HomeMy WebLinkAboutBuilding Permit #615 - 214 BLUE RIDGE ROAD 4/19/2008BUILDING PERMIT
TOWN OF NORTH ANDOVER
I
APPLICATION FOR PLAN EXAMINATION
Permit NO: � / �, Date Received
Date Issued: ` / " o®
IMPORTANT: Applicant must complete all items on this
LOCATIO
Print
PROPERTY OWNER DSS `e -P -'v' -
v Stereo �B••�VO
0? 4t �`' 6 O1�
MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Exp.
Date:
Residential
Non- Residential
New Building
One family
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
Repair, replacement
Assessory Bldg
Others:
Demolition
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
Address:
CONTRACTOR Name:—)6r 1• Cd—1
Address: y+ o r>7 S
Supervisor's Construction License:
Exp.
Date:
Home Improvement License: • �2
6 5—
Exp.
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: $ -� , tri �—o FEE: $ Sze
Check No.: f b V Receipt No.: b� l 0
4
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner Signature of con#racto
r--) --) -A � j
Location
No. (,�
re -
i
. 000-
� .-,5
/Y-/� 2- N-41,
Check #
I
Date /41.
6
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
TOTAL
2 1 0 9
Building Inspector
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
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
DATE REJECTED DATE APPROVED
Reviewed on Signature
HEALTH Reviewed on Signature
COMMENTS
11
Zoning Board of Appeals: Variance, Petition No:
Planning Board Decision:
Conservation Decision:
Comments
Comments
Zoning Decision/receipt submitted yes
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
FIRE DEPARTMENT - Temp Dumpster on site yes
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Located 384 Osgood Street
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
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
No
NOTES and DATA — (For department use)
❑ 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)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
Li 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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2008
The Commonwealth of Massachusetts
Department of Industrial Accidents
u u Office of Investigations
' d 600 Washington Street
t Boston, MA 02111
0
5Y°y www.mass.gov/dia '
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name (Business/Organization/Individual): 77� ( O
Address:a
City/State/Zip:
Phone .#: I --\ a - 6 S' Z - � (0 Z
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with 4. ❑ I am a general contractor and I
2.Xemployees (full and/or part-time).* have hired the sub -contractors
I am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees 'These sub -contractors have
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.t
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
❑ 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.]
r� a Vjit'i.
Type of project (required):,
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. ❑ Electrical repairs or additions
11. El Plumbing repairs or additions
12.0 Roof repairs
13. ❑ Other
*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 work and then hire outside contractors must submit a new affidavit indicating such,
xContractors 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 -contractors have employees, they must provide their workers' comp. policy number.
I am an employer that isproviding workers' compensation insurance for my employees. Below is thepolicy and job site
information.
Insurance Company N
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 he%by ceitify� a pains and p�iesjury that the information provided above is true and correct
not write in this area, to
City or Town:
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3
6, Other,
Contact Person:
or town official
Permit/License #
City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
Phone #:
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ropoml Page # of pages
Proposal Submitted To:S� �j Job Name Job #
Address ` Job Location
Date Date of Plans
Phone # r� p q 7 Fax # Architect
We =hereby specifications and estimates for: w_
I
.... .........
-t
.. _............. .
. _. _ ........
rproposehereby to furnish material and labor - complete in`accordance with the above specifications for the sum of:
Dollars
with payments to be made as follows:
J
Any alteration or deviation from above specifications involving extra costs will be
Respectfully
executed only upon written order, and will become an extra charge over and
above the estimate. All agreements contingent upon strikes, accidents, or delays submitted
beyond our control. Note — this proposal may be withdrawn by us if not accepted within _ days.
'
acceptance of Propogai ,
01
The above prices, specifications and conditions are satisfactory and are Y Y��
Signature
hereby accepted. You are authorized to do the work as specified.
Payments will be made as outlined above.
Date of Acceptance Signature
., NC3819 MADE IN MEXICO
ACORD. CERTIFICATE OF LIABILITY INSURANCE
F4/17/2008'
PRODUCER
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
M.P. ROBERTS INS AGCY INC
1060 Osgood Street
North Andover, MA 01845
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
TYPE OF INSURANCE
(978) 683-8073
INSURERS AFFORDING COVERAGE NAIC#
INSURED NOEL CASTILLOVEITIA
INSURER A: PENN -AMERICA INS
INSURER B:
24 SCHOOL STREET
INSURER C:
NORTH ANDOVER, MA 01845
INSURER D: MASS WORKERS COMP ARP
INSURER E:
EACH OCCURRENCE $ 1,000,000
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.
