HomeMy WebLinkAboutBuilding Permit #643-12 - 233 MASSACHUSETTS AVENUE 3/7/2012TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit N0: 7 Z
Date Issued:I I
IMPORTANT:
Date Received
must complete all items on this
LOCATION oJ3 G�S � 1\jor'h BY)cw\jerF ry (nj
Print
PROPERTY OWNER 0 n �tYl CSW CC Unit #
Print
MAP NO: PARCEL: 2-3. ZONING DISTRICT: Historic District yes no
Machine Shop Village yes o
100 year-old structure yes n
DESCRIPT1UN UY WUK1L iU-=rrr,,.rvtuvmv
Re�acp Atuo en cors, �i uo s�oc`m c�� rs
(Identificatio%n Ple%ase TAP or Print Clearly)
OWNER: N
q ---)V- cn-S 1 q.8
Address: I v 0(A (-�n\wr, W)f� om S
CONTRACTOR Name: Brie l`,s 0v,:�V, Phone:
Address: �'nb`� 1`U - v. t C• r .,
Supervisor's Construction License: C SS L-06KAD .- i) Exp. Date: ala0 f aU 1'i
Home Improvement License: S Exp. Date: I ao t a,
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT: MOO OO P/E\\R $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F.
y
Total Project Cost: $ VU FEE:
Check No.: , Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the g,gaTmy fund
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)
o 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: Doe.Building Permit Revised 2008mi
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 Reviewed on Siqnature
ft
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Siqnature &Date Drivewav Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
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-$1000 fine
NOTES and DATA — (For department use
❑ Notified for pickup - Date
Doc:.Building Permit Revised 2011 June/mi
Location fp4sz� zve__
No. 2 -
Check # / �-
25077
Date I?- 71�
TOWN OF NORTH ANDOVER
Certificate of Occupancy,
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee
TOTAL
�3 � L-4��-
Building Inspector
F, 03/06/2012 12:10 8945665
FRED IRENE DIPRIMA PACE 01/02
Family Owrnedl:Coperamd
254 North Broadway a Salem, NH 03bft: * In the Breckenridge Mall
www..brooksSWG.com , (979) 886��0 + (4303) 994-4485
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Paym m to be malt a Ia1MW
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50 % (S } . Start of lob
5o % (S ) lot reek
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(5 ) 8alanoe upon completion
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(advice op" of more then -5016-of the total =tW ON a'metob! ammgat a8
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DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
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Salol Security Number
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men t.kt10 DmmkMYMM..n...1.r.eYla. W � �O B.rnfl. f.r'6e wmk.era@!ei t.Yalrnlfa e7namal, N.fa�te.altr' iseenYlo.aYt�ttY.tk tl®er..t.i dlenb,(.d�rront IAM
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Paym m to be malt a Ia1MW
20 % ($) upon alonim ombttct; 811001ta Vmyl SWIM a WInf90ws a Doors
50 % (S } . Start of lob
5o % (S ) lot reek
50 % (S ) 60% swond'week
(5 ) 8alanoe upon completion
Note: 0 Gemmed Alter 3 Om 50% Of Remakft Ralence Is None Amlabla
Noftoec No egreementtvraome brgYmvenrent antragkw yuak 9m1 reoyre a dorm payment
(advice op" of more then -5016-of the total =tW ON a'metob! ammgat a8
obto ddv" of order mat�b mw edttib ceder a d/or e0ffirlice
uoma99WWWROWMA
254 N. Braedwav - Breekortridgo Mail
VftO nOOrws
5W.
alem NH 0=9 894.4458
101852
dW0VWpftta
relala the rplrt to tlesk tbtrau�,.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
IN wrrNm wK Fof
r4wnn
havetdgned their names this zA.F" day of trAmSigner _Social Seantty Numbertuner
vet
am the Owner -
Salol Security Number
s Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
('rrn,cructrott Super i�e,r S�•riatr�
License: CSSL.M730
MARK DIPRI ''r i r
18 HAWKDR'3yE.
SALEM
Cornrnissioner Expiration
02/20/2014
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10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 101682
BROOKS CONST. CO., INC. OF LAW
Type, supplement Card
MARK DI PRIMA Expiration: 6/29/2012
254C N. BROADWAY STE 110 - —
SALEM, NH 03079 - ---�
DPS -CAI C' 5OM-04104-GIO1216
V
Office of Coneflless Reg
IMPROVEMENT CONTRACTOR
T= Registration:
101682 Type:
Expiration:
6/29/2012
BROOKS CONST. CO., INC. OF LAW Supplement Card
MARK DI PRIMA
254C N. BROADWAY STE 110
SALEM. NH 03079 �—
Undersecretary
Update Address and return card. Mark, reason for change.
1 Address Renewal r fment Employment P Y L
;ost Card
License or registration valid for individul use only
before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, MA 02116
Not valid without signature
The Commonwealth ofMassachilsetts
Department of IIIdustrial Accidents
Fji----. •)` t-1 ` OffirL of IIIVestigations
�-{ 600 Washington Street
Boston, PLL 02111
w)v;v.mass.gov/lila
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):: CQOS-�. (I. a�o.w t fence.
Address: a 5y N, Bkpt, , �p
City/State/Zip: <
Phone M w,
Are you an employer? Check the appropriate boat:
Type of project (required):
1. ❑ 1 am a employer with
4• ® 1 am a general contractor and 1
G. New construction
employees (full and/or part-time).
have lured the sub -contractors
2. ❑ 1 am a sole proprietor or partner-
listed on the attached sheet.
