HomeMy WebLinkAboutBuilding Permit #807-14 - 200 SUTTON STREET 5/9/2014TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit N0: �b% s �� Date Received
Date Issued:
IMPORTANT: Applicant must complete all items on this page
t
LOCATION
- ; Print.
PROPERTY OWNER
Prinfi 4OO Year Old Stru
MAP -NO: 5�P% . PARCEL:_ OU . ZONING DISTRICT: _ .H,istoric District
Machine Shop,
yes
fn0o
yes
.TYPE OF IMPROVEMENT.
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
❑ Two or more family
❑ Industrial
Iteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
p Septic ❑Well
p floodplain • 0 Wetlands
0 Watershed District
El Wat&,!Sewer _ '=
DESCRIPTION OF WORK TO BE PERFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: UbM 12tjai.Tn4 Phone: 9 78.6Fig- 2z V3
Address: Zoo SUn" 5r&a
�..� 1 G 'Phone:- d' 4_Ya �_-i/�' _
CONTRACTOR. Name:. L,_...__ _
r
Address:
Supervisor s Construction License: G '-fi r Exp Date X)o
_ �'� - Y_
a
r r
Home Improyement Lidense: __-E Date: ;
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: $ 4,5000 - FEE: $ 0.00
Check No.: fx % 2 > Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have�access to the guaranty fund
�ignaiu_re'.or,•r�genvvwnera :,i - w . JiyiiaWlt:-,i �unua��
Plans Submitted LJ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans 11
- Plans Submitted: ❑ Plans Waived ❑ ,Certified Plot Plan ❑ Stamped Plans ❑
JW-RDF::-SEWERAGEDISP.OSAL"
Public Sewer ❑
Tanning/MassageBodyArt ❑ ..
.Swimming Pools ❑
Well ❑
Tobacco.Sales
=Food PackagingfSales ❑
-Private:(septic tank, etc._- ❑ -- ;
permanent 4%mpster on-site El
THE..FOLLOWING SECTIONS FOR'OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
:CONSERVATION
COMMENTS
HEALTH
COMMENTS
.'DATE. REJECTEDDATE:APPR:OVED
El
Reviewed on Signature
Reviewed on Signature .
Zoning Board of Appeals: Variance, Petition N
Manning Board Decision:
Conservation Decision:
Comments
Comments
Zoning Decision/receipt submitted yes
Water & Sewer Con nectionlSignature & Date Driveway Permit
DPW TowA Engineer: Signature:
Located 384 Osgood Street
EIRE DEPAR�fMr NT Temp Dumpster on site :yes no
Located at X1 4{Main Street '`
Fire'De p'' t
partrrie►rt•signature/date Y.; --.:= •, ,�..� ��:.,�.r• r. - r
.COMM.ENTS
Dimension --
Number of Stories: Total square feet of floor area, based on Exterior dimensions._
-Total land -area, sq. ft.;
ELECTRICAL: -Movement of Meter location-, niast-or service drop requires approval of
..Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL.Chapter166.Sectbn21A=F and G min.$10041000:fine
NOTES and DATA — (For department use
LI Notified for pickup - Date
Doc.Building Permit Revised 2010
Building Department
-The fohl-aw'ing i"s alli'st of he required.forms to be filled outIor:the. appropriate. permit to .be obtained.
Roofilg, Siding, Interior Rehabilitation Permits
n - v�ZAA
i B gilding Permit Application
o Workers Comp Affidavit
,,.a Photo Copy Of H.I.C. And/0'r 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
o 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
a 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)
L3 Copy of Contract
o Mass check Energy Compliance Report
o 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 apu•?al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submAted with the building application
Doc: Doc.Bui?ding permit Revised 2012
Location
No. OU7—/</
Check # ?7 /
27557
Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ r —
Foundation Permit Fee $
Other Permit Fee $
TOTAL
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NORTH ANDOVER BUILDING DEPARTMENT
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
at: is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c11,S150A.
