HomeMy WebLinkAboutBuilding Permit #419-12 - 20 LACONIA CIRCLE 11/16/2011 ■
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit N0: Date Received
Date Issued:
ORTANT:Applicant must com lete all items on this page
LOCATION d ',-
Print
PROPERTY OWNER S+(-V U) cc Lt Unit#
Print
MAP NO��PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
100 year-old structure yes no
TYPE OF IMPROVEMENT PROPOSED USE
Resid ial Non- Residential
❑ New Building N,6ne family
❑A,Odftion El Two or more family 11 Industrial
Iteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other _
�JSeptic '`;®`W lI� '®F�oodpMal O Wetlands ® Wa ers ed istrictx
i D Water/Sewer:
DESCRIPTION OF WORK TO BE PERFORMED:
(Identification Please Type or Print Clearly)
OWNER: Name: l4-✓ryt 's4--eve" K fe—JLt Phone:
J '
Address:�0 ���,,�� cc ►�
tt --
CONTRACTOR Name: �,s.,c �L �� .�fc,� 4f Phone:
Address: 09-Ir T S /v�2�
Supervisor's Construction License: OtLfc-, 1 1 • t MExp. Date: 02
Home Improvement License: M4 C�,- m,__ �-► Exp. Date: 1 C°- 1a. -- 13
i 3tj 3 66
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE;BULDING PERMIT.•$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
Total Project Cost: $ R ,bo FEE: $_lo-z X 2 = 2-0
Check No.: Jq Ee� Receipt No.: aqJ 0
NOTE: Persons contracting 4ith unregistered contractors do not have access to the guaranty fund
gnature of#Ag t/0wnerr
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
CGMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board 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.$100-$1000 fine
NOTES and DATA— For department use
❑ Notified for pickup - Date
Doc:.Building Permit Revised 2011 June/mi
- � w
J
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
orkers Comp Affidavit
hoto 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
v 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: Doc.Building Permit Revised 2008mi
Location U LC/LG/y/
No. Date —
�oRTM TOWN OF NORTH ANDOVER
3: .. o
AL
4 . 0 *
9
Certificate of Occupancy $
AGMUSBuilding/Frame Permit Fee $
1E
Foundation Permit Fee $
Other Permit Fee $
TOTAL /"v $ D Z
Check #� 2, 011
24820 Building Inspector
NORTH
TONM of Andover
No.
To , dover, Mass.,AK
1 6 •
COC HI CME WICK
7,ps0RATED
7 U BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
BUILDING INSPECTOR
�.
THIS CERTIFIES THAT................ t Rt 4.
...............✓....................................
.............................................. Foundation
has permission to erect........................................ build s on ...�Q......LALol/.�tl.440...................................... Rough
mow to be occupied as.........W6epilin
....... ........ .... v Chimney
......... ....
provided that the persopermit shall inevery respect c form 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 MON
ELECTRICAL INSPECTOR
UNLESS CONSTRU N T Sixow. Rough -
........................................................................ Service
BUILDING INSPECTOR
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.
GARY RICH 101
ANNE HARROLD
20 LACONIA C#WEa / `6. d 8003/ 53-7054/
NORTH ANDOVER,MA 184 V t
,,_... DATE
PAY TO THE N C)(� 6D• `� ,
ORDER O _
DOLLARS of
Bank Home
merica's Most nvenient nka
L �U �J
FOR OV ... �...._. -.____...... ._..__ .....M'
1: 2 L L3 ?05 5l: 135304359 ?911' 131010
1
The Commonwealth of 1Vlassachusetts
Department oflndustrial.Accidents
Office of Invesfigations,
600 Washington Street
Boston,MA 02111
SY www.mass.govldia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information
Please Print Legibly
Name(Business/Organization/lndividual): +
Address:
City/State/Zip:�t� Phone#. -
Are you an employer?Check the appropriate box: _
1.❑I am a em to er with 4. Type of project(required):
p y �� ❑I am a general contractor and I
employees(fall and/or part-time).* have hired the sub-contractors 6 ❑New construction
2.❑I am a sole proprietor or partner listed on the attached shget.1 7. ❑Remodeling
ship and have no employees These sub-contractors have
working for me in any capacity. workers'comp,insurance. g, El Demblition
[No workers'comp.insurance 5. E] We aie a corporation and its 9. ElBuilding addition
required.] Officers have exercised their 10.❑EIectrical repairs or additions
3. T am a homeowner doing all work right of exemption per MCYL 11.❑Plumbing repairs or additions
Myself [No workers'comp. c.152, §1(4),and wehave no
insurance required.] 112.[]Roofrepairs
9. )�r employees.[No workers
comp,insurance required.] 13.❑Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
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.
-i'am an employer that isproviding workers'compensation insurance for•sny employees Below is tlae policy anrljob site
info.-Mation. /� .
Insurance Company Name: !� �(
Policy#or Self-ins.Lic.#: 1'a I tJG �j( �- g?b p a b
� � Expiration Date:,_1-- 17—
Job
:,_1--- 17--•Job Site Address:_ ,2 0 L1+C A,�' r .,i- ty p W lr�►�oPa,
Ci /State/Zi :
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$250.00 a day against the violator. Be advised that a copy of this statement may be,forwarded to the Office of
Investigations of the D9 for insurance coverage verification.
