HomeMy WebLinkAboutBuilding Permit #691 - 29 MILLPOND 5/23/2008BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: I
Date Issued:
IMPORTANT: Ap
LOCATION '�� � t
Date Received
,ant must complete all items on this page
PROPERTY OWNER
Print
MAP NO: PARCEL: ZONING DISTRICT: Historic District
Machine Shop
v-tt�ao ;t•,NO
yes : no
aqe ves no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One family
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
Repair, replacement
Assessory Bldg
Others:
Demolition
Other
Septic - Well
Floodplain Wetlands
Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED•
Type or Print Clearly)
OWNER: Name:V
Address: ( 1_a�
CONTRACTOR :Name: O
hone: 9 7 O -0L7F'
Address:-- Ui -. t1�
Supervisor's Construction License 6`_ Exp. Date: .Cos
J
}} A
Home Improvement License: S &� d Exo. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT: MOO PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ �J 7 , 0-0 FEE: $aft
Check No.:
�� T Receipt No.: 0? r✓ ��
NOTE: Persons contracting witegistered--�ontractors do not have access to the guaranty fund
of Agent/Owner T ignature of contractor
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 2.2008
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
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
M
Planning Board Decision:
Comments
Conservation Decision: Comm
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 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
6M Gel r-. -e (/tip S
❑ Notified for pickup - Date
Doc.Building Permit Revised 2008
I
DU
Location
` ons aL—
No. (.,5 Date 2 i7
�aRTM
TOWN OF NORTH ANDOVER
Certificate Occupancy $
of
sACNUst<�
Building/Frame Permit Fee $'
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
2 78
Building Inspector
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Board of Building Regulations and Standards
One Ashburton Place - Room 1301
Boston, Mass husetts 02108
Home Improvemerik; �t actor Registration
MARK AUDETTE
MARK AUDETTE
18 HIGH RD.
NEWBURY, MA 01951
DPS-CA1 0 50M-w!or�PC4490
�',�e �rnu�uue�l�a o�✓j�racler�selZ�
Board of Building Regulations and Standards
HOME 110110 Eh1ENT CONTRACTOR
Req�str�dtii3 ;�;�5g90
escp"&2009 Tr✓# 255443
n4"Oual
MARK AUDETTE �:;'1�";y - r;:s�=� r•�'',
MARK AUDETTE
18 NIGH RD.
NEWBURY, MA 01951
—•--- Admf�flefrator
1'
t
Registration: 155890
Type: individual
Expiration: 5/1512009 Tr# 255443
pdate Address and return card. Mark reason for change.
[] Address E] Renewal [] Employment 7 Lost Card
License or registration valid for lndividul use only
before the expiration date. If found return to:
Board of Building Regulations and Standards
One Ashburton Place Rm 1301
Boston, Ma. 02108
Not valid without signature
XUA 13rNEISU I dH WI Z 1 : 1 1 GOOZ 92 ReW
k
�ti�onl�nve� a� �tir�e�s
rd of,Buetdfng Regulations and Standards
nstruction Supervisor L-icen"
L'aeett&e CS 85725
B��Shdate 11/�6t1956
Eickrtiott� 1 f6t2008
rE
3195 f `r Commissioner
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
M 6 www.mass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name (Business/Organization/Individual): (.L.C_e&_d
Address:_Y` Ji9Lj ea.,+ l_er1&,_Q )
City/State/Zip:j L)1�,- LL�_k4 (4J -1f ()hone.#:
Aro employer? Check the appropriate box:
1. I am a employer with 1:40
4. ❑ 1 am a general contractor and I
employees (full and/or part-time).*
'a
have hired the sub -contractors
2. ❑ I amsole 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 required.]
Type of project (required)':,
6. �;e�mode:g action
7.
8. ❑ Demolition
9. ❑ Building addition
10..0 Electrical repairs or additions
11. []PI gr epairs or additions
12. oof repairs
13.0 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.
Contractors 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 isproviding workers' compensation insurance for my employees. Below is thepolicy and job site
information. ;,J�_�,�IIc[Insurance Company Name: — (,l`P.i>`- i_ i ` `j CO
Policy # or Self -ins. Lic. M, (( O�3U Expiration Date: q
Job Site Address: V�
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
I do hereby 9AYWunder the
4 7 F= i;,7 r
use only. Do not write in this area, to
City or Town:
of perjury that the information provided
r a
T7nt.•
or town officia[
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk
6. Other
Contact Person:
is true and correct
G
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." '
i
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 ortrustee 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 beanemployer."
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-contractor(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 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:
'T lae Commonwealth of Massachusetts -
Department. of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 40:6 or 1-877-MASSAFE
Revised 1122-06 Fax # 617-727-7749
www.mass.gov/dia
ACORQ CERTIFICATE OF LIABILITY INSURANCE
1 05�ii2�
PRODUCER 603-742-1452 FAX
Brown & Brown of N H, Inc.
93 Washington St
9
Dover, NH 03820
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE NAIC #
INSURED Great North Property Management Inc
95 Brewery Lane #10
Portsmouth, NH 03801
INSURERA MEMIC Indemnity Co 11030
INSURER B.
INSURER C:
INSURER D
INSURER E
COVERAGES
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PND CLAIMS.