Also, note Permits are required under Fire Prevention laws Chapter 148 Section
1 OA.
The debris will be disposed of in:
(Location of Facility)
Signature of ermit Applicant
/,,,o/�
Date
fle e 1 /is iSSvcC
F
7L &, p 5-7�06em; I'.
--Me, 0,�4,ey 4 rPe
May 09
TRAVELERS
lty 9186884165 page
INSURED'S NAME AND ADDRESS
VDAC
THIS IS A QUOTE, NOT A POLICY
WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
QUOTE PROFILE — VERSION 01
POLICY NUMBER: (7PJU1B-0554N64-9-1 4)
RENEWAL OF : (7PJUB-0554%4-9-1 3 )
WORKERS COMPENSATION
LBM REALTY TRUST INSURANCE PLAN
MATHIAS, DEBRA L., TRUSTEE & ASR (WCIP) # MA
200 SUTTON STREET
NORTH ANDOVER MA 01845
POLICY PERIOD FROM: 05-28-14 TO 05-28-15
TOTAL ESTIMATED ANNUAL STANDARD PREMIUM $ 4023
PREMIUM DISCOUNT NONE
0900-20 EXPENSE CONSTANT 338
TERRORISM 105
TOTAL ESTIMATED PREMIUM 4466
TAXES AND SURCHARGES 137
DEPOSIT AMOUNT DUE 4603
Employer's Liability BI Limit: $ 100000 Each Accident
500000 Policy Limit
100000 Each Employee
INSURER; TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA
Adjustments of Premiums shall be made ANNUALLY
Deposit Amount Due: $ 4603 ******************************
POLICY NUMBER: (7POUB-05541\164-9-1 4)
DATE OF ISSUE:04-08-14 ST
OFFICE: DIRECT ASSIGNMENT701
PRODUCER: MATHIAS INS AGCY INC
29HST
ST ASSIGN: MA
May Uy GU 14 U /: 14 hr raXLbl" 1 hea ity '-1160664100
TRAVELERS J
page i
WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
QUOTE PROFILE
POLICY NUMBER: (7PJUB-0554N64-9-14)
INSURER: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA
INSURED'S NAME: LBM REALTY TRUST
MATHIAS, DEBRA L., TRUSTEE &
CLASSIFICATION
LOCATION 001 01
FEIN 046688547 ENTITY CD 001
LBM REALTY TRUST
MATHIAS, DEBRA L., TRUSTEE &
MATSES, CHARLES A., TRUSTEE
200 SUTTON STREET
NORTH ANDOVER, MA 01845
SIC CODE: 6531 NAICS: 531390
CLERICAL OFFICE EMPLOYEES
NOC.
BUILDINGS—OPERATION BY OWNER
OR LESSEE.
