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Home My WebLink AboutBuilding Permit #721 - 20 SAW MILL ROAD 6/6/2008Permit NO: Date Issued& - (.-, `` 0 BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received & .,: 2 2-0eq �6'6ryO\ �of ~ o I IMPORTANT: Applicant must complete all items on this page I LOCATION c'7 S �� M l Print PROPERTY OWNER Z-tAAJ PRr L o Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Villaqe ves no no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial e air re lacem Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: 0 $00 5F QecAL (ZQA 4n t Or , 2�bs �toQ 14 o'F aee1C. Tb M mod c" w/caevv51 e -Q-yG 9'1't w.9 : 4 to 1 t h Cr V LJWIdc3.JS Gvtj 4-- RA±z Identification OWNER: Name: 'Stnnt fir (. Address: Ia.d -i-v 6a,.✓te, L 0/1 5cf-cfzrZ Al. ;ase Type or Prid Clearly) �o �► sfir��-�t � -J oillt - NIA01k d CONTRACTOR Name: ,Agit NI"A ed Phone: Address: Supervisor's Construction License: '? �o o j Exp. Date: 1 A 3 /a Home Improvement License: /y-7 40-Z . Date: -7 - 7 - 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: $ 3�, �� • ``' FEE: $-438- Check 438 - Check No.: � Receipt No.: t ��— NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contracf-o 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 COMMENTS Reviewed on r9(A Y '!—�AP. 10 r) l nIe CC / l K"-4 Reviewed o • 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 MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine No Doc.Building Permit Revised 2008 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 Locatio * No. Date �•d� NORTH TOWN OF NORTH ANDOVERA" 3?O� •t`•o ••,hO O 4 9 f ` Certificate of Occupancy $ s'NuS t� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # ' —,Ar 0 2j, 2 1 / Building Inspector \ § �LO § u 2:0 \«$% /$K fid: » 2 2 c ; o m �k\2d\ujd. : ^ ° � ) m�� \ 2 I ; 4L / �\$ / The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Y d 600 Washington Street t Boston, MA 02111 �e v` 5 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): t�;LL— STra2 2en.� 1�1. c Address: d S>r" o.,�ls Fr-,o City/State/Zip: Phone.#: 57?' &Co- 3 0 F Type of project (required):, 6. ❑ New construction 7. ff Remodeling 8. Demolition 9. ❑ Building addition 10..0 Electrical repairs or additions 11 -0 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. I Homeowners Nvho submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. (Contractors that check 1:1 his box must attached an additional sheet showing the narrie of the sub -contractors and state whether ornot those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that isproviding workers' compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #:' Expiration Date: Job Site Address: 90 SA w rn ► Z L_ City/State/Zip: P. ,q,n/r4ni e4 - 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Phone #: ? i f (OGO 310917 area, City or Town: or town officiaL Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact .Person: Phone #: Areyou an employer? Check the appropriate box: 1. ❑ I am a employer with O ' 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. Or, am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised. their myself. [No workers' comp, right of exemption per MGL insurance required.] t c. 152, §1(4), and we have no employees. [No workers' comp. insurance reouired.l Type of project (required):, 6. ❑ New construction 7. ff Remodeling 8. Demolition 9. ❑ Building addition 10..0 Electrical repairs or additions 11 -0 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. I Homeowners Nvho submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. (Contractors that check 1:1 his box must attached an additional sheet showing the narrie of the sub -contractors and state whether ornot those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that isproviding workers' compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #:' Expiration Date: Job Site Address: 90 SA w rn ► Z L_ City/State/Zip: P. ,q,n/r4ni e4 - 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 certify under the pains and penalties of perjury that the information provided above is true and correct Phone #: ? i f (OGO 310917 area, City or Town: or town officiaL Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town CIerk 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,opera'tera 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, §25CO) 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 cerlificate(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 1,40T 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. # 617-727-4900 ext.406 or 1-877-MASSAFE Revised 11-22-06 Fax # 617-727-7749 ww°w.mass.gov/dia '54ei )l tr d 74J M9 o x"V ALL- S*PA(Z.