HomeMy WebLinkAboutBuilding Permit #876-11 - 32 MARBLEHEAD STREET 6/21/2011Permit NO: P7a —j/
Issued:
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
.1 /l//
RTANT: Applicant must
Print
Date Received
all items on this
Print
MAP NO: (PARCEL:.
ZONING DISTRICT:
Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
❑ New Building
Resi ential
One family
Non- Residential
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
Others:
❑ Demolition
��-�
�iSeptrc� Well
�
o, Water/S.,ewer
_ ❑ Other
�1Floolain�' .r
�-; ��. ❑.tVWetlan-dsg
) 5
-�--
_ � Watershed�District;
DESCRIPTION OF TO BE PERFORMED:
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/WORK
A-f'J 1 r)Ji Y ✓iSi , .. _ .. _.
& P n
OWNER: Naive:
(Identifies ' Please Type or Print Clearly)
NlOrE
Address:_ 32,�,Q iii_ Ff C�•r-
CONTRACTOR Name: 0 1 - -y� t )M<y phone:
Address: —&:, j
Supervisor's Construction Licenser �f Exp. Date: 2) a� v
Home Improvement License: Exp. Date:Lf Zq- )
ARCHITECT/ENGINEER Phone:
Address:
Reg. No.
FEE SCHEDULE: BULDING PERMIT. • $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $_ 4 L 60 FEE: $
Check No.: c;2'I � Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guars fund
Signature)of Agent/Owner" - - K
�
Signature�ofcontractor
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
NOTE:
❑ 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
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
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
9 -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
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
Zonirig.,Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comme
Water -& Sewer- Connection/Signature & Date - — _ _ _ _ Driveway P---;'-
DPW
ermitDPW Town Engineer: Signature:
384 O od Street
FIRE DEPARTMENT - Temp Dumpster on site yes
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Located sgo
no
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.$10041000 fine
NOTES and DATA — (For department use
Doc:.Building Permit Revised 2008mi
Location 12 - -41
No. f,76 - // Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check#
24268
/luilding Inspector
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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): > GU�V_LZ7 / (' f Ur
1 r
Address:
City/State/Zip:k9 .26J jyj,lY Mik 0 "Phone #: G'1 7269
Areyou 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).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached shget. $
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We ate a corporation and its
required.]
officers have exercised their
3. ❑ I 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.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12. ❑ R . of repairs
13.[ ther I X(,��
=.y arraut L114L wccrcs oox if t must also rill out the section below showing their workers' compensation policy information.
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-coptractors 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:_ F-2 kjo
Policy # or Self -ins. Lic. #: Expiration Date: 12-071— 2 (D I
Job Site Address:__ 2 City/State/Zip: N ,k� j, -
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.
Ido Hereby certy�'v uni eJ#eains and penalties ofperjury that the information provided above is true and correct.
--C\.� �i
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):
I. 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-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. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia
CSG
CONTRACTOR WORK ORDER
Conservation Services Group Printed: 6/9!2011
Contractor Informafion I Customer/Site Details
Dave Hope LYNNE RUDNICK] Phone (eve): (978) 771-5564
HRH 32 MARBLEHEAD ST Phone (day): (978) 771-5564
57 Chase St
Methuen, MA 01844 NORTH ANDOVER MA 01845 2312 Q Site ID: S10000624779
Appointment Details
Completion Deadline:
Location Description Quantity Unit $ Total $ Notes/Revisions
Work Order: HRH 20110609
OVERALL Air Sealing -Hours 4 70.00 280.00
ASL
Attic Slope Dense Pack 6"
110
2.02
222.20
KWL
Potyisocyanu'rate 2"
444
2.76
1225.44
BEDROOM
Door: Polylsocyanurate 2"
2
46.00
92.00
KFL
Kneewall Floor Dense Pack 8"
128
1.94
248.32
KFL
Kneewall Floor Dense Pack 8"
324
1.94
628.56
AFL
Open Attic 11" Cellulose
320
1.34
428.80
OTHER
Wall Ins. Interior 3" Cellulose
444
1.77
785.88
EXTERIOR
Wall Ins. Multilayer Siding 4" Cellulose
160
2.24
358.40
OVERALL
12" Mushroom Vent
1
115.00
115.00
OVERALL
8" Roof Vent
1
83.00
83.00
Total for Work Order HRH_20110609 : $4,467.60
Grand Total: $4,467.60
Road Blocks
Asbestos Possible Asbestos Containing Material Observed
STEAM HEAT
K & T Wiring Knob and Tube Wiring Noted Electrician Letter on File
FOUND 1N THE BASEMENT knee wails knee wall floors, walls, everywhere lic !140209 all areas cleared.
