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Home My WebLink AboutBuilding Permit #619 - 21 MOODY STREET 4/14/2010BUILDING PERMIT o`tt��o qti 0 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received p�gATlG 4`� �SSACH�15�� Date Issued: fv IMPORTANT: Applicant must complete all items on this page LOCATION 5- ( Print PROPERTY OWNER—.d A=jdj M 41 o Print' MAP 210 0 PARCEL:-? LrIf ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial DC Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer UtSGKIF I IUN OF WORK TO BE PREFORMED: Vim ri q 1 Sir z r Identification Please Type or Print Clearly) OWNER: Name: ,, s /l'1 r;Ay i Phone: Address: J S - CONTRACTOR Address: -3?,' l : 9> Supervisor's Construction License: -, 7 Exp. Date: / �ls-f/T Home Improvement License: / 6:$* 4.f S _ Exp. Date: 71i 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: $-. jl, �d ®' FEE: $ 10"4^ Check No.:�� Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to a guaranty fund ,Signature of Agent/Owner Signature of contracto 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 �F. COMMENTS Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: FIRE DEPARTMENT - Temp Dumpster on site Located at 124 Main Street Fire Department signature/date COMMENTS uocatea su4 us 000 street yes no 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 - Date Doc.Building Permit Revised 2010 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: Building Permit Revised 2008 Location No. 6 Date, TOWN OF NORTH ANDOVER Certificate of occupancy $ Building/Frame Permit Fee $ A -IS Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check #-"q�; 22952 h Build g Inspector TRAVELERSJ� TRAVELERS SERVICE CENTER P.O. BOX 1564 ELMIRA, NY 14902-1564 07795-L3 CP 01 6640 G6640LKR 09360 07795 P1 RAYMOND BERUBE 361 CHICKERING WAY NORTH ANDOVER MA 01845 ACCOUNT BILLING SUMMARY POLICY TYPE POLICY PERIOD Page 1 of 2 Account Bill Account No. 4624N3106 Date of This Bill 12/28/09 >:TOTAL ....... .......................-..................... ................................ $ 822:::.0.0 :. MINIMUK.D.UE::>::> $278.97 27.8 . :9.7.:. PAYMENT MUST BE RECEIVED BY: JANUARY 15, 2010 6242B353 680 Commercial Package 12/15/09 To 12/15/10 Current Installment Charge TOTAL BALANCE TRANSACTIONS SINCE LAST STATEMENT Total Transactions (See Transaction Detail Section) MIN. DUE BALANCE $273.97 $822.00 5.00 $278.97 $822.00 +822.00 TOTAL BALANCE $822.00 TRANSACTION DETAIL POLICY NUMBER 6242B353 680 Commercial Package 12/15/09 Renewal TOTAL TRANSACTIONS CONTINUED ON NEXT PAGE 822.00 $822.00 Please detach the payment coupon and mail with your payment in the enclosed envelope to: TRAVELERS, CL REMITTANCE CENTER, HARTFORD, CT 06183-1008. ................................................................................................................................ 648842H 2009362 7014 700 OXW988 Payment Coupon TD INSURANCE INC RAYMOND BERUBE 4624N3106 Make checks payable to: TRAVELERS TRAVELERS CL REMITTANCE CENTER HARTFORD, CT 06183-1008 Include Account Number on the check. e Change of Address? Place an "X" here. Print changes on reverse side. PAYMENT MUST BE RECEIVED BY JANUARY 15, 2010 9934363234143331303640393939392800002789700008220064 $822.00 $278.97 PL -9837 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Lnvestigations kvi 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leogibly Name (Business/Organization/Individual): Address: -3 � r C City/State/Zip:A A,,. 'J ekvl -- Phone #: q J Sr 6 —7 -2 " z g Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ 1 am a general contractor and I em s (full and/or part-time).* have hired the sub -contractors 2. am a sole proprietor or partner- listed on the attached sheet I ship and have no employees These sub -contractors have working for me in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. Building addition 10. (] Electrical repairs or additions 1 I.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other .. -- _–____ ...... ... ....r...aaav iia: Vui iStGvv^ZUI.^'.. nerniv gnpisnn` Wau rn!Y._ - t _nrnr.r carina ....ria., Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contactors that check this box must attached as additions] 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. #: Job Site Address: Expiration Date: 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 hereby ce der the pains and/penal^es of perjury that the information provided above is true and correct Official use only. Do not write in this area, to be completed by city or town off ciaL City or Town: Permit/License # Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing 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-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 thea piicauun iiir the be, requested,F A ± y permit or license is being not he Departmme;i 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 permittlicense 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 Washington Street Boston, MA 02111 Tel. # 617-72.7-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-72.7-7749 www.mass..gov/dia � w o as u 0 LE 0 U)w° Z -oz °�° w°' �Q c U c° w a a -M w�' cn w a W w W -� 0 � V cn w o a U C7 °�° P4 cu w W H w 4 w' O z cn v o cn E a. y L y.r N 0 N G O CD W W 0 Qu w C V Q z So.�m 0 O FM4 0 O 1% Y/ W W W W W 0 Qu w C V Q 0 O FM4 0 O 1% Y/ W W W Nlassachusetts - Department of Public Safet- Board of Building Rei-ulations and Standards Construction Supervisor License License: CS 35867 Restricted to: 00 RAYMOND V BERUBE 361 CHICKERING RD N ANDOVER, MA 01845 ('��nunissiuner Expiration: 12/15/2011 Tr#: 10708 T111 IM. ' � Ituard of 13uiidin;, hc„ulalintrs :uul ` i..uiin:ar 's. 110ME IMPROVEME4T CON'rR.AC. P 105523 ... E pirataon: 71.17/2010 Tr;ft 2707:-' Type. :nd vslual j t".. 'MC,,0 V.,BERUBE 1 !l.;yn and Bcrubeu �yr 0 Page # of page Proposal Submitted To: Job Name Job # Address / Job Location Date Date of Plans Phone # Fax # Architect We hereby submit specifications and estimates for: 3y1 r We propose hereby to furnish material and labor — complete in accordance with the above specifications for the sum of: Dollars with payments to be made as follows: Any alteration or deviation from above specifications involving extra costs will Respectfully be executed only upon written order, and will become an extra charge over and submitted E4, 1 t above the estimate. All agreements contingent upon strikes, accidents, or delays �- beyond our control. Note — this proposal may withdrawn by us if not accepted within days. C;kme ttaure of 1jrLip sal The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Signature Payments will be made as outlined above. Date of Acceptance Signature .: NC3819 -3 c We propose hereby to furnish material and labor — complete in accordance with the above specifications for the sum of: Dollars with payments to be made as follows: Any alteration or deviation from above specifications involving extra costs will Respectfully be executed only upon written order, and will become an extra charge over and submitted E4, 1 t above the estimate. All agreements contingent upon strikes, accidents, or delays �- beyond our control. Note — this proposal may withdrawn by us if not accepted within days. C;kme ttaure of 1jrLip sal The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Signature Payments will be made as outlined above. Date of Acceptance Signature .: NC3819