7. ❑ RemodeIing
ship and have no employees
These sub -contractors have
g, n Demolition
working for me in any capacity.
employees and have workers'
comp. insurance.
9 Building addition
[No workers' comp. insurance
required.]
5. ® We are a corporation and its
10.0 Electrical repairs or additions
3. ❑ 1 am a homeowner doing all work
officers have exercised their
I Ln Plumbing repairs or additions
myself o work'
y � workers' comp.
right of exemption MGL
mpon per
12.0 Roof repairs
insurance required.] t
c. 152, § 1(4), and we have no
13.0 Other
employees. [No workers'
comp. insurance reauired.l
Any applicant that checks box 91 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicuting they are doing ail 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 aur an employer that is providing workers' compensation insurance for Illy employees. Belo 111 is the policy and job site
information. l
Insurance Company Name: �f��'1�i'Gr tn��A>'Y-V)(V
Policy # or Self ins. Lic. M �L /!�, a 1031 S Expiration Date: 5Z)(a /Z o 1 Z.
Job Site Address:_a23 I" I CESS .I \ City/State/Zip: � (� 01�q
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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under tlpaA�id penalties ofperjury that the information provided above is trite and correct.
Phone #: 60�_ �.� O
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector
6. Other
Contact Person: Phone #:
Feb 13 2012 11:03 P.02
� 'iCi�'i y•�i5•�'�'�•Y •> .F•.'t 1• :ij 'I!t ,.I'• '..'s"er�`.i �"�•f'�r�•i,
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Att OF LIABILITY a • !U NCE DATE,MM1pDM/YY)
. ,.
Tits -CERTIFICATE 18 ISSUED. AS A MATTER OF INFORMATION ONLY AND CONFERS hb RIGHTS UPON THE CERTIFICATE HOLDER, THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR AL TME. COVERAGE AFFORDED BY TNF. POLICIES
BELOW. THIS CERTIFICATE OF'INSURANCE DOE$ NOT CON6TITUTE A CONTRACT TWteHN THE ISSUING INSURER(S), AUTHORIZED.
REPRESENTATIVE OR PRODUC[:ft,• AND "I FfE CERTIFICAI'� •HO(,QR,,
...
' 1MFt01dYANT:' If the aerttficate holder !s an ADDITIONAL INSURED, the PaBcy(W), M4$t be ndorsed, If,SU13ROGA11ON IS WAIVED, �ub)ect to
the terms and conditions of the Policy, certain Policies may require an Endorsement. A eta ntant on this certificate does not confer fights za the
certificate holder In lieu of such endorsement s .
Paoiliici:R NT cT tdexiat a Costo
iNSiJFiANC£ gQI,U"rxON3 CORPORATION 11 N (603) 82-4600 F t603l302-2024
60 Westville PA o"r mOaeta@ scinsures.cam
INS RflnAoaa
Plaistow 270 03065 Pe0r1rS s : • K04
SrOOke COnstxuction-Co.• of Lawrence, inC I sURERC x ltl oTE
254 N. Aroadraay INBU o:
THIS IS To CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TC
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT
CERTIFICATE MAY BE -ISSUED OR,MAY PERTAIN, THE INSURANCE AFFORDED BY THE POUCIE
EXCLUSIONS AND CONO(TIONS OF SUCH POLICES. LIMITS SHOWN MAY HAVE $FEN REDUCED BY
AP" WER
TYPL OF INSURANCE p W
OSNERAL UAIMWTY
X COMMERCUIL gENW& UASkITY.: .
A CL AIMUTADE ajOCCUR P564012311
j1/2012
GWL AGGREGATE UMITAPPLIL'S PER '
IC POU p BLO: LOC' -
AuTQIJIOaILE UAaILrjY ;
ANY AUTO
O EO FOULER 116090 /26/2011
• MREC Am 'Z AAUUTOSWNLC
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C WOl"W COMPENSATION
AND EMPLOYSRi' LIARRAY
ANY PROPRI,Et0PJPARTNER1E)( CUTK N 1 A
OFIaCERlMEMeER F7(CLUDEOI
(yy�ensd,nroty rn NH) 8834275 2011
/16/
OESCRI OF ERATIONS,bM w
DESCRIPTION Ole OPERATIONS 1 LOCATIONS INEHICLES (AlWdi ACORD t01.Addlet®nai Remarks Sanddufp R Moro space is
INSURED NAMED ABOVE FOR THE POLICY PERIOD
OTHER DOCUMENT WITH RESPECT TO WHICH THIS
'SCRIBED HEREIN IS SUBJECT MALL THE TERMS,
I CLAIMS,
P LINMV
EACf4 dCCIJRRB= 00,61
EiiAL AGGREGATE 6 2,000,660
PRdDUCT$ - CoMP/OP AtIG B _2g000,000
Q60, 600
SDOILYINJURY(Parmion)• S '
LIODILY INJURY (Per mu") t
EACH OCCURRENCE E ... . _ '.
0
SHOULD ANY OF TFII" ABOVE DESCRIBIM POLICIES BE CANCELLED BEFORE
THE- EXPIRATION OATE THEREOF, 'NOTICE WILL BE OELIVERW IN -
Dors 6 Xi>m Oswald AC60MANCE WITH H9-POUCY PRQVI310M.
• 233 Massachusetts Ave
N. 'And.ovmr, MA 01845 AUT"ORIMOR9PRee5 N11 TIVE
ACORD 26 (201010) ' ®1!881 010 ACORD caRPORATIQN. Aft rights dented
INS025 (2010051.ot The ACORD name snd logo are -registered marks c# ACORD ; ':