INSR
LTR
DD'L
NSRD
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE MM/DD/YY
POLICYEXPIRATION
DATE MM/DD/YY
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY
U_REMT13
PREMISES Ea occun nce $ 100,000
CLAIMSMADE CI OCCUR
MED EXP (Any one person) $ 5,000
A
PAC6696325
06/20/07
06/20/08
PERSONAL a ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG $ 2 , OOO , 000
POLICYF_j PRO-
JECT LOC
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT $
ANYAUTO
(Ea accident)
ALL OWNED AUTOS
BODILYINJURY $
SCHEDULED AUTOS
(Per person)
HIRED AUTOS
BODILY INJURY $
NON-OWNEDAUTOS
(Peraccident)
PROPERTY DAMAGE $
(Peraccident)
GARAGE LIABILITY
AUTO ONLY -EA ACCIDENT $
ANYAUTO
OTHER THAN EA ACC $
AUTOONLY: AGG $
EXCESS/UMBRELLA LIABILITY
EACH OCCURRENCE $
OCCUR CI CLAIMSMADE
AGGREGATE $
DEDUCTIBLE
RETENTION $
$
WORKERS COMPENSATION AND
WCSTATU- T -
EMPLOYERS' LIABILITY
TBD *SEE BELOW
TORYLIMITS ER
D
ANY PROPRIETORIPARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
E.L. EACH ACCIDENT $
E.L. DISEASE - EA EMPLOYE $
Ifyes, describe under
E. L. DISEASE -POLICY LIMIT $
SPECIAL PROVISIONS below
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
THE INSURED HAS APPLIED FOR WORKERS COMPENSATION THRU THE MASS WORKERS COMP
ASSIGNED RISK POOL. A CERTIFICATE OF INSURANCE WILL BE ISSUED DIRECTLY FROM
THE CARRIER ONCE ASSIGNED.
t`CDTICIf%ATO unl Ml-
SUSAN RAGAN
214 BLUERIDGE ROAD
NORTH ANDOVER, MA 01845
ACORD 2512nnl im
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIO DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIN UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESE E
UACORD CORPORATION 1988
04/18/2008 14:00 FA% 19786833147 M.P,ROBERTS INSURANCE
10001
CERTIFICATE OF LIABILITY INSURANCE
(ATEIMMIDDIYYYY)
4/18/2008
PRODUCER
M. P. ROBERTS INS AGCY INC
1060 Osgood street
North Andover, MA 01845
(978) 683-8073
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE NAIL#
INSURED DI ATI CONSTRUCTION
MICRAED P. DIODATI D/B/A
22 THOMAS ROAD
laWREN CE, MA 01843-3227
INSUIERA PROVIDENCE MMUAL
INSURER 8:
INSURER c:
WS 0,
INSURER E:
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
POUCIES,AGGREGATE LQ1M SHOWN MAY HAVIEGEEN REDUCED BY PAID CLAIMS.
em
ADM
OF INSUPANCS
POLICY NUMBER
OA M F
P E
LIMITS
GENERAL LIABILITY
EACHOCCURRENCE f 18000,000
8 COMMERCIAL(BENERAL LWelllrr
CLMAMADE OCCUR
I" I
PREMISES Em acwonw 1 100,000
MEDEXP(ARyensperm) i 5,000
A
CPPOO61931
4/15/08
4/15/09
PERSONALSADV INJURY f 1.000 000
GENERAL AGGREGATE / 2,000,000
GENS AGGREGATE LIMIT APPIIESPER
Pa1CY Loc
PRODUCTS-wwiwACG f 2,000,000
AUTOMOBRELIAB0.flY
ANYAUTO
COMBINED SINGRELIMIT 1
(Ea ilcadoNI
ALL OVIMFDAUT06
SCHEDULED AUTOS
BoolLr iNJuar f
(Por pmm)
"MAUTO$
NON•OIAMEDAVTO5
BODarINJURY
(Pdw*=WenU f
PROPERTY DAMAGE f
(Pefeetleslt)
GARAGE LIABILITY
AUTO ONLY- EAACCMENT S
OTHERTHAN EAACC f
AUTOONLY: AGG i
ANYAUTO
EXCESKIIA ELLA LIABILITY
( OCCUR CI ClAIMBMADC
EACH OCCURRENCE i
AGGREGATE f
f
f
DEDUCTIBLE
f
RETENTION 5
WORKERSCOW15WATIDNAND
EMPLOYERS' LIABILJtV
ANY PROMTORAA�YR
OPFICEAAldINfER PXQwKw
it,eeenlDeunax
M P below
I T RVLIMRS I IER
EL EACHACC►DENT 5
E.L. 013EME - EA EMPLOY $
E.L. DISEASE - POLICY UMIT S
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONSI VE14WS l EXCLUSIONS ADDED BY ENDORSEMENT N SPECIAL PROVISIONS
F-978-688-9542
SUSAN RAGAN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANOELL601 MAC THE EXPIRATION
214 BLUE RIDGE ROAD DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ID 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. _ r _ L I
ACORD2600011081 CACORD CORPORATION 1985