INSR
DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECi1VE
POLICY EXPIRATION
LIMITS
AUTHORIZED REPRESENTATIVE !1. t __
Beth Fa adore/BETH �: X�
GENERAL LIABILITY
EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY
DAMAGE TO RENTED $
Ea occuIzMZL—
CLAIMS MADE D OCCURMED
EXP (Any one person) $
PERSONAL & ADV INJURY $
GENERAL AGGREGATE $
GEML AGGREGATE UMIT APPLIES PER:
PRODUCTS - COMPRW AGG $
POLICY 79 El LOC
AUTOMOBILE LIABILITY
ANY AUTO
COMBINED SINGLE LIMB $
(Ea accident)
I
ALL OWNED AUTOS
SCHEDULED AUTOS
BODILY INJURY
(Per person) $
HIRED AUTOS
NON -OWNED AUTOS
BODILY INJURY
(Per accident) $
DAMAGE $
(Per accident)
HPROPERTY
-
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT $
OTHER THAN EA ACC $
ANY AUTO
AUTO ONLY: AGG $
EXCESSIUMBRELLA LIABILITY
EACH OCCURRENCE $
OCCUR a CLAIMS MADE
AGGREGATE $
$
$
DEDUCTIBLE
$
RETENTION $
WORKERS COMPENSATION AND
3102800830
09/05/2007
09/05/2008
1 WC STATU- OTH-
A
EMPLOYERS LIABILITY
ANY PROPRIETORWARTNEWEXECUTIVE
E.L. EACH ACCIDENT $ 5OO OO
E.L. DISEASE- PJB EMPLOY $ 500,00
OFFICER/MEMBER EXCLUDED?
If yes, describe under
SPECIAL PROVISIONS below
E.L. DISEASE - POLICY LIMIT $ 500,000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
CERTIFICATE HOLDER (_AN(_FI I AT Id
ACORD 25 (2001108) CACORD CORPORATION 1988
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
Millpond Condo Association
DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
c/o GNPM
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
95 Brewery Lane, Su i to 10
OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES.
Portsmouth, NH 03801
AUTHORIZED REPRESENTATIVE !1. t __
Beth Fa adore/BETH �: X�
ACORD 25 (2001108) CACORD CORPORATION 1988
05/22/2008 13:47 FAX 9784858204 CHASE & LUNT
2001/002
DATE (MMIDDIYYYY)
AC -ORD CERTIFI :ATE OF LIABILITY INSURANCE S&F9 os 22 09
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
& Lunt LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
P O .Chase 6 un HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW,
47 state street
Newburyport mh 01950
Phone:979-462-4434 Fax:)78-465-6204
"Holding Corp.
Ino.
K Holding Coilp, JGCA Inc
rowery Lane
smouth NH
INSURERS AFFORDING COVERAGE NAIC 9
INSURER A;
T1;16 ZIrAV91eTa 39357
INSURER B:
W..f ...i Union Fire ins. Co. ,
INSURER C!
Federal InaUrance Company
INSURER D:
_ . —
INSURER E:
$
AVYClwuea
YHE POLICIES OF INSURANCE LISTED BELOW h AVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICAY
ANY REQUIREMENT, TERM OR CONDITION OF i JJY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE N
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND
POLICIES. AGGREGATE LIMITS SHOWN MAY HE VE BEEN REDUCED BY PAID CLAIMS.
ISR POLICY NUMBER DATE MM/D DA MMIDDPIY
TR NSR TYPE OF INSURANCE
GENERAL LIABILITY
COMMERCIAL GENERAL LIAIBILI1)'
X CLAIMS MADE 71 OCCUR
C X Errors s Omission EBU3900861 02/16/08 06/01/09
GEN'L AGGREGATE LIMIT APPLIES Pt A.
POUCY JEIQT LCC:
AUTOMOBILE UADIU Y .
A ANY AUTO $A -0822M284 -06 -SEL 02/16/08 06/01/08
ALL OWNED AUTOS HA-124SH498-08-SEL
SCHEDULED AUTOS
X HIRED AUTOS
X NON.OWNEDAUTOS
GARAGE LIABILITY
7 ANY AUTO
ExCMSIUMURLi LIABILITY
B X_ OCCUR F cLAIMSMAD=_ 82097170 02/19/08 02/19/09
DEDUCTIBLE
RETENTION 5
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
ANY PROPRIETORIPARTNERIEXEGUTIVE
OFFICER(MEMBER EXCLUDED?
if yes desanbe under
SPE61AL PROVISIONS below
DESCRIPTION OF OPERATION$ / LOCATIONS J L EHICLES / EXCLUSIONS ADDED 13Y ENOORSEMENT I SPECIAL
RE: Mill Pond Homeowne.^B Association
TE HOLDER
:D, NOTWITHSTANDING
AY BE ISSUED OR
;ONDITIDNS OF SUCI+
LIMITS
EACH OCCURRENCE
8
PREMISES (Ea occursn�
$
MED EXP (Arty one ParBen)
$
PHRSONALB,ADVINJURY
i
GENERAL AGGREGATE
$1000000
PRODUCTS -00 1OPAGG
9
Ea claim
1000000
COMBINED SINGLE LIMIT
S 1000000
(Ea adidenp
BODILY INJURY
$
(Per person)
BODILY INJURY
S
(ParP=dem)
PROPERTY DAMAGE
S
(Per ecCdenk)
AUTO ONLY - EA ACCIDENT
5 '
OTHER THAN EA ACC
S
AUTO ONLY: AGO
S
EACH OCCURRENCE
$3000000
AGGREGATE
S 3000000
TORY LIMITS ER
�
E.L. EACH ACCIDENT
E
E.L, DISEASE - EA EMPLOYEE
$
E,L, DISEASE -POLICY LIMIT
1 3
CANCELLATION
SHOULD ANY OF THE ABOVB DESCRIBED POLICIES BE CANCELLM RWORE THE EXPIRATIO
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN
NOTICE TO THE CBRTIFICATF MOLDER NAMEO TO THE LEFT, BUT FAILURE TO DO $O SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY IOND UPON THE INSURER, ITS AGENTS OR
Town OE North Andover
ACORD 25 (2001108) O ACORD