Loading...
HomeMy WebLinkAboutBuilding Permit #696 - 270 GREENE STREET 4/3/2012Permit NO: (4 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received Date Issued: �3�` - 1 IMPORTANT: ADDlicant must complete all items on this page LOCATION Z70 -1 — Print PROPERTY OWNER I kT&z X6Z-(-M0 T '4C -A>&W ?JQ1TN E1S14-1t> Unit_ #_ Print MAP NO: 2A PARCEL: S6 ZONING DISTRICT: Historic District yes no Machine Shop Village yes o 100 year-old structure yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building X One family ❑ Addition 0 Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other �- 0 Sepc®e�ll77 7a;Ftloodpl, ���Water/Sewer „ aml , i®Wetlands t ��. � ®Wat�rshedD�1t,� DESCRIPTION OF WORK TO BE PERFORMED: IV�D��LG Ident'fication Please Type or Print Clearly OWNER: Name: {'er to t �; I '���2r ham•: V MPhone: es/7-S6r-/o6� Address: l ";'g ma ve -.-e-k 5'1�, Ess (&e, 4.t, %17)% CONTRACTOR Name: f'h , G 446,- b irOe-c o 11Z.- Phone: cj 7 8A94y- yG 19 Address: 73 i�L FSS E �,t V1 Lp,-, 14AVf4A?1t7-(c. /*71 Supervisor's Construction License: CS f Home Improvement License: is-Z66a Exp. Date: 64- Z `/- / Z -- Exp. Exp. Date: q-19 -1Z 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. T Total Project Cost: $ 1-/06d> FEE: $ Check No.: S3/, 50,� Receipt No.: ��� NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Si nature ofAgent/QwnerF _= Signature of�contractor j 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 COMMENTS HEALTH COMMENTS Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments 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 servicedroprequires approval of Electrical Inspector Yes DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A —F and G min.$10041000 fine Doc:.Building Permit Revised 2011 June/mi 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 o Photo Copy of H.I.C. And/Or C.S.L. Licenses< ❑ Copy of Contract ;;� o Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition or Decks o Building Permit Application o Certified Surveyed .Plot Plan o Workers Comp Affidavit ❑ 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) o Mass check Energy Compliance Report (If Applicable) o 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 o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o Mass check Energy Compliance Report o 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 2008mi Location 40 �j - d� GC rti.L < -�— - No. 6594a Date 3 - I Z Check #—:3-� 25380 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ s Other Permit Fee $ TOTAL $ L Building Inspector • 0 z o ai w2 v cn O U A .ti w° a°' C U w EOEE� U p+ p w G w O w a w X00 p w u� U) i7. O c� p aG G w" w x w w cq o z U) Q 0 cn , 0 c o LZ C y O O ` .du ..Q c a� #mom a Jl E a i.. • 0 C •Z v 0 CL N c.. COD 0 is m cc_+ N W N � 3 c a N c W O E ,o loo - ca z o coa a20 C3 .N O. Cj A Z O • c �- O a O `..O c = c : 4d *.-COD o ~ W.O W.- LA .. c .. •H C t A c O0- m•y C3 im H CLCL m� x cv .o ` �' •o f- so.�m m a Z 0 N c 7 cm m cc c m v O Cm c N CD Z 0 Z O g 5 . • G)o 0.. 94 4..1 CD O CD ■ �■ L O v Z °D CL O CO) Wcm C ,w C C0+ Q CD.� h O O '� m m L O � 3� 0o O p i Cc O CL 01 Q C �p O .G� J 'O FL O C Z co 0 CL C3 y c C c CLH 0 Ul ©. rrr LW w cc W M/DD/YYYY) ACORP, CERTIFICATE OF LIABILITY INSURANCE DATE (MDATE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAMEw' Doug I as Lox— I City Insurance Agency, Inc. PA/C,No Ext): 978.373.3381 (A/C,No).978.521.5301 II 709 South Main Street E-MAIL GENERAL LIABILITY ' - - 1,000,000 ADDRESS: I DAMAGETO RENTED-- - P.O. BOX 1297 PREMISES (Ea occurrence; _ S -- INSURER(S) AFFORDING COVERAGE NAIC N Haverhill, MA 01831 INSURER A: Providence Mutual Ins Co. X15040 INSURED Decicco & Father Construction INSURER B: AIM Mutual Ins Co. 73 Pleasant View Avenuei INSURER C : PRODUCTS - COMP/OP AGG . $ 2,000,000 I Haverhill, MA 01830 INSURERD: AUTOMOBILE LIABILITYc M• t (Ea accident) _ INSURER E: – ----�— I INSURER F: $ - ALL ObVNED SCHEDULED i AUTOS AUTOS COVERAGES CERTIFICATE NUMBER: dwe11-12 BOUILY INJURY ;Per ac iden q REVISION NUMBER; 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 THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY