HomeMy WebLinkAboutBuilding Permit #602 - 233 MAIN STREET 3/15/2007 L
BUILDING PERMIT NORrh
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TOWN OF NORTH ANDOVER 32 may:'
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
9SSACHus
Date Issued: /S O
IMPORTANT: Applicant must complete all items on this page
LOCATION 1�'11xr 1
Print
PROPERTY
Print
MAP NCS' PARCEL: ;ZONING t31STF IGT HISTORIC DISTRICT,; 'yes
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
[I Addition J4Two or more family 11 Industrial
Alteration No. of units: ❑ Commercial
Repair, replacement ❑ Assessory Bldg ❑ Others:
Demolition11Other
Septic ❑Welly : y !bFloodplatn 1 t/etland W tershed.:Di�strict
0 Water/Seiker �,
T
DESCRIPTION OF WORK TO BE PREFORMED: q
-- tMOvP t Y�� �� t' LRrd3tyr��'S CWS�fG@'1i t11P..R.-{GI't ivLt
W �f 9 Jr Iz w . s Goo-.-% W A U4 -Gt c 4 y
Identification Please Type or Print Clearly)
OWNER: Name: (747 o L f'Ll to-r/!Z� � Phone:
'
ST '
Address: a�Z f4,, dia Mpsz O(�
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A
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CONTRACTOR �NarnP+$ t3 Phone: � c Da
S7'
Address: yew dA` 1 '-- . �x ►
Su ery soe Construction Lac Ise. L 2 /1 �l Exp. Dater 05 U� 2��- r
A
Horn Impro cement Lice sa: P•
ARCHITECT/ENGINEER
Phone: w
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: $ / oo ' FEE: $ o�
Check No.: 1�� Receipt No.:
NOTE: Persons contract
inwith unregistered contractors do not have acs to t&guarantyfund
Signature of Agent/Owne 4n C.. Signature of contractor
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
DATE REJECTED DATE APPROVED
CONSERVATION ❑ ❑
COMMENTS
DATE REJECTED DATE APPROVED
HEALTH ❑ ❑
COMMENTS
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 ❑
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
i
r
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature& Date Driveway Permit
Located at 384 Osgood Street
FIRE:DEPARTMENTa'- Temp�,Dufmpster onsite, es f.,,=-� no
Located at 124 Main Sop Y
Fire Deportment signaturefdat+
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
❑ Notified for pickup - Date
Doc.Building Permit Revised 2007
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
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
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
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 2.2007
Location c:;�33
No. Date '
NORTH TOWN OF NORTH ANDOVER
3? ° SOL
41
f 9
Certificate of Occupancy $
♦ i
'�
Building/Frame Permit Fee $
sACMus
Foundation Permit Fee $
Other Permit Fee $ _
TOTAL $ �
Check #
2 0 V
Building Inspecto(/
From:Margaret Butters At:HUB International New England,LLC FaxiD:HUB International Ne To:No Andover Building DDate:3/15!2007 11:17 AM Page:2 of 3
i
OP ID p
DATE(MIWDD/VYYY)
ACORD. CERTIFICATE OF LIABILITY INSURANCE MAOPID 03/15/07
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HUB International New England HOLDER.THIS CERTIFICATE DOES NOT AMEND.EXTEND OR
299 Ballardvale St. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Wilmington MA 01887
Phone: 978-657-5100 Fax:978-658-9185 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURERA: Acadia Insurance Company
INSURER B:
Marceau Construction Corp. INSURER C:
P. 0. BOX 66 INSURER D:
Methuen MA 01844
INSURER E: '
I
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.
w Wit -TION
LTR S TYPE OF INSURANCE
POLICY NUMBER DATE(MMIDD/YY) DATE(MMIDD/YY) LIMITS
GENERALLIABMY EACH OCCURRENCE $1000000
A }{ COMMERCIAL GENERAL LIABILITY CPA0044219-18/06 08/15/06 08/15/07 pREMISEs(Eeocc"Lc e) $250x000
CLAIMS MADE �OCCUR MED EXP(Any one person) $5000
PERSONAL&ADV INJURY $1000000
GENERAL AGGREGATE $2000000
GEMLAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $2000000
17 POLICY F7 jEa 7LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
A ANY AUTO MAA0044391-19/06 08/15/06 08/15/07 (Eeaccident) $1,000,000
ALL OWNED AUTOS BODILY INJURY
X SCHEDULED AUTOS (Per person) $
X HIRED AUTOS
BODILY INJURY $
X NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $5,000,000
A X OCCUR LICLAIMSMADE CUA0177743-11/06 08/15/06 08/15/07 AGGREGATE $5,000,000
$
DEDUCTIBLE $
X RETENTION $ $
WORKERS COMPENSATION AND TORY LIMRS ER
A EMPLOYERS LIABILITY WCA0075242-14/06 03/19/06 03/19/07 E.L.EACH ACCIDENT $1000000
ANY PROPRIETOR/PARTNER(EXECUTIVE
OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE 1$1000000
If SPEs.CIAL PROVISIONS cribe under
CIALPROVISIONS below E.L.DISEASE-POLICY LIMIT $1000000
OTHER
A Property Section CPA0044219-18/06 08/15/06 08/15/07
A Equipment Floate CPA0044219-18/06 08/15/06 08/15/07
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES/ XCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
Town of North Andover as additional insured.
