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HomeMy WebLinkAboutBuilding Permit #307 - 200 VEST WAY 10/15/2009 79- 6goQ— TOWN OF NORTH:ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: 0 J -0 IMPORTANT:Applicant must complete all items on this page LOCATION PROPERTY OWNER )GL nu4 tSJ 14 Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no 0 0 t0 - 0 Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial Re air, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: 300 V/S e,�U6 Yt;;_, -V JcLoce Identificatiog Please Type or Pri t Clearly) OWNER: Name:_ ,��G JA �. C., zQ 5 -' Q �j.xelz.�tS Phone: �1 7� �-66(1 Address: 7-Cjb nw sz vz " Yl/f � CONTRACTOR Name: t$ ( - t Phone: L 1'" 3 7 --7�� Address: 18.7 CEDAlt I Supervisor's Construction License: (94497,; ` Exp. Date: A0 c Home Improvement License: 0 4_. 30 Exp. Date; �/ '� —010 ARCHITECT/ENGINEER Phone: I Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. r� � Total Project Cost: $ 40 0 0 , FEE: $ qk 1101- �J Check No.: 1 2 Z U Receipt No.: 2Z �3 -- NOTE: Persons contracting with unregistered contractors do not have access to the guranty fund �ignature of Agent/Owne - 4 ignature of con#racto 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 COMMENTS HEALTH Reviewed on Signature COWENTS —e 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) U ❑ Notified for pickup - Date 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) i ❑ 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 2008 oN wn oORTiy f4 over No. dover, Mass., 0 LAKE /� COC MIC ME WICK V ORATED BOARD OF HEALTH Food/Kitchen PERMIT T Septic System BUILDING INSPECTOR THISCERTIFIES THAT............. ......V........... ............................................................................................. Foundation has permission to erect........................................ buildings on ....... ....... ........................... Rough Chimney to be occupied as...Lo......I..... .............................. . .... provided that the person accepting this permit shall in every respect conform 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 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRrUAN S. ARTS Rough j Service ..... .........................e......................................................... ........ BUILDING INSPECTOR Final Occupancy Permit Required to Ocmpy 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. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, A" 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le 'bl Name (Business/Organization/Individual): rl�, L /"t' C5 Address: 197 C,&*DA< S J City/State/Zip: 144N6Z 4) LL , IM ' Phone#: 9 7 B -373 - 74a-9 Are you an employer? Check the appropriate bog: Type of project(required): I.❑ I am a employer with 4. ❑ 1 am a general contractor and I 6. ❑New construction el mployees(full and/or part-time).* have hired the sub-contractors �,� 2. am a sole proprietor or partner- listed on the attached sheet.t 7. 0 Kemodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for 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.❑ I am a homeowner doing all work right of exemption per MGL l l.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.0 Other comp. insurance required.] tnr.y applicant that checks box#1;:�.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. 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 is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: 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 here;Yc and he ins penaltie of perjury that the information provided abo a is tru andcorrect Si aforeDate: I S 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#: 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 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 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-contractors)name(s), address(es)and phone number(s)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 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 bum 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 Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washir gton.Street Boston,MA 02111. Tel. # 617-7274900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 5-26-OS www.mass.govldia Board of Building Regulations and Standards CONTRACTOR HOME IMPROVEMENT Registration:, 1045301. Tri 271960 Expiration vT/1412010 luga z Y 7ype ABA CESATI CONTRACTOR Michael Cesati ' `�..�.�1. 187 Cedar Street '� �� Administrator Haverhill,MA 01830 Bo�tdo B il�d�°'sgRcegthio o�-andn S - - - - - - - - - - - -- - - - ,a Construction Supervisor License License: CS 48724 EX piFat ttfk r —¢ 8/2010 Tr# 21928 i Restrs ct►q pp.�?� MICHAEL A CESATI� 187 CEDAR ST HAVERHILL,MA 018 �( c Commissioner Atlantic Charter Insurance Company VDAC NCCI Co. No.:29211 Policy Number: WCV00839600 1. INSURED: Prior Policy Number: New Michael A. Cesati Producer: 187 Cedar Street Getchell Companies Insurance Haverhill, MA 01830 Federal ID Number:011469814 Services, Inc. Risk ID Number: PO Box 844 Stow, MA 01775 Business Type: Individual SIC:9999 NONCLASSIFIABLE ESTABLISHMENTS Other Named Insured:See WCE106 Other Work Places: See WCE107 2. POLICY PERIOD: The Policy Period Is From: 4/28/2009 To 4/28/2010 12:01 A.M. Standard Time at The Insured Mailing Address 3. COVERAGES: 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 3A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 100,000 each employee C. Other States Insured: Part Three of the policy applies to the states, if any, listed here: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A All states except Monopolistic State Fund States D. This policy includes these endorsements and schedules: See WCE105 4. COVERAGES: The premium for this policy will be determined by our Manual of Rules, Classifications, Rates & Rating Plans. All information required below is subject to verification and change by audit. Code Premium Basis Total Rate Per Estimated Classifications No Estimated Annual $100 of Annual Remuneration Remuneration Premium See WC 00 00 01 Minimum Premium: Deposit Premium: $500 $500 Interim Adjustment: Annually Servicing Office: Estimated Premium (Minimum Premium) $500 25 New Chardon Street Boston, MA 02114-4721 / tr" Issue Date 05/06/2009 Countersigned By: Date Copyright 1987 National Council on Compensation Insurance Form: 100m ACORD TM CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 110/15/2009 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION MINICHIELLO INSURANCE AGENCY ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 229 SOUTH MAIN STREET ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. BRADFORD MA 01835 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA: PATRONS GROUP MICHAEL CESATI INSURER B: 187 CEDAR STREET INSURER C: HAVERHILL MA 01830 INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, 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 SR POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR INSRD TYPE OF INSURANCE DATE(MMlDDfYY) DATE(MMIDDIYY) GENERAL LIABILITY CTR 00007983 09-21-09 09-21-10 EACH OCCURRENCE $300,000 X I COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurence) $ CLAIMS MADE ❑OCCUR MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $300,000 GENERAL AGGREGATE $600,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $50,O OO PRO- POLICY JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) I PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR ❑CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE �, $ RETENTION $ WC $ WORKERS COMPENSATION AND TORY LIMITS ER EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER I I L DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION BUILDING DEPT DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 20 DAYS WRITTEN NORTH ANDOVER MA 01845 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR (REPRESENTATIVES. AUTHORIZED REP77 / ACORD 25(2001/08) ©ACORD CORPORATION 1988 Location t No. 30--)— Date �oRTM TOWN OF NORTH ANDOVER F L Certificate of Occupancy $ • • . JACMUS t� Building/Frame Permit Fee $ r '� Foundation Permit Fee $ Other Permit Fee $ C (TOTAL $L Check # �C3 '1 7yo 22557 Building Inspector