HomeMy WebLinkAboutBuilding Permit #969-15 - 21 WILSON ROAD 5/27/2015t%ORTH
BUILDING PERMIT 0* yi
V6
TOWN OF NORTH ANDOVER 0
APPLICATION FOR PLAN EXAMINATION
C .1c....
Permit No#: Date Received
Date Issued:
11–M—PORTANT: A-p-plicant must complete all items on this page
LOCATION rL
Print
PROPERTYOWNER 63�'We,-1
Print 100 Year Structure yes no
MAP PARCEL: 4-1 *7 ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
El New Building
El One family
El Addition
0 Two or more family
El Industrial
El Alteration
No. of units:
El Commercial
9 Repair, replacement
0 Assessory Bldg
El Others:
El Demolition
El Other
1 El Septic - El Well
El Floodplain O -Wetlands
11 Watershed District
1--E] Water/Sewer
-------
DESCRIPTION OF WOKK I U 13t PtMt-UMIVItu:
F. I
Identification - Please Type or Print Clearly
OWNER: Name: G-re,� 114,IeA.,��,EvSkCti Phone:
r r-
Ar1r1race-
Contractor Name:Paijl S roy,4)464i,-� Phone: C71 S- -50 -
Email: 9a,,A S cc4-, 3 4 ,- L, a evi , k - CC,0,1
Address: 3 5- 26o�:KLw,,V &,D ruine- tA , *'� 01YU.
Supervisor's Construction License: r- 5 - 0 917 S' 3 —Exp. Date:
Home Improvement License:J=443-7 J- Exp. Date: ZA // 7
ARCHITECT/ENGI NEER
Address:
Phone:
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: $ FEE: $
Check No.: /292 0 Receipt No.
NOTE: Persons contracting with unregistered contractors do not have
ZP�? 3 5�
tyfund
Plans Submitted [I Plans Waived 11 Certified Plot Plan [I Stamped Plans 11
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/Massage/Body Art
Swhmn'ng Pools
well
Tobacco Sales
Food Packaging/Sales El
Private (septic tank, etc.
Pennanent Dwnpster on Site El
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS.
Reviewed On Signature_
Reviewed on Signature
Reviewed on Signature
. Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Plarming Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
TT�
i it
e, UEk�
[ffi� g,.hA L(ro/q4Xe,
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 rnin.$100-$1000 fine
NOTES and DATA — (For department use)
Ll Notified for pickup Call Email
Date Time Contact Name
Doc.Building Pennit 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
4, Building Permit Application
4 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
:)TE: 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
OTE: 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
2012 IECC Energy code
Engineering Affidavits for Engineered products
10TE: 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 �—,? / �4) " /-1-0/,) 'R/
No. 96 � - /�
Check # loag
Date
lz�
TOWN OF NORTH ANDOVER
Certificate of Occupancy $-
Building/Frame Permit Fee $ ;Za x
Foundation Permit Fee $--,-
Other Permit Fee
TOTAL
'-/6uilding inspector
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The Commonwealth ofMassachusetts
Department ofIndustrialAccidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.govIdia ctors/Electricians/plumbers.
ce Affidavit: Builders/Contra
Workers' Compensation Insuran 11 THE pERAUTTING AUTHORITY.
TO BE FILED WIT
Name (Business/Organization/Jndividual):_
Address:_i_�_?&YK _(_�C>
City/State/Zip: pezc�
Are you an employer? Check the appropriate box:
_� I I
zz
� i�, , ,
?Phone #: 7
1.01amaemployerwith -' -time).*
__ ;�_MPIOYees (full and/or part
2. El I am a sole proprietor or partnership and have no employees Working for me in
any capacity. [No Workers' Comp, insurance required.]
3.FJ i am a homeowner doing all work myself. [No workers' comp. insurance required-] t
4.FJ I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5.FJ I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance.$
6. n We are a corporation and its. office rs 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. E] New 'construction
8. El Remodeling
9. El Demolition
10 E] Building addition
JI.E] Electrical repairs or additions
12.' . Plumbing repairs or additions
Q
13. Roof repairs
14.F1 Other---.
I
*Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all worka,nd then hire outside contractors must submit a now affidavit indicating such.
tContractors 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-c6ntiactors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' coMpensation insurancefor my emplbyees. Below is thepolicy andjob site
in rmation.
00
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 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. ofperjury that the information provided above is true and correct
I do hereby celtAyy under t�heains andpenalties Date: ?
