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Home My WebLink AboutBuilding Permit #681 - 260 MARBLERIDGE ROAD 5/20/2008Permit NO: (w BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received NJSACH' Date Issued: _ -)'o - o IMPORTANT: Applicant must complete all items on this page LOCATION %''% f4L' l D' 5/ Print PROPERTY OWNER 1-)-04? l� V -eyR pr Print MAP NO: PARCEL: ZONING DISTRICT: -Historic District Machine Shop'Villag ,yes no yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One Addition Two or more family Industrial ration No. of units: Commercial Repa' , 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: :1� a V-0 pk 4 Phone: ci7e Address: 0 i%%��QRI#J C1,- e- `�1 f9 CONTRACTOR Name: ��n �� I✓T 1� Phone: �!�`� Address: } R'P e i % 4? R,9- Supervisor's ti' - Supervisor's Construction License: 0 5, -. -F, -3 Exp. Date: b/7 /o Home Improvement License: l Exp. Date: l 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: $�P®FEE: $ 13 1 Check No.: `J 1 � Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Sianature 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: INSPECTIONAL SERVICES DEPARTMENT:13PFORM07 Revised 2.2008 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 d -a Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp_ Dumpster on site yes t 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 i....... _......... _... _..... ---.-.-..-..------._------------ ------- ------------------ ........... ............................... ........ _....... _.._..._..._............... ............ ....._......_._....................................................................... _...... _._.... ................................................................................. _..__._. Doc.Building Permit Revised 2008 Location�� No. Date &ORTry TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $_ JncMU Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 21 165 Building Inspector m m m m V/ m mm u v y d C � d CODCD C7 n Z CA CD O 'O CL r a MM O CZ = CO) 0 CD CD O CL Q CD CD 0 CD CR) CCP P C CD NDS — CD CZ O y = I co a v CO) O "0CD Z n. �► C) CD a C CD F cn O I C 0 c"oa = 9 _ Ewa �' dc CD CO) m®m fA m d C ]� m aid � m 4o m . o ti -� IE co m a ,a c o Z�.� ?o 0 •. CA CA a CL ir � O O y a,. co) ��, . d y CL CL dCD 57 P. y h Q :. N �o m o CAo CD ^c1' m O .rt n3 CD �C IT so o. -o. Com: gym: ru p o o C" p o o L" p n :r G o o w 0 Cf)� 0 n y o x O E H 0 Proposal Siding Jerry Lavallee Remodeling Windows Roofing P.O. Box 374, Bradford, MA 01835 Carpentry Cell. 508-633-9141 �� 64Sb� k/ fi 1v"' 31V,57 W PROPOSAL SUBMITTED TO PHONE DATE STREET JOB NAME CITY, STATE AND ZIP CODE ARCHITECT G DATE OF PLANS We hereby submit specifications and estimates for JOB LOCATION JOB PHONE All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an extra 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. Our workers are fully cov- ered by Workmen's Compensation Insurance. Rcceptance of 3propool —The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will bemadeas outlined above. Date of Acceptance:"� % h n Signature Note: i This proposal withdrawn by us if not accepted within 3c.) days. Signature x'7-/ V Signature NOTICE OF ASSIGNMENT EMPLOYER: COMBO I.D. JOHN C08TANTINO DBA COSTANTINO ELECTRIC 000479707 226 LINCOLN AVE HAVERHILL, MA 01830 COVERAGE GROUP 0483231. The.Waiver of Our Right to Recover from Others Endorsement is available on Pool policies. Contact your agent for details. AGENT SAMUEL J DURSO IS AGCY OR 198 MASS AVE PRODUCER: N ANDOVER, MA 01845 AGENCY FEIN: 042455633 OF OPERATION STATUS OF EMPLOYER Individual Coverage under this assignment applies to Massachusetts operations only. For coverage outside of Massachusetts, contact .the appropriate Pool or Plan for that state. INSURANCE COMPANY: GRANITE STATE INS CO RESIDUAL MARKET OPERATIONS P 0 BOX 409 PARSIPPANY, NJ 07054-0409 (800) 645-2259 CLASS ESTIMATED RATE ESTIMATED CODE TOTAL ANNUAL PREMIUM REMUNERATION ----- -------------- ---------- ---------- ELECTRICAL WIRING - WITHIN BUILDINGS & DRIVERS 5190 EMPLOYERS LIABILITY 100/100/500 9845 LOSS CONSTANT 0032 STANDARD PREMIUM EXPENSE CONSTANT 0900 TERRORISM CHARGE 9740 ESTIMATED ANNUAL PREMIUM DIA ASSESS. 