HomeMy WebLinkAboutBuilding Permit #875 - 31 GLENORE CIRCLE 6/21/2011TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued: (a - 2,1 z J
IMPORTANT: Applicant must complete all items on this Daize
LOCATION 31 c o rq_ Ci/ -
Print
PROPERTY OWNER He n rpt T/
Print
MAP NO: 3 PARCEL: ZONING DISTRICT: IQ t Historic District yes no
Machine Shop Village yes o
TYPE OF IMPROVEMENT
PROPOSED USE
Resi ntial
Non- Residential
❑ New Building
VOne family
❑ Addition
❑ Two or more family
❑ Industrial
Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ S' ptic D Well'
Floodplain, T
0 n, ❑
❑ Watershed District
;ter/Sewed
lir a�tur i iuNur UKK TO BE PERFORMED:
znS241j Wtictew q-%rt/e- -or-
(Identification Please Type or Print Clearly)
OWNER: Naive: Ir n r -)t 7Y Phone: Y? /o
Address: :3 rei i,r
CONTRACTOR Name: �,lr� e ,t e �o i -T e VL 7� Phone: 978 3 7,7 C*266 2,
Address: `,l �o / 14Y a Ly Aaf—/kye r -A
'
Su ervisors Construction License:
Supervisor's __ y 75'67 Exp. Date: ff 17 1.2011
Home Improvement License: "1 Scl 2 3 2 Exp. Date: y A a A�
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT. $92.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ Y T FEE: $ 75 `f
Check No.: OLS,Receipt No.: ` 4s -I—
NOTE: Persons contracting with unregistered contractors do not have access to the guara#&fund
Signature of Agent/Owner - � Signature of -�4
✓�
Location , �d
No. e�� Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
TOTAL
-0
Check # S, S—
v2--C-1 --
242 0 1 Building Inspector
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
c
r
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision:
Com
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
L
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
Doc:.Building Permit Revised 2008mi
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
❑ 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
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
o Photo Copy of H.I.C. And C.S.L. Licenses
o 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)
Li Engineering Affidavits for Engineered products
MOTE: All dumpster permits require sign off from Fire Departlrient 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
❑ Workers Comp Affidavit
o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan
p And
Hydraulic Calculations (If Applicable)
o Copy of Contract
o Mass check Energy Compliance Report
❑ Engineering Affidavits for En ineeredirro
NOTE: All dumpster permits require sign off from Fire Departmentrior to issuance e 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
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Owl -,-
261 Hyatt Avenue
Bradford, MA 01835
978.3720262
CONTRACT
Dr. HENRY & MY TY
31 GLENNORE CIR
NORTH ANDOVER MA. 01845
APRIL, 28 20011
SCOPE OF WORK: INSTALL WINDOWS & TILE FLOOR
INSTALL 7 PLYGEM LOW -E WINDOWS TO FIT EXISTING OPENINGS.
REPAIR ANY DISTURBED AREAS, PAINT INTERIOR OF ROOM IN
OWNERS CHOICE OF COLOR.
TILE FLOOR WITH OWNERS SUPPLIED TILE AND GROUT.
-owdowmtl 601A
261 Hyatt Avenue
Bradford, MA 01835
978.3720262
COST OF JOB $6580.00
PAYMENTS:
1/3 TO ORDER WINDOWS 1/3 AT TIME ROOM IS PAINTED, AND FINAL
PAYMENT IS MADE WHEN TILE IS INSTALLED.
poi/
HOME
ER
ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID AC
DATE(MM/DD/YYYY)
1
LYONS -2
01/21/11
PRODUCER
Chase & Lunt LLC
P 0 Box 590
47 State Street
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.
Newburyport MA 01950
POLICY NUMBER
Phone : 978-462-4434 Fax: 978-465-6204
INSURERS AFFORDING COVERAGE NAIC #
INSURED
INSURER A: Northland Insurance Companies
INSURER B:
Lyons Development Corp
Catalina Lyons
261 Hyatt Ave
Bradford MA 01835
INSURER C:
INSURER D:
INSURER E:
EACH OCCURRENCE $ 1000000
uW r �rvw�o
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 PAID CLAIMS.
LTR
NSR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE MM/DD/YY
OLICY EXPIRATION
DATE MM/DD/YY
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $ 1000000
A
X COMMERCIAL GENERAL LIABILITY
WS053021
10/06/10
10/06/11
_EU RENTED
PREMISEs(Ea occurence) $ 100000
MED EXP (Any one person) $ 5000
CLAIMS MADE [i] OCCUR
PERSONAL &ADV INJURY $ 1000000
GENERAL AGGREGATE $ 2000000
GENT AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OPAGG $ 2000000
POLICY PRO LOC
JECT
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT $
ANY AUTO
(Ea accident)
ALL OWNED AUTOS
BODILY INJURY
$
SCHEDULED AUTOS
(Per person)
HIRED AUTOS
BODILY INJURY $
NON -OWNED AUTOS
(Per accident)
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT $
ANY AUTO
OTHER THAN EAACC $
AUTO ONLY: AGG $
EXCESSIUMBRELLA LIABILITY
EACH OCCURRENCE $
OCCUR CLAIMS MADE
AGGREGATE $
DEDUCTIBLE
RETENTION $
$
WORKERS COMPENSATION AND
-
EMPLOYERS' LIABILITY
TORY LIMITS ER
E.L. EACH ACCIDENT $
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
E.L. DISEASE - EA EMPLOYEE $
If yes, describe under
E.L. DISEASE - POLICY LIMIT $
SPECIAL PROVISIONS below
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
VIA EMAIL: danghi@comcast.net
CERTIFICATE HOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
Gobeil Home Improvement IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
Groveland MA AU D R PRESE VE /
ACORD 25 (2001/08) V@ ACORD CORPORATION 1988
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: Ao e
e
City/State/Zip: 144 y e v_ k `� Q O 18"35-- Phone #:
Are you an employer? Check the appropriate
box:
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
2. I am a sole or
have hired the sub -contractors
listed
proprietor partner-
on the attached sh%et. t
ship and have no employees
These sub -contractors have
working for me in any capacity.
[No workers' comp. insurance
workers' comp. insurance.
5. ❑ We ate a corporation and its
required.]
3. ❑ I am a homeowner doing all work
officers have exercised their
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.❑ Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12.0 Roof repairs
13.❑ Other
-,u m, our me section below showing their workers' compensation policy information.
i 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 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:
Policy # or Self -ins. Lic. #:
Expiration Date:
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 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
Investigations of the DIA for insurance coverage verification.
I do hereby certcfy,under the. Aand penalties of perjury that the information provided above is true and correct.
370 Q
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
_ Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk
6. Other
Contact Person:
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 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 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 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. 4 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax # 61.7-727-7749
www.mass.gov/dia