HomeMy WebLinkAboutBuilding Permit #638-15 - 20 STAGE COACH ROAD 2/5/2015TYPE OF IMPROVEMENT
PROPOSED USE
Residential.
Non- Residential
❑ New Building
0 06 family
❑-Addition
❑ Two -or -more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
epair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
Septic®W�ell
ood
�® Flp �n_�Wetlands��g
;. Watershed ®istrict } t
DESCRIPTION OF WORK TO BE PERFORMED:
%1 jf)O �a I c5- 4tr/A1,D e GCJS
�� -Identification - Please Type or Print Clearly
-
OWNER: "Name: 3-oAA( Lu.v�vy . Phone:
S /e*-
A:
ARCHITECT/ENGINEE
Phone
Address: Reg. No:_
FEE SCHEDULE. BULDING PERMIT. • $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COS-TBA4SED ON $125.00 PER S.F.
Total Project'Cost: $ FEE: $ C7�,
Check No.: a �� Receipt No.: ' -K 27010
NOTE: Persons contracting with unregistered contractors do not have access: uaranty fund
Si` nature of A ent/®wner e g- ��°; � .,
Signature ttactot` w;.ky
of con
Plans Submitted ❑ Plans Waived Certified Plot Plan ❑ Stamped Plans ❑
T 1 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
PLANNING & DEVELOPMENT Reviewed On Signature
COMMENTS
CONSERVATION Reviewed on Siqnature
COMMENTS
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
e, DPW Town Engineer: Signature:
t_ocatea 3214 usgooa atreet
ARE DEPARTMENT Temp ®umpstero n siteyess not.,
Me ;-a, Streett� �t a '"
=ire Dep,�a A men t s nature/date
4
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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 Call Email
Date Time Contact Name
Doe.Building Permit 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
❑ 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/Cross Section/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: Building Permit Revised 2014
Location
No.(,5;;( bate
Check
28470
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Rame Permit Fee
Foundation Permit Fee $
Other Permit Fee
TOTAL $
Building Inspector
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MAL
The Commonwealth of MassachVSelys
Department oflndustriaf Accidents
Office of Investigadons
1 Congress Street, Suite 100
Boston, MA 02114-2017
www mass gov/dia
Workers' Compensation Insurance Affidavit: Buflders/Contractors/Electricians/Ptombers
Applicant Information Please Print Leeibly
Name (Business/Orgmization/Individual): RENEWAL BY ANDERSEN
Address: 30 FORBES ROAD
Ci /State/Zi : NORTHBORO, MA 01532 Phone #: 508-351-2200
Are you an employer? Check the appropriate bog:
1.0 I am a employer with 30 4. I am a general contractor and I
Type of project (required):
employees (full and/or part-time).*
have hired the sub -contractors
6. ❑ New construction
2.0 I am a sole proprietor or partner-
listed on the attached sheet.
7. ® Remodeling
ship and have no employees
These sub -contractors have
g. Demolition
working for me in any capacity.
employees and have workers'
g. ❑ Building addition
[No workers' comp. insurance
comp, insurance
required.]
5. 0 We are a corporation and its
10.0 Electrical repairs or additions
3. [:11 am a homeowner doingall work
officers have exercised their
l l .0 Plumbing repairs or additions
myself. [No workers' comp.
right of exemption per MGL
12, Roof repairs
insurance required.] t
c. 152, § 1(4), and we have no
employees. [No workers'
13.0 Other
comp. insurance reouired_1
*Any applicant that checks box W must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub -contractors have employees, they must PwWde their workers' comp, policy number.
lam an employer that isproviding workers' compensation insurance for my employees Below is thepolfcy and job site
information.
Insurance Company Name: OLD REPUBLIC INS. CO.
Policy # or Self -ins. Lic. #: MWC 30293800 Expiration Date: 10/01/15
Job Site Address -,4_0_ s�� e �"`-�"� 11 �� 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 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
under the pains and penalties of perjury that the information provided above is true and correct,
Date:
1-220
use only. Do not write in this area, to be completed by city or town ojjicial.
City or Town:
Issuing Authority (circle one):
I. Board of Health 2. Building Department
6. Other
Contact Person:
Permit/License #
3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
Phnna ![.
AHDECOR-01 YADAVI
�- CERT'IFICAT'E OF LIABILITY INSURANCE "N »
THIS CERTIFICATE M ISSUED AS A MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE C__j ERTIFICATE HOLDElt TW
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 Pollry(ies) must be endorsed, if SUBROGATION E NAWEp
the terms and conditions of the policy, certain policies may require on endorsement A statement on this certiflcabe does to
certificate holder in lieu of such endorseme s . not confer rights to the
PRooln
Fr
Nmk of Minnesota Inc. Ilis.com
elb 28 Century Bhp (877 X65-7378
P.O. Boz 305191No • (888) 467 2378
019URERA:01d Republic Insurance
tee:
Renewal by Andersen Corporation C: _
30 Forbes Road MURM D:
Northborough, MA 01532
COVERAGES CERTIFICATE NUMBER; REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSUREDNAMED A80WITH RESPECT TO WHICH THIS
VIX FOR THE POLICY PERIOD
INDICATED. NOTIMTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT
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 MAY HAVE BEEN REDUCED BY PAID CLAIMS.
L TYPE OF INSURANCE NUMBER
A X oW101115 ULL 6EMERAL UASHM LIMITS
CLAIMS -MADE MoccuR 02840 1EACH OCCURFJ34M $ 1,000.00/09/2014 90/09/2015 _ 500.01
MED EICP one pmm $ 10,01
PERSONAL & ADV I1.IURY 3 1,000,01
GENL AGGREGATE LIMIT APPLIES PER
X POLICY ❑ JJEECTT ❑ LOC GENERALAG(6tEGJ1TE 3 4,000,0(
AUTOMOKE LIR&LRY 3
3
A X ANY AUTO 302675 10101/2014 10101/2015 8=LY IN3URr (Par p"W) 3
ALL oM61) 8CFED1ILED
AUTOS AUTOS eODILYINJURYlPerW 3
HIREDAUrOS AUTOS
UNBRELIA LIAR 3
A I IM EXCLUDED? U� `M1r+,AI �°11a02'3800 1 10101=41 10101IMS
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OESCRPTIM OF OPERATIONS N LOCATIONS / VEICLES IACORD 101, AddMmgl Remeds SehAde, my be aftchod Imme epeee h;;—A"—
SHOULD
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SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF. NOTICE W LL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
01988,2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014101) Tho AMRn name e...d e..._ - ------
0
Massachusetts - Department of Public Safety
Board of Building Regulations and
Standards
Construction Supen-isor
z,4rr"
License: CS-MI25
"
i
JABS L MORIN
86 GARDENER
t
LYNN MA 0190f
A I 10
Expiration
Commissioner
10/06/2016
wRoce Of Consumer Affairs & Badness Regulation i
ME IMPROVEMENT CONTRACTOR
glstra#iom 170815
Ezplta0on: `= Tow
12/�9l2015 Supplement r.
RENEWAL 13Y ANbERSONCORWORATION
JAIME MORIN
104 OTIS STREET
NORTHSOROUGH, MA 01532
s
Underweretary
DIESON PREdsum ov-9
H-LCI-S