HomeMy WebLinkAboutBuilding Permit #724 - 281 MIDDLESEX STREET 5/7/2007BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: �- Date Issued:' Date Received TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ gr amity ❑ Ad ' ion [?Two or more family ❑ Industrial P -Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 4 R" `, r ,r(a x:M f�'^z+r .4. Y 9`„:: �7k 3a.f. nm !*°f -3' �€�,'i�•� - �BE '41 ,f7 DESCRIPTION OF WORK TO PREFARMED: Identification Please OWNER: Name: .S or Print Clearly) 60- --0ZP, ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BOLDING PT: $12.00 PEP -41 ,$1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ ZW*1 FEE: $ GI o Check No.: I a —+p Receipt No.: (a 0 1 �3 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund U 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:BPFORM07 Revised 2.2007 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 PLANNING & DEVELOPMENT ❑ COMMENTS CONSERVATION COMMENTS HEALTH _ A:COMMENTS ❑■ DATE REJECTED DATE REJECTED DATE APPROVED 11 DATE APPROVED DATE APPROVED 1-1 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 Located at 384 Osgood Street Ellf� tPAF�'AIIEN` y Temp D uFn sten ©rl��'S� a tlE ; s�Tfn 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 MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine No NOTES and DATA — For department use ❑ Notified for pickup - Date ....... . ........................ ................................. ........................ _............................... .......................................... .................................. _.......... -................... ............. ...._....................................................... ................. _..... -...................... ..._....... ....................................... .................................... _._ ............. _.................. Doc.Building Permit Revised 2007 Location -1 Date NORTH TOWN OF NORTH ANDOVER 0�,..•D .• �M ` Certificate of Occupancy $ �� s'••• E��' Building/Frame Permit Fee $j'' AC Mus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # i a-+ <I) 20^1 63 C4�-� Building Inspector N m m m y m m Cos CD-v Z POO 0CL O _W C2. a� Ooc CD p CL. �c d CD o ... O to CD CO) CD O CO) d d O CO) C2 O CO) 32 so CD CD CD a, H CO) I 0 CCD O CD W ? i S CO2 'O CA t M=2 Z - ?c y -4 .o .ftm N T O y =r•aid m N p IE O �m O = O • O ' O m IR . 0 O i i� OO N• n .m IM CL Er o N m cood 0 er. O 1p1 N t`f N OR m Q co c N .W a .t�m O � �cno O m 7 z � , N co O cf) y Oq Cb' m r o CD : C�? 0, Cf) 0 C/A 4 R C!1 -x :1'17 w Poo G '�1 �' C� ;;o r:°� � 1,71 1110 o z n �� 'P7 G 117 c I o0 F! Ej M M v 1 to �y CL 0 c Phe Commo►rwealth of Massachusetts Departme►tl of Indrtstrial Accidents Office of 111vestigatior►s 600 iVashi►tgto►r Street Boston, MA 02111 ^H immixtass.gov/din Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/l,iiiii_ibers Applicant Information Please Print Legibly Name(Btisiness/OrganizationMdividual): // , .C)' A1,4 a HC-1/so /Y" Address: \7'r6 City/Stale/Zip: /YO �i(1.D d 0eP,t, ✓� Phone li: %���� Are you an employer? Check the appropriate bo . ❑ I am a employer with 4. 91 am a general contractor and I employees (full and/or part-time).* 2. ❑ 1 am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ 1 ann a homeowner doing all work myself. [No workers' comp. insurance required.] t have hired the sub -contractors listed on the attached sheet. t These sub -contractors have workers' comp. insurance. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Pl ing repairs or additions 12. Roof repairs 13.