HomeMy WebLinkAboutBuilding Permit #304-12 - 318 MAIN STREET 10/7/2011 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: t 2 Date Received
I$ Date Issued:
IMPORTANT:Applicant must complete all items on this page
LOCATION A
Print
PROPERTY OWNERJ 6 a
Print
MAP NO: doh.U PARCEL: ZONINGDISTRICT:ISTRICT:
Historic Di
- - strict yes no
Machine Shop Village yes no
�mifi
TYPE OF IMPROVEMENT PROPOSED USE
esidential Non- Residential
11 New Building One family
❑Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑Commercial
;'Repair, replacement ❑Assessory Bldg ❑ Others:
❑``�bemolition ❑Other
_ - in
Fli s - t HOW ®' UWate shed District�.
�w _
DES C.t 11.13 ON OF WOR1C TO E !.0 �,0 iD:
to
ml
�iifi �� � � ti � h �w t <u-.4
{ (Identification Pleske Type or Prin Clearly)
OWNER: Name: Phone.
Address: HAU0
CONTRACTOR Name: /WON A t c
Phone:
Address:
Supervisor's Construction License: Exp- Date: /--
Home Improvement License: /(������ Exp. Date: Z( ��Z
ARCHITECT/ENGINEER Phone:
lit Address: ---
Reg. No.
FEE SCHEDULE:BULDING PERMIT.*$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
Sdo
' Total Project Cost: $ 7;�5'� _ FEE:
Check No.: ✓ �7 Receipt No.: Q y 6r-2—
NOTE: Persons cont ng with unregistered contractors do not have access to th guara ty fund
S ature of�AgerifilOwne- - _ _ lgnature'`of�contr
=--= - —_._ MTN.
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
A
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 OFFICEUSE
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Slnature
COMMENTS
Zoning Board of Appeals:Variance, Petition No: Zoning.Decision/receipt submitted yes
Planning Board-Decision: Comments
A Conservation Decision: Comments
a
Water& Sewer Connection/Signature&Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
( � FIRE DEPARTMENT -Temp Dumpster on site yes no
..J Located at 124 Main Street
Fire Department signature/date
COMMENTS
Dimension
a
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. i.:
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
I
NOTES and DATA-- For department use
i
U 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.
oofing, Siding, Interior Rehabilitation Permits
r,)4, Building Permit Application
jJ110rkers 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
MOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Per
Addition Or Decks 1
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
a Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contrac�
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (IfsApplicable)
o 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 Pert'
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. Acid 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
TOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg .Perr
In all cases if a variance or special permit was required the Town CIerks 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 recordin,
must be submitted with the building application
Doc: Doc.Building Permit Revised 2008mi
Location j / of'If
No. -� �Z'- Date
NpRTq TOWN OF NORTH ANDOVER
� s
41
Certificate of Occupancy $
"'°'�<� 9
MuBuilding/Frame/Frame Permit Fee $
s,Kst
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
q
2 Building Inspector
� G
AORTH
Town of Andover .,
No
o , dover, Mass., �o
y` Q LAKE
COCMICMEWICK V
7�AQRATED P'P�t"`�
S ` BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT...... C'�............................ Foundation
�-� ... . Cl�'. ............
iy S�
haspermission to erect........................................ buildings on .....Z.......49.................................................................................. Rough
S / r(` ae �` Chimney
to be occupied as........................................./ .. ............................ ........................................................................................
provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final'
this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of
Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS
ELECTRICAL INSPECTOR.
UNLESS CONSTRUCTI STARTS Rough
........................r«��^ !!...........:r`.:."...............................;................. Service
BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry (Mall To Be Done FIREE_DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
SEE REVERSE SIDEJI
i
.� Licens" CS.- 4527$ _
THOMAS-W`PRICE
Al ORCHARD-ST• .` r
MERRIMAC,MPi
Expiration: 11/182012
t'f,innti..iuter T'. 6337
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR F before the expiration date. If found return to.
