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HomeMy WebLinkAboutBuilding Permit #226 - 236 SUMMER STREET 9/23/2009 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 2 Date Received Date Issued: 305' IMPORTANT:Applicant must complete all items on this page LOCATION 4� Sum M e\p L5+— PROPERTY OWNERPt� j�YV\ aAP\ Print MAP NO: _PARCEL: ZONING DISTRICT: Historic District yes �ff�4 Machine Shop Village yes o TYPE OF IMPROVEMENT PROPOSED USE 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 ESCRIPTION O ORK TO BE PERFORMED: o� i I entification ea a or Print Clearly) OWNER: Name: Phone: �ct Address:—2-342 5 �vht�►'►�� 50` (�, dv� CONTRACTOR Name:_4 'tri edoi bl Phone: 6 Address: q �L)rrlm ( � Supervisor's Construction License: 63 Exp. Date: Home Improvement License: �� l 5! Exp. Date: /j/6ko to ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. �tv Total Project Cost: t 1 $ �o�.�Qd FEE: Check No.: Ja Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the aran and g f — inature of A ent/Owner Signature of contractor 9 g -- - 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 Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments 1 Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway 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 f i i i i ❑ 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 ❑ 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: Doc.Building Permit Revised 2008 Location u m m No. Date Z-3 i 40RT1y TOWN OF NORTH ANDOVER � s Certificate of Occupancy $ $�cMusEt� Building/Frame Permit Fee $ (qq Z � Foundation Permit Fee $ Other Permit Fee $ TOTAL. $ Check # 22440 Building Inspector NORTH F ® Of : Andover 0 No. 2Z7,� dover, MaSS., T O �- LA E COC MICKEWICK V ADRATED S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System j�,�,� BUILDING INSPECTOR Y�THIS CERTIFIES THATP ................................... ..................................................................... Foundation has permission to erect....................................:. buildings on 23� Jn�.w� T .........:......... Rough .. ........................... .................................... p O Chimney to be occupied as..........-�( .. .... . ...... .........[. -®........................................................................... provided that the person acceptin this permit shall in everyspect 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 c��(2 PERMIT EXPIRES= IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU ST TS Rough .......................... Service BUILDING INSPECTOR Final Occupancy-Permit Required to Occuf y 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. i 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 Le ibl Name(Business/Organization/Individual): Address: -f tr►-1 City/State/Zip: , c Phone#: ��� 7 U Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction Swployees(full and/or part-time).* have hired the sub-contractors 2.YLrIl am a sole proprietor or partner- listed on the attached sheet. 1 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.El Electrical repairs or additions required.] officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL . 11.El Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' 13.Q Other comp.insurance required.] *A.ny applicant that checks box#1 must also full 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 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: no✓ 1 L Policy#or Self-ins.Lic.#: QQ Lr J �� Expiration Date: ILI K �� j Job Site Address: 03(g City/State/Zip: ('"e I 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 u er the ains and penalties of perjury that the information provided above is ue and correct Sip-nature: Date: / 3 Phone#: Official use only. Do not write in this area, to be completed by city or town officiate 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 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 retuned 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 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 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 5-26-05 www.mass.gov/dia AC R® CERTIFICATE OF LIABILITY INSURANCE wmIwmwVYYY► PRODUCER 9/23/09 JaDles O'Connell Insurance THIS CERTIFICATE IS 13SUED AS A MATTER OF INFORMATION 754 Boston Rd ONLY ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Billerica, MA 01821 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. IIBUItm INSURERS AFFORDING COVERAGE NAIL ly ERIC BITZGERALD INSURERA NAUTILUS INSURANCE COMPANY DHA F'ITZGERALD CONSTRUCTION LINSURPR R s Statm Insurance COMOR 9 SUMMIT RD R G BILLER CA, MA 01821 R COVERAGES R INSURANCETHE CIESOF STED l �FANBEENj ED TO THE UFMTH OVE CSD� IST�ORANY REEQUREMEMR(ONDrrOCONPAC OR OTHER DOCUMENT RESPECT TO THICERTAE FAY BE ISSUED MAY PERTA 4 THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,ELUSIONS AND II16R CONpltYO OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUMD BY PAID CLAIMS. •• _. POLICY NUMOER Y F CTUVb policy ExSi 7rON GENERAL L14BIUTY IMATS A X COMNERCIALGENEPALLIABILITY NC500326 OOCUR PaCHOCcuRRENCE s 1 000 00 11/6/08 11/6/09 PANf° s�E �°., s CLAMSlMOe � — AED EXP ryarm psam) S 5 000 PERSOML&ADVINJURY $ 1,000.000 GERL AGGREGATE LUTAPPLIES PER GENERAL AGGREGATE ! 2 000 000 POLICY PRO LOC PRODUCTS-0Owj0pA00 = 2 O0 AUTOMOBILE UANUTV ANYAUM � SINGLELMIT S ALL 0 WNE D AUTOS SCHEOULEDAUrOS BODILY INJURY I HIRED AUTOS IPSP ) NONOWNEDAUTOS BODILY INIURV i �vOI-p 6TMirdDAMADE S GARAGE LIABILITYAWYAU70 AUTO ONLY.EA ACCIDENT S OTHERTNAN EAAOG I AUTO ONLY: AGG S E7ICE8&/UABRELLAUABIUTY OOCUR CLAM MADE EACHOCCURRENCE I AGGREGATE s DBDLIcnelg s ETENTION $ $ YNORKOO COMPENSATION AND EMPLOYERS'LIABILITY WC SrATU• OTW- 13 �CE� �w o?IEOUTnIE Y�j WC004520269 11/3/08 11/3/09 E,L.EACHACOrE:Nr s i0p 000 wIfyrdYloy In NH) --� MICAl I° Iw3w a EL.DrSFABE-PJ 00PLOYE t 100.000 OTIER E.L.D BASE-POLICY M ' 0O 000 UIESCR"ON OF OPERATIONS/LOCATIONS J VEMCLE6 r r:6K o.USIONSADDED BY ENDOMENMT/SPECIAL PROVI1110HU3 INAL SIDING AT 236 SUMMER ST CERTIFICATE HOLDER CANCELLATION SHOULD ANY OFTHGABOVE DESCRIBEOPOUCIES SECANCELLE D BEFORE THEMIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAY&wr4rmm TOWN OF NORTH ANDOVER ATTN BRIAN LEATEIE NOTICE TO THE Cf"I"OATE HOLDER NAMED TO THE 1.EFr,BUT FA ILURR TO pO BO 6NALL 978-690-9542W POSE NO OBLIGATION OR LIABILITY OF ANY MV WON THE INSURER,ITS AGENTS OR NORTH ANDQ{►$R REPRESENTAWES, AUTHORIZED REPREMENTA ACOR D 25(2009/01) ✓ ®1988 2 9 CORD CORPORATION. All rights reserved. The ACORO name and logo are registered Marks ofACORD Proposal Page No. of Pages ) � I CID CTIN • Rccfing 9 Summit Road • Vinyl Siding 97S-4CS-9390 Dillerica,MA O1S21 • Decks PROP ALPBM ED TO PHONE DATE 1D STREET JOB NAME �f CITY, ATE d ZIP DE A JOB LOCATION AFUrrEcT v� DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for. ................................................................ ............................ ...................... ........................................................................:............................................................................................................................................................................................... ......,P '.. ......................_.................................................. . r -� /7J . .. .. - �........ ._r....................................................................................... ........... / J/ r �s................., D. , ........... 1 . ................ ............ ........_ ��... ... 5....... .................... C f./f.. .......................................................................................................................................... ...... ....:.........................................................................................................................................................................:........................................................... G... i ..... ........ .......... ... 7P cam.... r 4 ......... ........................... ......................................... /fl-ra,a.... .........0si° ......' ..............._1 _l ..:..... ./. ........(,1/.� `......... �e �1` l _d......... ..... ..............:. ...I............................... -,/ � s .. .....,1 ��` - . �. ._ '......:D......... r .......................... [/........................... © ..............._.................... .............. ................................................................._ .. ........: .......... c.. .. .......... .......................... ....................... .. . e. o A .. ..... ....... . ............ .s9...... ....a- ............... ... . ... . ..... .A&V- ..... . .......... .... . . . .............. .......... .. ............. ................................ �� 1 .................................. ......_... ................. ...................... MP PrOP0811! hereby to furnish material and labor—complete in accor an a with above specifications,for the of: / �,6 � dollars($ ). Payment to be made as follows: All material is guaranteed to be as specified.All work to be completed in a workmanlike AuthorizBd re manner according to standard practices.Any alteration or deviation from above specifications Si natu involving extra costs will be executed only upon written orders,and will become an extra g charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control.Owner to carry fire,tornado and other necessary insurance. Note:This proposal may be Our workers are fully covered by Workman's Compensation Insurance. withdrawn by us if not accepted within days. Arreptanrt of Proposal —The above prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized Signature '�� to do the work as specified. Payment will be'made as outlined above. Date of Acceptance: Signature ,per �� � \ Board of Building Regulations and StandarJs HOME IMPROVEMENT CONTRACTOR Regist rat oft, 108715 EzpV,.ation: 8`/21/2010 Tr# 273157' l ' YYPI- RBA T.K. FITZGERAfl GONSTFt <'j Thomas Fitzgeralds 9 SUMMIT RD BILLERICA,MA 01821 Administrator 1�7'/ze >%16- PjjlF BIUla�.�z o� ac�zuae Y BOARD QF BUILDIN REGULATIONS Construction Supervisor License Number CS 057635 Expjres t2/1" F2009 Tr.no: 14269 Re�tric s K THOMAS K FITZGf�Ip 9 SUMMIT RD 0/ BILLERICA, MA 01821 Gommissloner ,