HomeMy WebLinkAboutBuilding Permit #482-14 - 28 SECOND STREET 12/6/2013Permit NO:
Date Issued:
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
IMPORTANT:
-
'
LOCATION
.8
PROPERTY OWNER
MAP NO: PARCEL:
Date Received
licant must complete all items on this page
Print
Print 100 Year Old Structure J.1es n
ING DISTRICT: Historic District yes no
Machine Shop Village yes no
.TYPE OF IMPROVEMENT
PROPOSED USE
Reside ial
Non- Residential
❑ New Building
ne family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
C+Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septic ❑ Well
❑ Floodplain ❑ Wetlands
❑ Watershed District
❑ Water/Sewer
-8V
OWNER: Name:
Address:
DESCRIPTION OF WORK TO, BE PERFORMED:
Idekification ,Please Type or Print Clearly)
cAr
CONTRACTOR Name:,1a4,in sbQnr.6 A4 Phone:
Address:
Supervisor's Construction License: t�,�-� .�2c� Exp. Date:
Home Improvement License: 1 Exp. Date:
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: $C1Od FEE: $
Check No.: Receipt No.:
NOTE: Persons contracts g with unregistered contractors do not have access to ate guaranty fund
Signature of Agent/Owner _ J ig�afure -of contractor ` .
Plans Submitted Li Plans Waived ❑ Certified Plot Plan ❑ tamped Plans ❑
Plans Submitted ❑ -,Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE_OF: SEWERAGEDiSPDSAL
Public Sewer ❑
Tanning/Massage/Body Art El_
Swimming Pools El
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.APPR-OVED -
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
r�
HEALTH y' Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decisionlreceipt submitted yes .
Planning Board Decision:
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Tow).2 Engineer: Signature:
'FIRE DEPARTMENT •Temp Dumpster onsite- .yes
Located -at 124.Mair, Street -
Fire Departure►it signature/date"R
COMMENTS
Locatea ob4 us ooa Jareei
no
_Dimension
Number of Stories:
-.Total land area, sq. ft.:
Total square feet of floor area, based on Exterior dimensions._
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.fin.e
NOTES and DATA — (For department use
EI Notified for pickup - Date
Doe.Building Permit Revised 2010
Building Department
The fol rswing is'=a-list of the required forms to belilled 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-G.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
o 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 apo% -al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submAted with the building application
Doc: Doc.Building Permit Revised 2012
Location
No. 2 r -1 Date 4^
TOWN OF NORTH ANDOVER
w
Certificate of Occupancy $
Building/Frame Permit Fee $a CFO
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
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COVERAGES CERTIFICATE NUMBEP-13-14 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
N
� ® DATE (MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE 2/1/2013
THIS CERTIFICATE IS ISSUED AS A° MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
+C,ERTWICATE 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
ilii 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 ,
CONTACT Kristi Gravel
NAME:
�Anastasi Insurance Agency', Inc.
4 Brookfield Rd
PHONE (508)248-1440 IFAx A,'.
1C No (508)248-1441
EMAIL k ravel@anastasiinsurance.com
ADRE .
INSURERS AFFORDING COVERAGE NAIC #
'P.O. BOX 1261
,Charlton MA 01507
INSURERA:Travelers Ind. Co of IL-ARWC 13579
INSURED
INSURER B:
Barry r S Roofing Inc a.
INSURER C:
126 Beach Plain Rd
INSURER D:
INSURER E :
Danville NH 03819
INSURERF:
COVERAGES CERTIFICATE NUMBEP-13-14 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 THE 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
LTR
TYPE OF INSURANCE
ADDL
SUBR
POLICY NUMBER
POLICY EFF
MIDD
POLICY EXP
MMM
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY
DAMAGE O
PREMISES Ea occurrence $
MED EXP (Any one person) $
CLAIMS -MADE 0 OCCUR
PERSONAL 8, ADV INJURY $
GENERAL AGGREGATE $
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMPIOP AGG $
POLICY PRO- LOC
$
AUTOMOBILE LIABILITY t
COMBINED SINGLE LIMIT
Ea accident
BODILY INJURY (Per person) $
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
( BODILY INJURY Per accident) $
NON -OWNED
HIRED,AUTOS AUTOS
PROPERTY DAMAGE
Per accident $
$
UMBRELLA LIAB
OCCUR
EACH OCCURRENCE $
AGGREGATE $
EXCESS LIAB
CLAIMS -MADE
-
DED I I RETENTION $
$
A
WORKERS COMPENSATION
-
WC STATU-OTH-
I I
AND EMPLOYERS' LIABILITY Y / N
TORY LIMITS
E.L. EACH ACCIDENT $ 100,000
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? ❑
(Mandatory in NH) -
N / A
D
/26/2013
/26/2014
E.L. DISEASE - EA EMPLOYEE $ 100,000
If yes, describe under
DESCRIPTION OF OPERATIONS below
I
r
I
I
E.L. DISEASE - POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required)
ISHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
IAUTHORRED REPRESENTATIVE
Anastasi/ANAKGI
ra •nan nnwn ♦n�nn /�f�nnnnATn\1 •11 ... -1-a.--_--,-J
e
This form satisfies all basic requirements of the state's Home Improvement Contractor Law (MGL chapter 142A), but does not include standard
language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of "A
Massachusetts Consumer Guide to Home Improvement" before agreeing to any work on your residence. You may obtain a free copy by calling the
Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website.