Registration: IOg526 Type Office of Consumer Affairs and Business Regulation
Expiration: 9/2112.012 Private CorporaUor 10 Park Plaza-Suite 5170
Boston,MA 02116
THO S PRICE tNG
THOMAS P -
RICE
41 ORCHARD ST
MERRIMAC,MA01t 0'1 `== undersecretary 1Yotval)dwillloutsignature
( G..,,...
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DO NOT SIGN THIS CONTRACT Ili`MERE AREA B SPI.
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Goatrado �l,rbltatlon _ `_ ',,
Tbe Aamze Improvement Color Law provides-homeowners writh the rightto initiate an arbitration action(as an
alteroativc to covet action}if they have a drsptue vtbh ao�acmt.Tire sffine;iglYt is�arbomatieally afrmded'bo a
. how T� wotrtd have to tcsolv_caoy disptde hrdsha bas with a homeowner in court aahess
�:i �to the optional dame provided below.This clause would - the contractor Bre same right to
arbitration as is afforded t84be homeowner the Home I
by Imisovememt;nrsuacasrLaw.
The contractor and the homeowner bereby muivak agree is advance that in the event the camcactor Bas a disputa
this coffiact,the c�tar—yy submit the dispute to a private mt*afion firm which app vved by-
Ubm terry o Office of Consumer Affairs and Butness+s.��' he
To to requiredGeneral
Hameowaef's S Sigaaftee
NOUCIL The ' ofthe
• i by the ..The dam parties �PiY Only to the agreement of the parties m aluxrmtivt drspcciG rtsolwQon
May ioitial .8 ve-disptde rrsohition even where this s�tion is not
Isepardwy signed by bas paYtim
Homeowner's Ri&fs
A homeownefs rightsunder tbe Ham hopmveauant Contractor LI.(MG.L ediapter 142A)aod other coawmar
protection laves(i–MOL chapter 93A)may not be waived is any way,even by agreamenr- Howva4 homeownem
may be occluded from cmtaln rights if the contractor they choose is not property as ptescn'bed by law.
Honxawarxs who secure their own bm7dmg pemms are auwmaftcally excluded fiom aA Cwaranty pend provisions of
the Home Improvement Coubuctur Law. The contactor is nspenSibi:for completing the work as described,m a
timaly and Worlmals'ke manner Homeowners may be entitled to otlrer seethe legal rfghta if the con maw guawt=
or provides as express.vvaaamy far vvozlcmansbip or materinis. In addition to ge»s or warranties provided by the
all goods sold is Massachusetts copy as anpiied wavanty pf mWr0bftUIMW*and ftp fbr a particular
purpose-An emUnaation of oflmr matters on which the homeowner and ODUWdCtWbWfttDy agree maybe added t0ft
bruits offt coa6act as long as they do not restrict a bomeowner's basic consumer rigbts. If you have questions about
YOM rfgbl%contain tete Coasumar lafatmatian Hotline(listed below).
Bzecadon of Contract
The conisM must bs aweeubed in duplicate and should not be signed
`tmtlla copy of all exhrbits and refinencqd
documents have been attached Farcies are also advised nut to sign the domancint until all blank scodons bane been
filled in or marked as void,deli or not applimbie. Ore original signed copy of the contract with attachmetefs it to
be given do the owner and the other kept-by the ..Anton to the origimi contract must be in writing
and aggreed to by both tomes-Contracted wart may not begin until both parties have received a fully tawcutod copy of
_ . the coutlucl,and the three
dayraaission period has expired.
'kawlanted Payments
A chador may not demand payments is advance of the date gMcified on the payment schedule is cases where the
homeowner deemsbim&erseifto be fir>encislly maeo a Hovmver,is instnnexs where a mor dexars him self
m �° �'regrure that the Gala m offunds noryet due be placed in a joint esamw
wennot es a pre3 Wsite to ung the weed`-VlrAxhawal of.6mds fiinm Wd account would requh ttie
sigrres of both parties.
Additional Information
Ifyou have goal questions or need additional information about the Home Improvement Contraetor Law or dh,
a oasom rigs,or WYon wish to obtain s free copy of°A Consumer Grande to the Home Improve rum cnnuactor
.,._.. - Law,°contact _ ..
