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HomeMy WebLinkAboutBuilding Permit #512-2016 - 209 GREENE STREET 10/26/2015BUILDING PERMIT TOWN OF NORTH ANDOVER _ APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received Date Issued: NORTH �O�,�t LED F6 q�O o � IMPORTANT: Applicant must complete all items on this page PROPOSED USE LOCATION PROPERTY .OWNER ` ia MAP PARCEL. ., Resi ential Y ..... yes no P rint±r c PKOne family Print- ZONING DISTRICT:Historic 100 Year Structure r: District _. ❑ Industrial Machine Shop Village .:kyes , .° no TYPE OF IMPROVEMENT PROPOSED USE Resi ential Non- Residential ❑ New Building PKOne family ❑ Addition ❑ Two or more family ❑ Industrial ❑ A eration No. of units: ❑ Commercial epair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 11 Septic 'El Well'. ❑ Floodplain ❑ Wetlands _ ❑ Watershed District w 1i Water/Sew`er ', . DESCRIPTION OF WORK TO BE PERFORMED: ce 4 r`ti s/4 // - Please OWNER: Name: JkQ;-ff1 M. Py_LZe Address:Gmey,� Contractor Name:' t c rVe or Print Clearly i Phone: ` 7 'c Phone: "1 Email: Address Su er�isor's Construction License: p 6 5 l 1 Exp Date Home Improvement License. Exp. Date..: ARCHITECT/ENGINEER Phone: 76 y-t7�g5- 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: $ 1 6&T LoU FEE: $ Check No.: Receipt No.: 2—q S 73 NOTE: Persons contracting with unregistered contractoq do not have acc_c to the guarantyfund 0 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/MassageBody 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 COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS e Reviewed On Signature_ Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition Planning Board Decision: Conservation Decision: Comments Comments Zoning Decision/receipt submitted yes Water & Sewer Con nection/Sii nature & Date Driveway Permit DPW Town Engineer: Signature: 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 NOTES and DATA — (For department use) ❑ Notified for pickup Call Email i Date Time Contact Name Doc.Building Permit Revised 2014 No 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 o 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 o 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 VOTE: 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. 6-72- � Date .r Check # 2 U U Y4 TOWN OF NORTH ANDOVER Certificate of Occupancy $ p, , Building/Frame Permit Fee $ b �"Z) Foundation Permit Fee $ Other Permit Fee $ TOTAL $ , r� Building Inspector J w = u. O OC m O U1N Uv+'i +� \ 'O O LL (n U '�„� O. (n a H Z (D Z J m O O 'O C 7 LL L by O d' > C U LL O a H Z C7 Z m J d L by O w — LL O °• N zui a U W J W L bA 3 w U f Ln m LL U °. Z N Q t bA � d' LL z W 2 Q W 0 W 5 6L ai O m O z ++ 41 N0 (A N p 41 Y Ln r L 2 Z G co Z LU w CL LU F— W a 0 w :a U) Z 0 m r a F— O U H Z V CO uiJ M ti Z w a O E i O O d Z N I W V/ CD .E m m s � � v � O Q CLQ ai Q Q v_ J � .CL O U) Z � O U cU C CL D Janusz Dziedzic (978)683-5286 213 Haverhill St Methuen Ma Licenses #: CSSL-100965 HIC #:154770 For: Work Contract Judith A. Pulzetti 209 Greene Street Norh Andover, MA 01945 10-23-15 Work consist of: Removal and disposal of the old roof Install new drip edge Install 3ft ice and water shield and paper for the rest of the roof Install new shingles costumer choice Total includes labor and material: $ 7,000.00 The Commonwealth of Massachusetts . ' . Department of IndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization&dividual): f� Address:.Zck? Caro e. S)- /C DU �i /t/v o Q City/State/Zip: Are you an employer? Check the appropriate box: Phone #: 1. a employer with ..... : employees (full and/or part-time).* .2. [61 am'a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.. ❑ I am a homeowner doing all work myself [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.# 6. ❑ We are a corporation and its officers have exercised their right of exemption per MGL C. 152, § 1(4), and we have no. employees. [No workers' comp. insurance required.] Type of project (required): 7. [] New construction 8. (] Remodeling 9. ❑ Demolition 10 F1 Building addition 11.0 Electrical repairs or additions 12. [] P bing repairs or additions 13. Roof repairs 14. ❑ Other *Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit #his 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-coniractors have employees, tliey must provide their workers' comp. policy number. X am an employer that is pi'ovidhig workers' compensation insurance for my employees.' Below is'the policy and job site information. Insurance Company Policy # or Self -ins, Lie. #: 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 MGL c. 152, §25A is a criminal violation punishable by 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. 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 thep�ain's�andp�ennaldes ofperyury that the information provided above is true and correct: 0:._..... _,.. f"�iU1/G`% I i'. ✓� Il��� Date: 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. EIectrical 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 lure, 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 beanemployer." 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-contractor(s) 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 poll'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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia 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 •s sed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. Also, note Permits axe required under Fire Prevention laws Chapter 148 Section 1 OA. The debris will be disposed of in: �q (Locatio qacility) 12 -2 -rte Date -D) ep-t, BIAS % 15S H e- 41,y d ree- A60Ra CERTIFICATE OF LIABILITY INSURANCE FDATE(MM0/26/)15 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS 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 policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Armand P. Michaud Insurance Ag 105 Haverhill Street Methuen, MA 01844 NAMEACT TrudyLawler PHONE Fax (978 685-2549 / No: (978) 794-0822 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: Safety Insurance Co 7/30/16 INSURED INSURERB:*SafetV Insurance Co Janusz Dzledzic 213 Haverhill Street Methuen, MA 01844 INSURER C: INSURER D: INSURER E: INSURER F: PRODUCTS - OOMP/OPAGG $ COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF MMIDD/Y POLICY EXP MM/DD/YYYY LIMITS A GENERAL LIABILITY X COMMERCIALGENERALLIABILITY CLAIMS-MADE � OO✓UR BMA0022291 7/30/15 7/30/16 EACH OCCURRENCE $ 1,000,000 PREMMIS EES (E'occuD $ 100,000 MED EXP (Anyone person) $ 10,000 PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'LAGGREGATELIMITAPPLIESPER 17 POLICY PRO LOC JECT PRODUCTS - OOMP/OPAGG $ $ B AUTOMOBILE LIABILITY ANYAUTO ALLOWIED X SCHEDULED AUTOS AUTOS HIREDAUTOS _ AUTOS NON -OWNED 6210613 7/14/15 7/14/16 EOaBINEcd.DtSINGLELIMIT $ BODILY INJURY (Per person) $ 100 BODILY INJURY (Peraccident) $ 300 P eacGtlentDAMAGE $ 100 UMBRELLA LIAB EXCESS LIAB F OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / NI.PR ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) f yes, describe under DESCRIPTION OF OPERATIONS below N / A WC STATU- OTH- E.L. EACH ACG CENT $ E.L. DISEASE -EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space isreguired) CERTIFICATE HOLDER CANCELLATION © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD Phone: (978) 685-2549 Fax: (978) 794-0822 E -Mail: konniephifer@michaudinsurance.com SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. Building Department AUTHORIZED REPRESENTATIVE 1600 Osgood St Bldg 20 Ste2035 North Andover, MA 01845 Konnie Phifer © 1988-2010 ACORD CORPORATION. All rights reserved. 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