Homeowner Information
Contractor Information
Name
Company Name
?Q Al e405164
Barry Roofing, Inc.
Street Address (do not use a Mt Office Box address)
Contractor/ Salesperson/ Owner Name
SQcancl
John Shannahan
City/Town State Zip Code
Business Address (must inc Jude a street address)
2 Park Street
Daytime Phone Evening Phone
City/Town State, Zip Code
CT)8 6E3 -b�
Haverhill MA 01830
Mailing Address (It different from above)
Business Phone 978-866-1860 1 Federal Employer ID or S.S. Number 27-2784801
Home Improvement Contractor Reg. Number
Expiration date
Law requires that most home
emenrationactors
169197
5/26/2015
umbeave
a valid registration number
a valid
The Contractor agrees to do the following work for the Homeowner:
(Describe in detail the work to completed, specifying the type, brand, and grade of materials to be used, use additional sheets if necessary.)
C
if 4,1 rood'
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ihs44l� 30�r /anc Tmbe,-cmc �cH i -c c�✓�� �'�%ngles
— �nS4-,I(i tra 9) 5611 Ch id'
Clean u
Required Permits - The following building permits are required
and will be secured by the contractor as the homeowner's agent:
(Owners who secure their own permits will be
excluded from the Guaranty Fund provisions of
MGL chapter 142A.)
Proposed Start and Completion Schedule - The following schedule will
be adhered to unless circumstances beyond the contractor's control arise
IR 10 13 Date when contractor will begin contracted work.
► j 3 Date when contracted work will be substantially completed.
Total Contract Price and Payment Schedule
The Contractor agrees to perform the work, furnish the material and labor specified above for the total sum of:
Payments will be made according to the following schedule:
an
$ /QiGU upon signing contract (not to exceed 1/3 of the total contract price or the cost of special order items, whichever is greater)
$ /6i by Q / IV / 13 or upon completion of stock delivery.
$ /0$07 upon completion of the contract. (Law forbids demanding full payment until contract is completed to both part y's satisfaction)
The following material/equipment must be special $ '�� to be paid for��i�
ordered before the contracted work begins in order
to meet the completion schedule.(**) $ 'r to be paid for
NOTES: (*) Including all finance charges (**) Law requires that any deposit or down -payment required by the contractor before work begins may
not exceed the greater of (a) one-third of the total contract price or (b) the actual cost of any special equipment or custom made material
which must be special ordered in advance to meet the completion schedule.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Invesfigations
600 Washington Street
Boston, MA 02111
www mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name (Business/Organization/Individual):
S Peopw (fo
Address:
City/State/Zip: Mo o l& -,?G Phone #: CQ )8 O (o U
Are yog_an employer? Check the appropriate box:
i. 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.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ 1 am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. El 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.
i Homeowners who submit this affidavit indicating they a're 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 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:. A{ <�3C-��qqS�
Policy # or Self -ins. Lic. #: Expiration Date: 112-6
Job Site Address:,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 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.
I do hereby cerf�fy pMer the pains and penalties ofperjury that the information provided above is true anti correct.
Phone #: n ��� RD6 - 1 2(92Oi
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License
2
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 -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 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 (ifnecessary) 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 Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston} MA 02111
Tel, # 617-727-4900 ext 406 or 1-877-MASSAFF,
Revised 5-26-05 Fax # 617-727-7749
www.mass,govfdia