_ Consetme�.Inf Holme
Of 0r,ofConsumer AM=and Busmass Regulation
10 Pard:Plata,Room 5170,Bosmm,MA 02116
(617)973-8787 or 1{888)2833757
Ifypowantto veFr{y Su regan of a conn�xor of ifyonhave"q:zeioris o�need additional information scally
about the GODUVOWlegistration component:oftheHomeImproveniear-GmaaatenLaw,contact
Daecmr ofHome Impravesnt Ccamacto;Ramon
Bureau ofBut7fimgR%,dWons and Standa+da
One Ashbiutan Place,Room 1301,Boston,MA 02108
. (617)727-33200 or 1-800-223-0933
For asslsmrtae with infarnoai mediation of dispmes err tD register f nat:omptaints against a business,ca]L-
cousuaw Complaint Sectiem
Office of the Aitorncy General
(617)727-8400
AND/OR
Batter Busirxss Bureau
(508)652800
(508)755-2548
(413)734-3114
P1
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Atlantic Charter Insurance Company VDAC
Policy Number: WCV00845602
NCCI Co. No.:29211 Prior Policy Number: WCV00845601
1. INSURED:
Thomas Price, Inc_ Producer:
Andrews Insurance
41 Orchard Street282 Main Street
Merrimac, MA 01860 Federal ID Number:043053109 Risk ID Number: Groveland, MA 01834
Business Type: Corporation SIC:9999 NONCLASSIFIABLE ESTABLISHMENTS
Other Named Insured: Other Work Places:
2. POLICY PERIOD: The Policy Period Is From: 612/2011 To 6/212012 12:01 A.M. StandarTime
_ at The Insured Mailing Address-_
3. COVERAGES:
A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed
here: MA
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3A.The limits of our
liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident
Bodily Injury by Disease $ 500,000 policy limit
Bodily Injury by Disease $ 100,000 each employee
C. Other States Insured: Part Three of the policy applies to the states, if any, listed here:
i
I
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A
D. This policy includes these endorsements and schedules:
See WCE105
—4. COVERAGES: The premium for this policy will be determined by our Manual of Rules, Ction and change change bons, a es
Rating Plans. All intbrmabon required below is subject to verificaby audit-
s Premium Basis Total Rate Per Estimated
Code Estimated Annual $100 of Annual
Classifications No. Remuneration Remuneration Premium
See WC 00 00 01
Minimum Premium: Deposit Premium:
$500 $504
Interim Adjustment Annually
Estimated Premium(Minimum Premium) $503
1
Servicing Office; Surcharge(s)
25 New Chardon Street $504
Boston, MA 02114-4721 Total Premium and Surcharge(s)
Issue Date 05/25/2011 Countersigned By:..-------.. ..---._.... .••._.___... ..._____.......-- --pati......_
6;pyrlght 1987 National Council on Compensation Insurance
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
y www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Agglicant Information Please Print Legibly
Name(BusinessIOrganization%Individual): le-
Address:
eAddress:
City/State/Zim gm-n it-lar L r5/etsb Phone#(126 ng
Are you an employer?Check the appropriate bog: Type of project(required):
1.[ I am a employer with _ 4.0 I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑I am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers'compo insurance compo insurance.t
required.]. 5.F1 We are a corporation and its ME] Electrical repairs or additions
3.❑I am a homeowner doing all work officers have exercised their 1 L[] Plumbing repairs or additions
myself. [No workers'compo right of exemption per MGL c. 12.kRoofrepairs
insurance required.]or I have hired 152,§1(4),and we have no
the contractor listed on the attached employees.[No workers' 13.�Other
sheet cg=b insurance required.l
*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 anew 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'compo policy number.
Tam an-employer that is providing workers'compensation insurance for my employees.Below is the policy and job site
information.
Insurance Company Name: t, M
Policy#or Self-ins.Lie: ,, �— Expiration Date:
Job Site Address: 3 tR Mc vj Std ,f()oA' _ e!' 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 certify under the pains a enalties of perjury that the information provided above is true and correct.
Signa re: _ .2 Date: � � � Z( ZIP i
Phone: