HomeMy WebLinkAboutBuilding Permit #530 - 26 GLENWOOD STREET 2/2/2007TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION o�,t�•°".gtiC
Permit NO: t Date Received
l r 7 °BATE°
Date Issued: % 9SSACHUS��
IMPORTANT: Applicant must complete. all items on this age
LOCATION a(0 Gliyn u oc - '7"I 1t. No Ndoye(', }
PROPERTY
Print
MAP NO.: PARCEL:
TYPE AND USE OF BUILDING
,Is
ZONING DISTRICT:
HISTORIC DISTRICT YES ❑
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ Addition
C"Alteration
@16ne family
❑ Two or more family
No. of units:
❑ Industrial
❑ Repair, replacement
❑ Demolition
❑ Assessory Bldg
❑ Commercial
❑ Moving (relocation)
❑ Other
❑ Others:
❑ Foundation only
ro ,
Identification Please Type or Print Clearly)
OWNER: Name:
Address: 01% G �`en �.IdOC� C��� NL7( Amooe `,IA n 1,�4 S
CONTRACTOR Name:IJ1 OoKS Co T nC . Phone: 600 3
Address:
Supervisor's Construction License:Qom,(n9l cj Exp. Dater
Home Improvement License: 1 U Ga Exp. Date:
ARCHITECT/ENGINEER Name: Phone:
Address:
Reg. No.
FEE SCHEDULE. BULDING PER T. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.Total Project Cost :$ a`9
(0 a, FEES y42
Check No.: �l / Receipt No.:
Page Iof4 /g1 4k�
Location Q(! e— d a4 -1t
No.Date .0
NORTH TOWN OF NORTH ANDOVER
O: .•o I •,h•00
• L
9
Certificate of Occupancy $
sMuS Building/Frame Permit Fee $ 3L
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
19969 .�-^-•-_.
Building Inspector
TYPE OF SEWERAGE DISPOSAL
Art ❑
Swimming Pools 11F1Tanning/Massage/Body
g
Public Sewer
Well ❑
Tobacco Sales 11
Food Packaging/Sales ❑
Private ❑
11Permanent Dumpster on Site
(septic tank, etc.
Electric Meter location to
proj ect
INV 1 h: Persons contracting with unregistered contractors do not have access to the guarantyfund
w.
Signature of Agent/Owner 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
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE REJECTED DATE APPROVED
❑ ❑
DATE REJECTED
11
Q
DATE APPROVED
FIRE DEPARTMENT - Temp Dumpster on site yes no
Fire Department signature/date
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
Comments
Water & Sewer connection/Signature & Date Drivewav Permit
Building Setback (ft.)
Front Yard Side Yard Rear Yard
Required
Provided Required Provides Required Provided
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
NOTES and DATA — (For department use)
Page 3 of 4
Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM05
Created JMC. Jan.2006
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
o 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
Addition Or Decks
o Building Permit Application
❑ Surveyed Plot Plan
❑ Workers Comp Affidavit
o Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
New Construction (Single and Two Family)
❑ Building Permit Application
o 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
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:BPFORM05
Page 4 of 4
9
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05:00pm From -AIG
Macdonald At Panglone Ins Agcy Inc
Po BOX 428
104 Main St
North Andover, MA 01845-0528
!NSURED
Brooks Constructlon Company Inc
254 North Broadway
Salem, NH 0078-0000
+873 331 6588 T-106 P.001/0O2 F-389
`�`" a` 't °+:.t� � � ��}-- .,:�I, 7: t. i�.4t�"- •::f.• ,i, ' R• �:YP�' I'�s u:i..,`. ,
I:.• ..f;l � JY , .'rcy, a.:•rf �...r �.�, �.P,,.,.,,1`! � ,Ii1$ t' ,:.•` ;
.:a '�i:, Ji:,t:}•.:l $�%. .Il' •;.f.•. .�fjp�p 1, Sil..'' ,��• A I„.:.
:W �: :�L: .l ,1'�rw[ V;�lt•iiWf.�'_u.�.1 .�gJ.v�•,�'•__t"•...Ji^.•... .
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATI01I.
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW
COMPANIES AFFORDING INSURANCE
COMPANY A GRANITE STATE INSURANCE, COMPANY
uUVEtZAGa�S• ;.; ,, i; 5 • .:r�k;; ,;- :� .,•.:'!: J;. ;I1..I• ...
.. ... ', .. '• ..•.. '�'�i .•It .••:.i .1.•i. 1,t"• A.:. ..,ir�t; ;,;I•: : yl,:((:?•tlj:;�::;'.",}I,�":1:.'v'r:.'tl:;•: :li„�� }••n:v.1'
THIS IS TO CERTIFY THAT 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 TRIS CURTIFICATC MAY DE ISSUED OR MAY PERTAIN, THE INSURANCE AEFORDFO THE
POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN
MAY HAVE BEEN REDUCED 13Y PAID CLAIMS.