13579—MA
RATE BUREAU ID: 000352170
PREMIUM BASIS
ESTIMATED RATES ESTIMATED
TOTAL ANNUAL PER $100 OF ANNUAL
CODE REMUNERATION REMUNERATION PREMIUM
8810
9015
214065 .08
135910 2.99
171
4064
------------------------------------------------------------------------------------
.950 MERIT RATING MODIFICATION (9885) $ 212
TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 4023
EXPENSE CONSTANT(0900) 338
0.0300 TERRORISM (9740) 105
3.40% MA WC SPECIAL FUND AND TRUST FUND 137
TOTAL ESTIMATED PREMIUM 4603
DEPOSIT AMOUNT DUE 4603
DATE 0F ISSUE: 04—OB-14 ST ST ASSIGN: MA SCHEDULE NO: 1 OF LAST
Massachusetts;- Department of public S,afetY
Boar..d of Building Regulations and Standards
Construction Super%isor
License: CS -022855
na
MICHAE
L` NOAS '' s
26 CHAPEL ST S 7iLr, NEWBURYPORT MA
Expiration
954—„ lJ/ � ''r`' 06{20/2614
j Commissioner
ry The Commonwealth of.Massachuselts -
Department of XndustriglAccMiks
Office ofInvestigations
600 Washington Street
Boston, MA 02111
-www.massgov/dia
Workers' Compensation bsurance Affidavit: Builders/Cont°actors/ElectriclansMli4nber.s
Applicant Information Please Prim Legibly
Name (Business/Organizaiion/ind%viduai):
Address: Zoo "'2" �`
City/State/Zip:I� i�1./�2, �i 4 Phone #: 975-685-7,26-S
Are ou a
Ar employer? Check the appropriate box: Type of project (required):
1. am a employer with 4. ❑ 1 am a general contractor and 1 6. [] New construction
employees (full and/or part-time).* have hired the sub -contractors
2.E] 1 am a sole proprietor or partner- listed on the attached sheet. T 7• ❑Remodeling
ship and'haveno.employees These sub -contractors have 8. Vp0moliflon
working forme in. any capacity. workers' comp, insurance. 9. [] Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised.their
3. ❑ X am a homeowner doing all work right of exemption per MGL 11. [] Plumbing, repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roofrepairs
imurancere edv employees. WO workers'
�'. a 13.[] Other
comp. insurance required.]
4Any applicant that checks box#1 must also fill outthe section below showingtheir workers' compensationpolicy information.
1 -Homeowners who submit This affidavit indicating they tie doing allwork and then hire outside contractors must submit anew affidavit indicating such.
TContractors that checkthis box must attached an additional sheet showingthe name ofthe sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my erriployees Berow is the policy and job site
information.
Insurance Company Name;.
Policy # or Self ins. Lic. #: i ptV g -O�a 54N 64 -9 - i 3 Expiration Data: 5 (Z 61(4 -
rob Site Address; 7. ov G✓ (j bN City/State/Zip: 0401,1 M
Attach, a copy of the workers' compensation -policy declaration page (showing the policy number and expiration crate).
Failure, to secure coverage as requiredunder Section 25A of MGL o.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 flue
of up to $250.00 a day against the violator. Be advised that a copy of this statementmay be forwarded to the Office of
investigations of the DIA for iiisuran ce coverage verification.
I do hereby cert& under the pains andpenalties ofperjury that the information provided above is true and correct. -
si afore: Data:
Phone #:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other - - -
Contact Person: Phone #:
Informaiion and Ittsiructions
Massachusetts General Laws chapter 152 xequires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person hi the service of another under any contract of hire, -
express orimpiied, oral or'written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two oxmoxe
of the foregoing engaged in a joint enterprise, and including the legal representatives of a -deceased employer,.or the
redeiver or trdstee of an individual, association or ofiher legal entity, employing employees. ) Sowever the
owner of a dwelling house having not more than three apartments and who resides thereiu, 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 bean 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 coverage required"
Additionally, MGL 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 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 -contractors) name(s), address(es) and phone numbers) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are notrequired to cavy workers' compensation insurance. 1f an LLC or LLP does have
employees, a policy is required. Be advised thatthis affidavit may be submitted to the Department of Sudustrial
Accidents for con&mation 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 thepermit 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 favestigations has to contact you regarding the applicant.
Please be -sure to fill in the pormit/license, number which will be used as a reference number. In addition, an applicant
thatmust submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (ifnecessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)" A: copy of the affidavit that has been officially stamp ed 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 ox permit not related to any business or commercial venture
(i.e. a dog license orpermit to burn leaves etc.) said person is NOT 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 Coxr_Monwmlth of M1.0 machu setts
Dop-aximent o£Zndustrial Acadoz�ts
Office QUAVOsiigaftla
6bG Washington Street
Boston, MA 0211
TO. # 61M-274900 ext 406 or. 1-877�NAS,9AFF,
Revised 5-26-05 Fax # U M27 77 '9
wmmaagov/dia