❑ Other Any npplicant that checks box N 1 must also fill out the section below showing their workers' compensation policy infornmtion: t homeowners who sulnnit 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 subcontractors and their workers' comp. policy information. I am an employer that is providing workers' comperrsatiorr insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: 70/ 4-/& 7 F D l p;z0D. 7 _ Expiration Date: // l q_ 40 Job Site Address: % �� 171,046e'zfX ST_City/State/Zip: �>ld 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 forint of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised Qnat a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify under the pains and penalties of equty that the illforrnation provider/ above is true and correct. Signature: _ _Date: '—D% Official use only. Do not write in this area, to be completed by city or town of ficial. City or Town: Pernrit/License # Issuing Authority (circle one): 1. Board of health 2. Building Department 3. Cityrrown Clerk 4. Electrical inspector 5. Plumbing inspector 6. Other _ Contact Person: Phone tl: 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, constriction 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 eoutraet 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 nwnber(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 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 o -op ration -an srr}d 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-NLASSAFE Fax # 6t7-727-7749 Revised 5-26-05 V www.mass.gov/dia 0 T1. Hoard ol'Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 103358 Expiration: 7/7/2008 Type: Private Corporation A \/VAL.SH & SONSJNC. A,rinur..Wa]lsh,Jr. 1845 67' BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number:—CS 022680 Birthillate:­06/09/1-939 6j,,.ir.es,66/09/2008 Tr. no: 28249 "Restricit6b: 00 , "i ; ARTHUR J WALSHJR,' 55 PLEASANT ST N ANDOVER, MA 6845 Commissioner CERTIFICATE ®F INSURANCE ISSUE DATE (MM/DDNY) 11/08/2006 PRODUCER THISSCERTIFICATTEISII JEEDD ASAWT—TER OF INkORMATION ONLY AND Samuel J Durso Insurance Agency Inc CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 198 Mass Ave Suite IO1B COMPANIES AFFORDING COVERAGE North Andover, MA 01845 INSURED Arthur Walsh dba A. J. Walsh & Sons COMPANY A.I.M. Mutual Insurance Co LETTER A 55 Pleasant Street North Andover, MA 01845 COVERAGES 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 RESPECTTO 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. CO LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE(MM/DD/YY) POLICY EXPIRATIO DATE(MMIDD/YY) LIMITS GENERAL LIABILITY GENERAL AGGREGATE $ COMMERCIAL GENERAL LIABILITY LAIMS MADE[:::JDCCUR PRODUCTS-COMP/OP AGG. $ PERSONAL & ADV. INJURY $ OWNER'S & CONTRACTOR'S PROT. EACH OCCURRENCE $ FIRE DAMAGE (Any one fire) S MED. EXPENSE (Any one person) S AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per person) s HIRED AUTOS NON -OWNED AUTOS BODILY INJURY (Per accident) E GARAGE LIABILITY PROPERTY DAMAGE E EXCESS LIABILITY EACH OCCURRENCE—JU f MBRELLA FORM AGGREGATE f HER THAN UMBRELLA FORM WORKER'S COMPENSATION AND EMPLOYERS' LIABILITY �, WSTATU- TH- TOCRY O $ 100,000 A THE PROPRIETOR/ INCL PARTNERS/EXECUTIVE OFFICERS ARE: Rx EXCL 7014648012006 11/14/2006 11/14/2007 EL DISEASE—POLICY LIMIT $ 500,0W EL DISEASE—EA EMPLOYEE $ 100OOO OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Town of North Andover EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 15 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE G� CS # 022680 HIC# 103358 Proposal Submitted To: Address ; t 410 Phone # /� W We hereby submit specificatic A. J. Walsh & Sons 55 Pleasant Street North Andover, MA 01845 �- l 0 6v Fax # anri astimatcs fnr. of 978-688-6737 or 1-866-AJWALSH Job Name I Job # Job location Date Date of Plans Architect 0 We propose hereby to furnish material and labor — complete in accordance with the above specifications for the sum of: $ Dollars with payments to be made as follows: Any alteration or deviation from above specifications involving extra costs will be Respectfully executed only upon written order, and will become an extra charge over and submitted above the estimate. All agreements contingent upon strikes, accidents, or delays beyond our control. Note — this proposal may be withdrawn by us if not accepted within days. 01cceptance of Iroppogar The above prices, specifications and conditions are satisfactory and are ✓Signature hereby accepted. You are authorized to do the work as specified. / C/ Payments will be made as outlined above. Date of Acceptance Signature