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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% $89.00 This policy,including all endorsements,is hereby countersigned by 05/16/2011 Authorized Signature Date GOV GOV KIND PLACING CLAIM NAME SAFETY Aljane Insurance Inc STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP 281 Beach Street MA 5645 2 701 Revere,MA 02151 WC 00 00 01 A(7-11) Includes copyrighted material of the National Council on Compensation Insurance, used with its permission. I I — _t Page No. of Pages PROPOSAL SUBMITTED TO PHONE DATE STREET JOB NAME CITY,STATE and ZIP CODE JOB LOCANT AR'HITECT DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for: 1) s4 ,- . 14 aJ n" ( l � u,1, n` /'!•52 c�cl�r- .P ' � �� P d�c ✓� r't-' 11 Ll tr Cv;•+ -n r - L4) T--u' S (? (/ L c� , J r sc /,/its /ref. Xr N. We Propose hereby to furnish material and labor—complete in accordance with above specifications, for the sum of: O/i S W-. v1 r��. ,f\ - --r'� dollars($ 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"