD TN TX LIT VA VT WI
WV
D. This policy includes these endorsements and schedules:
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All required information is subject to verification and change by audit to be made ANNUALLY.
DATE OF ISSUE: 11-21-14 AA
OFFICE: SPRINGFIELD MA 354 DIRECT BILL
PRODUCER: M P ROBERTS INS AGENCY CYV44
Massachusetts - Department of Public Safety
Board of Building Regulations and
Standards
�Uorrstructjor, 'a-CIPerVUSOF
License: CS -075302
BENJAMIN C OSG-bo
69 Old Wage I-alf, CC
3
North Andover M -A 018�40V§j
f Z2 -51t,
Expiration
Commissioner
12/0412016