.fP J �' ,
erey Yt� enalties o er'u tliat the information provided above is
r do hbder t pa' s and
true an correct.
)i na
Bate:
`hone#:
Offccial use only- Do not write in this area,to he completed by city or town official.
City or Toxon: PermitUcense#
Issuing Authority(circle one):
I.Board of Health 2.BuildingDepartment 3.City/T9"Clerk 4.ElectricaIInspector 5.Plumbing Inspector
6. Other
ContactPerson:
Phone#:
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Industries of Massachusetts Mutual Insurance Company
54 Third Avenue, Burlington, Massachusetts 01803
(800)876-2765 NCCI NO 26158
POLICY NO. I AWC 7005870012011
PRIOR NO. I AWC 7005870012010
ITEM
1. The insured Vincent DiClemente dba M&J Contracting
Mail Address: 220 A Salem Street Medford Ma 02155
Street No. Town or City County State Zip Code
FEIN xxxxx7525
®Individual ❑Partnership []Corporation ❑Joint Venture ❑Association []Other
Other workplaces not shown above:
2. The policy period is from 05/17/2011 to 05/17/2012 12:01 a.m.standard time at the insured's mailing address.
3. A. Workers Compensation Insurance:Part One of the policy applies to the Workers Compensation Law of the states listed here;
MA
B. Employers Liability Insurance:Part Two of the policy applies to work in each state listed in item 3.A.
The limits of our liability under Part Two are: Bodily Injury by Accident$ - 100.000 each accident
Bodily Injury by Disease $ 500.000 aolicy limit
Bodily Injury by Disease $ 100.000 each employee
C. Other States Insurance:Coverage Replaced By Endorsement WC 20 03 06A
D. This policy includes these endorsements and schedules:SEE SCHEDULE
4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating plans.
All information required below is subject to verification and change by audit.
Classifications Premium Basis Rates
Code Estimated Per$101 Estimated
No. Total Annual Of Annual
Remuneration Remuneration Premium
i
INTRA 040216
SEE E(TENSION OF INFORMATIC N PAGE
Minimum premium$ 500.00 Total Estimated Annual Premium $ 1,653.00
As indicated interim adjustments of premium shall be made: Deposit Premium $ 1,742.00
® Annually ❑ Semi Annually ❑ Quarterly ❑ Monthly
MA Assessment Chg.
$1,310.00 x 6.8000% $89.00
This policy,including all endorsements,is hereby countersigned by 05/16/2011
Authorized Signature Date
GOV GOV KIND PLACING CLAIM NAME SAFETY Aljane Insurance Inc
STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP 281 Beach Street
MA 5645 2 701 Revere,MA 02151
WC 00 00 01 A(7-11)
Includes copyrighted material of the National Council on Compensation Insurance,
used with its permission.
I
I
— _t
Page No. of Pages
PROPOSAL SUBMITTED TO PHONE DATE
STREET JOB NAME
CITY,STATE and ZIP CODE JOB LOCANT
AR'HITECT DATE OF PLANS JOB PHONE
We hereby submit specifications and estimates for:
1) s4 ,- . 14
aJ
n" ( l � u,1, n` /'!•52 c�cl�r- .P ' � �� P d�c ✓� r't-'
11 Ll
tr Cv;•+ -n r -
L4) T--u' S (? (/ L c� , J r sc /,/its /ref.
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N.
We Propose hereby to furnish material and labor—complete in accordance with above specifications, for the sum of:
O/i S W-. v1 r��. ,f\ - --r'� dollars($
Pafiment to be made as follows:
All material is guaranteed to be as specified. All work to be completed in a`orkmanlike
manner according to standard practices. Any alteration or deviation from above specifications Authorized
involving extra costs will be executed only upon written orders, and will become an extra Signature
charge over and above the estimate. All agreements contingent-.upon strikes, accidents or
delays beyond our control. Owner to carry fire, tornado and other necessary insprance. Our Note:This proposal may be
workers are fully covered by Workman's Compensation Insurance. withdra,tM-by us if not accepted within days.
Acceptance of Proposal�he-above prices,,specifications
and conditions are satisfactory nd are hereby accepted.You ale aut rized to do the Signat
work as specified.PayT&t will be made as outlined above.
t _ _ _ �
Date of Acceptance: - ^-�' '� Signature
` ' ✓� �anzmeauuea,�C� a�,/�aaa�ivaelta
Office of Consumer Affairs&Bdsiness Regulation
HOME IMPROVEMENT CONTRACTOR ,
v+ C0NTRAC-rlNd5',------�Registration. ,- 134366 Type:
Expiration: 11%6/2013 DBA
_
I VINCENT DiCLEMENTE; t�
159 MYRTLE ST.. `, g
MEDFORD,MA 02165 -
i Undersecretary
'4' 'N9assachusetts- Department of Public S.i1r,x
Board of Building Rculatioris anti S#.inY1�S�tlS
Construction Supervisor License'"'
.f
License: CS 84935 .
VINCENT DICLEMENTE
159 MYRTLE ST
MEDFORD, MA 02155
Expiration: 2/2112013;
mmisiuncr ' s,.
Tr#: 9699"