4.4% OF STANDARD PREM. EST. ANNUAL PREM. PLUS ASSESSMENT INSTALLMENT BASIS: Annual COMMENTS Coverage effective 12:01 AM on 06/13/06 Subject to 05/10 Anniversary Rate Date. DATE OF NOTICE: 06/13/06 LETTER ID: 1088556 $7,000 4.18 $293 PREPARED BY * * VOLUNTARY DIRECT ASSIGNMENT * * $50 $343 $284 $2 $629 $13 $642 DEPOSIT PREMIUM: $642 THIS IS NOT A BILL COPY: EMPLOYER Theresa Schofield EXT 542 The Workers' Compensation Rating and Inspection Bureau of Massachusetts 101 Arch Street • Boston, MA 02110 (617)439-9030 • FAX (617)439-6055 - www.wcribma.org PATRONS MUTUAL INSURANCE COMPANY of CONNECTICUT GLASTONBURY, CONNECTICUT ARTISAN CONTRACTORS POLICY DECLARATIONS M. Medical Payments $5,000 Per Person N. Products/Completed Work $1,000,000 Per Occurrence $2,000,000 Aggregate 0. Fire Legal Liability $50,0001 Per Occurrence P. Personal and Advertising InjuryLiability $1,000,000 Per Occurrence .. PROPERTY COVERAGE r 'DESCRIPTION AND IOCATION OF PROPERTY Loc. 'L 6 FREEMAN STREET HAVERHILL, MA 01832 COVERAGES- LIMITS OF INSURANCE Loc. # Building # Limit ACV A. Building B. Business Personal Property 1 1 $2,500 C. Loss of Income ACTUAL LOSS SUSTAINED, NOT TO EXCEED 12 MONTHS. WAITING PERIOD: 72 HOURS Increased Property Off Premises: Automatic Increase — Coverages A & B: 0% ANNUALLY Property Deductible: $500 SU.B,. CT TO:THE FOLLOWINO.FORMS AND ENDORSEly:[ENTS AP -100 Ed. 2.0 AP 0611 01 99 AP 0643 12 99 AP 0432 12 03 BP -348 Ed. 1.0 GL -895 Ed. 2.0 AP 0700 12 02 AP 0740 12 02 AP 0688 06 02 AP 0690 06 02 AP 0692 06 02 AP 0365 10 06 YKINIhi): U1/1U/US INSURED COPY THIS IS NOT A BILL The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations a 600 Washington Street Boston, MA 02111 wM sv www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers pplicant Information i Please Print Legibl' Name (Business/Organization/Individual): Address: City/State/Zip: ✓10 Phone .#: 4, Are you an employer? Check the appropriate box: 1. [`l I am a employer with 4. ❑ I am a general contractor and I _ employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.$ 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 reouired.l Type of project (required):, 6. ❑ New construction 7. ❑ Remodeling 8. ❑ 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. lContractors 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. n i Insurance Company Name: Policy # or Self -ins. Lic. #:' o O o q-7 if 74 `7 Expiration Date: �� Q Job Site Address: 4:4: Q (/�ek e Q11b 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 Ido hereby certify de the pal a penalties of perjury that the information provided SiQnattire- (//// lit r. I not write in this area, City or Town: or town official Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 6. Other Contact Person: eats true and correct. 4. Electrical Inspector 5. Plumbing Inspector 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,opera'te.-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, §25CM 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 -contractors) 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 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 perm ittlicense 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. # 617-72.7-4900 ext.406 or 1-877-NlASSAFE Fax # 617-727-7749 Revised 1122-06 www.mass.govldia B