CERTIFICATE HOLDER CANCELLATION
NOAND-2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
No. Andover Building Dept. NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
FAX: 978-688-9542 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
REPRESENTATIVES.
A RE A
ACORD 25(2001108) 0 ACORD CORPORATION 1908
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BBRS Privacy Statement
http://db.state.ma.us/bbrs/hic.pl 10/20/2006
ZWd 60:01 ZOOZ ST JPW ZS82-S89-8L6:XPJ •1SN03 nU33MW
P.O.BOX 88
20 os9Wa street Marceau
Methuen,MA 01844
PWw 978.885-4708 Construction • •
Fax' 97868,5.3892
Fm
T= Notch Andover Building Dept From: Card Markey
Att w. Jeanine McEvoy Daft 3-16-07
Fax: 978-688-9542 Pages: 2
Enclosed is proof of HIC License. The owner,Wilfred Marceau,has the actual license in his wallet and
he is in Rorlda until the and of April. 1 will have him make a copy of it and fax it to me. I called theth
insurance company again regarding our certificate of insurance. Our WC policy expires March 19 so i
Will fax you a certificate with the renewal. Thank you for all your help today!
TO'd 60:OT ZOOZ ST JPW ZS82-S89-8Z6:xe3 -1SN00 nU3D8UW
NORTH
Town of
4Andover
No. � rorA�..11'� '•`' art
'' LA 70
W-K
o �` dover, Mass., nnr?
COC MICMEwICK V
Ids RATED P .(C7
7 BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
"W 06011000440 BUILDING INSPECTOR
THISCERTIFIES THAT.......... ... ....................................... ...................... ......... ...................................... ............... Foundation
3
has permission to erect...... ................... ............ buildings on�........ .......... ... ...... . ...•........ ......... Rough
to be occupied as.. .. chimney
.. . ....................................
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
UNLESS CONSTRU T S ELECTRICAL INSPECTOR
Rough
. .. .... ... ..... ........... ......................
Service
BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy 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
UT
600 Washington Street
Boston,MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Name(Business/Organization/Individual): *WGO t,.
Address: ' �95 C ooy S T U d uk 6 r
City/State/Zip: A 0[ZY Y Phone#:
Aryyo employer?Check the appropriate boa: Type of project(required):,1. I am a employer with aft 4. E] I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.E3 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g• ❑Demolition
working for me in any capacity. employees and have workers'
insurance.# 9• ❑Building addition
co
[No workers'comp.insurance mP•
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself.[No workers'comp. right of exemption per MGL 12.❑Roof repairs
insurance required.]t C. 152,§1(4),and we have no
employees.(No workers' 13.❑Other
comp.insurance required.]
'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.
;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-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: 4C.Ak r /i3 '
Policy#or Self-ins.Lic.#: W C A 0 0 5 4 I -1y Expiration Date: O
Job Site Address: 33 4444+'► S -i ZI Orliy4 City/State/Zip: �ld
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 cert" der the pains and penal of perjury that the information provided above is true and correct
Simlure Date: ! 0
Phone#: �' /S— 6
OfJlcial use only. Do not write in this area,to be completed by city or town offlciaL
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 employdrs 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-contiactor(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 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 burn 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. #617-727-4900 ext.406 or 1-877-MASSAFE
Fax#617=727-7749-
Revised 11-22-06
www.mass.gov/din
License: CONSTRUCTION SUPERVISOR
Number: CS 021191
. >' Birthdate: 05/02/1957
Expires: 05/02/2008 Tr. no: 22655
Restricted: 00
ROGER A DESJARDINS
4 COTTAGE RD
ANDOVER, MA 01810
Commissioner
Am
Marceau
Construction Corp.
Roger Desjardins-Vice President
P.O. Box 66-28 Osgood Street
Methuen, MA 01844
Telephone-978-685-4706/Fax-978-685-3852
Nextel-978-815-6634
Email:roger@marceauconst.com
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