eMPLOYER.T
ERS
Appltae to MA Operotene ONII,
LIMITS
ACCIDENT
SP POLIO LIMIT
CERTIFICATE HOLDER CANCELLATION
RICK AND KIM TU DISCO 811OULD ANY OF TNI'. ABOVE OLUCRISED POLIOIE8 at CANCELLED !iL•FORE TW
EXPIRATION DATE THEReOF, THL 18OUIN13 COMPANY WILL ENDEAVOR TO MAIL ui
26 GLENWOOD $T DAYS WRITTEN NOTICE TO TN6 C6RYIFWATE HoLOGR NAMED TO THE LEFT, OUT
NORTH ANDOVER, MA 01 W FAILURE TO MAIL SUCN NOTICE SHALL IMPOSE NO DOLIOATION OR LMILITY OF
ANY ION[) UPON THC COMPANY, ITS AGENTS OR REPAESENTAYIVE),
AUTHORIZED REPRESENTATIVE
fvl—
l'r
zoo Sul au0TSuBdVpjVu0a0Vjq OSCS 999 9L6 YVA 6V : ZT t7/IO ) nA7.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
M
a 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information �-`� Please Print Legibly
Name (Business/Organization/Individual): 2�i�k,S SIQI6 et/l !t%jjL r�Q%v /�(,G%'JQh/ 6 lNe
Address: 02S`� ✓V�gIq D.461WAZ
City/State/Zip: Sle- M Phone .#:
Are you an employer? Check the appropriate box:
WI 4. I
1. am a employer with
❑ am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ 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.#
required.]
5. ❑ We are a corporation and its
3. ❑ I am a homeowner doing all work
officers have exercised their
myself. [No workers' comp.
right of exemption per MGL
insurance required.] t
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance reciuired.l
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
S. ❑ Demolition
9. ❑ Building addition
10. ❑ Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12.❑ 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.
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 -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. 19
Insurance Company
Q�-f Ztis 1zCJ fiyc
Policy # or Self -ins. Lic. #: o`7 T 9,?/ Exp' ation Date:
96 6,18A., /'r g4le
Job Site Address: City/State/Zip: f /
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
Ido hereby certi u der the p 'ss and penalties of perjury that the information provided above is true and correct
Simature: Date: c:�o� d
Phone #: 6 6"? f --Q & 9 PP
use only. Vo not write in this area, to be completed by city or town officiaL
City or Town: Permit/License #
Issuing Authority (circle one):
I. 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."
MGI; 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 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:
Revised 11-22-06
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-*617-72-7-7749-
www.mass.gov/dia
BROOMS
$!DING - WINDOWS - DOORS
Family owned and operated
254 N. Broadway, Salem. NH 03079
WWW.BROOKSSWD.COM
603-894-4488 978-686-0260
BILL TO:
Rich, Kim Tudisco
978-682-0531
Rick Cell# 978-314-1110
26 Glenwood St
North Andover, MA 01.845
DATE INVOICE #
12/15/2006 7855
SHIP TO:
978-682-0531
Rick Cell# 978-31.4-1110
26 Glenwood St.
North Andover, MA 01845
Pam m - j9M GW 930 &%
Due on receipt
MD
12/15/200
Q' `amu llv�s�i7 0 � _ . e '�� ( •�
1
Bay
DH PW DH Bay window, build roof to match
3,162.00
3,162.00
roof on house, new inside finish, trim on outside.
1
credit
coupon
-200.00
-200.00
0tal Due
$2,962.00
1 iPayments/Credits
$-600.00
A service charge of '/P% of the unpaid balance per month will be added to
balance if not paid according to terms of contract on completion of contract.
0 `
$2,362.00
,. ,O NEWS LUST' M. pf .nPt:.ti �ervic,. :: N: idci _ . ,. - . r, - - -
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Date ..! ... ! ........? ... .
r,,o ° ry0
TOWN OF NORTH ANDOVER
s
PERMIT FOR GAS INSTALLATION
9
This certifies that ..'...... ...............
has permission for gas installation .......
in the buildings of •.- ..............................
at.. ... ..... r: ... ....... ,North Andover, Mass.
Fee -n ... Lic. No.. !........ ......�.� "'A ............
/ GAS INS¢EGTOR
Check # //0
3_�,9
MASSACHUSETTS UNIFORM APPLICATION
(Print or Type) ',
Mass. Date_,A
FOR PERMIT TO DO GASFITTING ate"' ---
New ❑ Renovation ❑ Replacement 2
ZQL;; Permit*
Owner's NameA ./)'
Type of Occupancy 1R eSI 7f_:• N T t r4
Plans Submitteed: Yesp No ❑
installing Company Name r i; j2 T A. `SAM M A T ri 0
Address t1oA C H iy1 A. ry 4-K1.
n1p THUetj t11 rl • Orkq�
Business T
Check one:
❑ Corporation
❑ Partnership
Certificate
Name of Ucensed Plumber or Gas Fitter
INSURANCE COVERAGE:
I have a current Iy'�biltty insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes lid' No ❑
If you have checked rtes, please indicate the type coverage by checking the appropriate box
°A liability insurance policy 0"� Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: 1 am aware that the licensee does not have the Insurance coverage required by
'Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner❑ Agent ❑
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under the pe ' i ued for this application ' be in compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of T7wA
laws.BY T%.U..
f cense:�•�
mber ure o cen u or atter
Title tter
Ver Ucense Number 8333
O IC yman
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