- CONTRACTORS INVOICE WORK PERFORMED AT: DATE YOI3R WOf#K ORDER NO, OUR` i31D NQ - - - - ------ ---- r-•.------- ... ^�. �........ ...... ..... v..... u..J� our arca.n n.auvu, provided for the above work, and was completed In a substantial workmanlike manner for the agreed sum of Dollars ($ _c� 1 Com, `-0 This is a ❑ Partial ❑ Full Invoice due and payable by: Month Day Year in accordance with our ❑ Agreement ❑ Proposal No. Dated Month Day Year TC8�. MADEIN USA CONTRACTORS INVOICE dwr MADE N m m X ,M m CAm IL c y d �■ � d CD MZ y � O o v Q,Q O Q rF CD O CD C CD tH� C1 � tON O CA O 'O Z CD O CCD O CCD 51 0 cn V J n O cn I, dy O y y � WO S C2 m n m C9 y Sa.On = m O S O _ _W)i -0 O n tr ••F C d O ik y cs, O O rGo Go O o C m O y 0 0 i O m n -+ m� y C y _? CL m c a W: U2 m y IE O Cos Mir O n O _ -aCD o �m mow ryCDa m o.� dob n'o n� 0 0; = o . =m • cn cn cn pd 00 wOQ 7d w a s cn �^. �n A. rD `0 H b � ro H rz t7l n O M • z 0 v )Mq 0 9 0 c a r s►�.��Ps �� 20,E CONTRACTORS INVOICE WORK PERFORMED AT: SATE: YOUR WORK ORDER NO.,OUR BID O t provided for the above work, and was completed In a substantial workmanlike manner for the agreed sum of Dollars ($ ), This is a ❑ Partial ❑ Full invoice due and payable by: I'Q.) BUJ Month Day Year In accordance with our ❑ Agreement ❑ Proposal No. Dated Month Day Year MADE IN USA CONTRACTORS INVOICE rlwr MADE N 05-27-'08 12;08 FROM-Byam BrosMahoney Ins +978-937-0745 T-288 P001/001 F-172 ACORD ULK 11HUA I t UI' LIAMLI I T INOUKANtor— At,LSTul 1 05/27 PRODUCER THIS CERTIFICATE 19 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Byam Bros -Mahaney Insurance HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 191 Pawtucket Blvd ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Lowell MA 01654 Phone:978-454-2926 Fax:978-937-0745 INSURERS AFFORDING COVERAGE NACrA INSURED INSURER A: Commerce Inauranee Compan INSURER B: _ All Star Remgdeling INSURER Stepphen Merrifield __._...- 25 Simonds Farm Rd INSURER D. N. Billerica MA 01821 -- — INSURER E: COVERAGES THE POLICIES AF INSURANCE LISTED BEW W HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REOUIREMENT. 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 I LTR D NS TYPE OF INSURANCE POLICY NUMBER YI OATS MMIDDJYY POLICY EXPIRATION DATE MMIDD/YY LIMITS AUTHORIZED REPRESENTATIVE GENERAL LIABILITY EACH OCCURRENCE $500 000 A X COMMERCIAL GENERAL LIABILITY WS8244 01/30/08 01/30/09 UA UCIVIM41ru PREMISES Eaoccwem& 310_0,000 CLAIMS MADE Q OCCUR MED EXP (Any opo PRD+) $5,000 PERSONAL IIAOVINJURY S GENERAL AGGREGATE $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COIV ITAGG $1,0004900 POLICY F jE�T 7 LOC —— AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT A ANY AUTO VS9241 07/26/07 07/26/08 (EaiC0ic1cm) F BODILY INJURY - ALL OWNED AUTOS f 100000 X SCHEDULEDAUTOS (Parpe(30n) BODILY INJURY HIRED AUTOS f �OOOOO NON -OWNED AUTOS (PeracideM) PROPERTY DAMAGE S 100000 (Per accident) GARAGE LIABILITY _AUTO ONLY-EAACCIOENT f - ANY AUTO OTHER THAN 'Wee i -- , .— AUTO ONLY. AGO S EXCESSIUMBRELLALIABIL17Y EACH OCCURRENCE f OCCUR 1_I CLAIMS MADE AOGREOATE- S — - f _ 3 DEDUCTIBLE _ s S RETENTIONATU WORKERS COMPENSATION AND III TRV LIMITS ER EMPLOYERS' LIABILITY j ANY PR0PRIET0RJPIU2TNERIEXECUTNE E.L. EACH ACCIDENT f - — OFFICERRAEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE S r „v46, de LuiDe Undar E.L. DISEASE • POLICY LIMIT S SPECIAL PROVISIONS bell. OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION TOWOFAN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN Town of North Andover NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. BUT FAILURE TO DO SO SHALL 1600 Osgood Street IMPOSE NO O�� T IA ITY OF ANY KIND UPON THE INSURER, ITS AOENTS OR - V �� + X��`r I��VH��ICE North Andover MA 01845 REPRESEN AfaEM i. AUTHORIZED REPRESENTATIVE B am Bros Ac;U LP Z5 (ZUU1JUB)rby�F,r�r,%0 ,% O'CFJRPORAnvN 1938 I