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 defitied 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 covera I ge required."
Additionally, MGL chapter 152, §25C(l) 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 (LLQ 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 pr 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 burn 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
I Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-NUSSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
Rightfax N1-1 5/28/2015 6:07:42 AM PAGE 2/002 Fax Server
CERTIFICATE OF LIABILITY INSURANCE
ATE(MM/DDIYYYY)
F0512R/2n 1.9
TWMAER'TIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
ERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
C Cl
HIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE
T T�
OR PRODUCER. AND THE CERTIFICATE HOLDER.
01
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUB ROGATION IS WAIVED, subject to the
terms and conditions of the policy, certain policies may require and endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER
CONTACT
NAME:
PHONE
FAX
GEORGE GATH INS AGCY INC
703 CHELMSFORD STREET
(A/C, No, Ext):
(A/C, No):
E-MAIL
LOWELL, MA 01851
ADDRESS:
73LFC
INSURER(S) AFFORDING COVERAGE NAIC
INSURED
INSURER A: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA
INSURER B:
PAULS CONSTRUCTION LLC
INSURER C:
D:
35 PARKWOOD DR
LINSURER
I
INSURER E:
PEPPERELL, MA 01463
I
1114� URER F:
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- NOTWITHSTrNDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN. THEINSURANCE
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
ADD
SUB
POLICY EFF DATE
POLICY EXP DATE
LTR TYPE OF INSURANCE
L
R
POLICY NUMBER
(MMMMYYYY)
(MIADD\YYYY)
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE
$
PCO,
COMMERCIAL GENERAL LIABILITY
CLAIMS MADE Ej OCCUR.
DAMAGE TO RENTED
PREMISES (Ea occurrence)
$
AED EXP (Any one person)
$
DERSONAL & ADV INJURY
$
GEN'L AGGREGATE LIMIT APPLIES PER:
SENERAL AGGREGATE
$
0 POLICY F] PROJECT [71LOC
DRODUCTS - COMP/OP AGG
AUTOMOBILE LIABILITY
COMBINED SINGLE
ANY AUTO
LIMIT (Ea accident)
ALL OWNED AUTOS
BODILY INJURY
$
— SCHEDULEAUTOS
(Per person)
BODILY INJURY
(Per accident)
$
— HIRED AUTOS
— NON -OWNED AUTOS
PROPERTY DAMAGE
$
(Per accident)
UMBRELLA LIABF]
OCCUR
EACH OCCURRENCE
$
AGGREGATE
$
EXCESS LIAB
CLAIMS -MADE
DEDUCTIBLE
$
$
RETENTION $
A WORKER'S COMPENSATION AND
EMPLOYER'S LIABILITY YIN
UB-2E76537A-15
03/09/2015
03/09/2016
X WC STATUTORY OTHER
LIMITS
ANY PROPERITOR/PARTNER/EXECLITIVE
OFFICER/MEMBER EXCLUDED? El
(Mandatory in NH)
N/A
E. L. EACH ACCIDENT
$ 500,000
E.L. DISEASE - EA EMPLOYEE
$ 500,000
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT
$ 500,000
DESCRIPTION OF OPERA-nONSILOCA-nONSIVEHICLES/RESTRICTIONS/SPECIAL ITEMS
TMS REPLACES ANY PRIOR CERTIFICATE ISSUED TO TFIE CERTIFICATE 14OLDER AFFECTING WORKERS COMP COVERAGE.
I
CERTIFICATE HOLDER CANCELLATION
TOWN OF N ANDOVER SHOULD ANY OFF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED
1600 OSGOOD ST IN ACCORDANCE WITH THE POLICY PROVISIONS.
rAUTHORIZED
REPRESENT&T�VE
UT 0 IZ r
N ANDOVER, MA 0 1845
ACORD25(2010/05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPORATION. All rights reserved.
Office of Consumer Affairs & Business Regulation
HOME IMPROVEMENT CONTRACTOR
-f168378
Registration:, Tipe:
Expi ration- -.21912017, Corporation
PAUL CORVINO
PAUL CORVINO
35 PARKWOOD DR-,`
PEPPERELL, MA0146;
Undersecretary
-S- -ty
Massachasefts - D afthrient o ufflic affe,
Board of Building'Regulations and Standards
Construcfioli supel-vilsor
License: CS -097783
Paul A Corvino
35 Parkwood Driii
PeppereR MA 01463
Expiration
Commissioner 12/08/2016