T14E POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR "ADUL15UBRI LTR TYPE OF INSURANCE INSR WVD - - ---------- PD�-EFF�POLICY EXP ' POLICY NUMBER (MMIDD/YYYY) (MM/DDIYYYY) : LIMITS GENERAL LIABILITY ' CPP0064047 06/20/2011106/20/2012 EACH OCCURRENCE S 1,000,000 I X I DAMAGETO RENTED-- - COMMERCIAL GLNLRAL LIABILITY PREMISES (Ea occurrence; _ S 300, 0001 CLAIMS -MADE `X OCCUR I MED EXP (Any one person) S 5 , 000 A PERSONAL & ADV INJURY S 1,000,0001 GENERAL AGGREGAI E S 2,000,0001 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG . $ 2,000,000 X POLICY PRO LOC JECT $ AUTOMOBILE LIABILITYc M• t (Ea accident) _ $ ANY AUTO i I I BODILY INJURY 1Perperson,) $ - ALL ObVNED SCHEDULED i AUTOS AUTOS BOUILY INJURY ;Per ac iden q $ NON -OWNED— OPCRTY DAMAGE HIRED AUTOS AUTOS I (Per a -dent) S —I $ — UMBRELLA LIAB OCCUR EACH OCCURRENCL S EXCESS LIAR CLAIMS -MADE I AGGRFGAIF $ DED RETENTION $ $ WORKERS COMPENSATION VtihiC6009518012010 09/19/2011 09/19/2012 V S IAI U- OTH- AND EMPLOYERS' LIABILITY YIN TORY LIMITS EH ANY PROPRIETOR/PARTNER/EXEC U'I'IV 09/19/2011 09119/2012 E.L. EACH ACCIDENT $ 100, 000 B OFFICERIMEMBER EXCLUDED? � : N I A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 100,000 f. yes, describe under - – ------- - DESCRIPTION OF OPERATIONS below I E.L. DISEASE - POLICY LIMIT $ 500,000 1 I � i ucoi. r[,r nury yr vrCtW �IvrvJ IVVA �IVrvJ VLKII.LCJ (Attacn AGVKU 7117, Additional KernarkS SCnedule, It rnore space is required) CERTIFICATE HOLDER CANCELLATION Town of N. Andover 1600 Osgood ST North Adover„ MA ACORD 25 12nin/nF1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE r ©1988-2010 ACORD COR TION. All rights reserved Interbartolo & RicuDero Partnershi March 23, 2012 Inspectional Services Department Town of North Andover Osgood Street North Andover, MA Re: 270 Greene Street, North Andover To Whom It May Concern: This is to confirm that Michael DeCicco of DeCicco and Father Construction is my authorized representative and is contracted to perform work on my property located at 270 Greene Street, North Andover, MA. If you have any question please do not hesitate to contact me. Peace Mi ael . Interbartolo Jr. General Partner - Interbartolo & Ricupero Partnership Ir3-270gs-tona-inspectional services-decicco authorized rep -032312 108 Maverick Street - East Boston - Massachusetts 9 02128 - (617) 569-1068 The Commonwealth of Massachusetts Department of Industrigl Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/ilia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): &C O ft71,_,) �DV 5 T ��/Gi7c0.t Address: City/State/Zip: Phone #: 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 employees (full and/or part-time).* 204 am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. I �• Q�.RP,,emodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. y, ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL I L ❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] employees. [No workers' .1311Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they aie 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. lam an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Policy # or S elf -ins. Lic. MAIC tC 6 ©©q%Sl �o O I zZi % Expiration Date: q —(7 ` t Z Job Site Address: 2-70 Ge ZEA/F S (City/State/Zip:_./1,e2nt- Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 cerf under the pains andpenalties of perjury that the information provided above is true and'correct. Phone 4: Phone#: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # q-3--r2- Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. CitylTown 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 ground's 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 -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 maybe 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 bum 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 masso'd-husetis Departaient of Industrial Accidents Office o£Investigatlons 600 Washington. Street Boston} MA, 021. Z t Tel # 61.7-727-4900 ext 406 or 1-877MMASSA.FE Revised 5-26-05 Fay ,# 617727-7749 wv w-mass,govAh'a