�C®130. CERTIFICATE OF LIABILITY INSURANCE
DATE(MMA)OIYYYY)
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
12/14/2010
PRODUCER
UCER
Emond &Associates
857 Turnpike Street
Ste. 133
North Andover, MA 61845
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.
TYPE OF INSURANCE
POLICY NUMBER
INSURERS AFFORDING COVERAGE NAIC It
INSURED
HRH Construction
A INSURER Farm Family Casualty Insurance
P. O. Box 5184
North Andover, MA 01845.
INSURER e:
INSURER C:
INSURER 0:
INSURER E:
EACH OCCURRENCE $ 1,000,000
PAVCnA/±oQ
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.
NSR
ILTR
AXN
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
POLICY EXPIRATION
LIMITS
EACH OCCURRENCE $ 1,000,000
GENERAL LIABILITY
✓ COMMERCIAL GENERAL LIABILITY
DAMAGE TOWEN-IMY-
PREMIE a rencel $ 50,000
MED EXP (Any one person) S 5,000
LAIMS MADE ✓) OCCUR
2005XO775
1120/2010
11 /20!2011
PERSONAL 8 ADV INJURY $ 1,000,000
GENERAL AGGREGATE S 2,000,000
n,
_
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG $ 2,_000,000
POUCY PRO- LOC
JECT
AUTOMOBILE
LIABILITY
ANY AUTO
-
COMBINED SINGLE LIMIT
(Ea accident) S 1,000,000
ALL OWNED AUTOS
SCHEDULED AUTOS
BODILY INJURY (Per (Per person)
HIREDAUTOS
200104287
03/162010
03/16/2011
NON-0WNEDAUTOS
BODILY INJURY
(Peracddant) $
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY
AUTO ONLY -EA ACCIDENT $
ANY AUTO
-
OTHER THAN EA ACC E
`
AUTO ONLY: AGG S
EXCESSIUMBRELLA LIABILITY
EACH OCCURRENCE $ 1,000,000
OCCUR FICLAIMS MADE
2001 E1159
07/122010
07/122011
AGGREGATE y 1,000,000
$ 1,000,000
DEDUCTIBLE
$ 11000,000
RETENTION $10,000
_
$
WORKERS COMPENSATION ANDSTATU•
OTH.
EMPLOYERS LIABILITYWC
-
E.L. EACH ACCIDENT S 500,000
ANY PROPRIETOR/PARTNER/EXECUTiVE
1.
OFFICER/MEMBER OCCLUDED?
undnder
20IfIges,05W6827
12/072010
12/072011
E.L. DISEASE - EA EMPLOYE $ 500,000
SPECIdescihe
AL PROVISIONS below
OTHER
E.L. DISEASE - POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
Operations by named Insured.
CCCrICICATC UAI non
--WGLLM 11Vn
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRrrTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES
AUTHORIZED REPRESENTATIVE
Department ot, PtJI)IjC Sjjj'etN
Board of Building Reon 4�
t;' " (';' 1 ds
Const'ructiorl' ' I;Itioll.% ;111(1 '
SUPervisor License
License: Cs 57754
Restricted to: 00
WILLIAM D HOPEZ
57 CHASE ST
METHUEN, MA 01844
jo Z
7�1 ---------- Expiration: 3/4/2012
(' nmiisiweiv Tr4: 18748
Office v k. nlia(i Jh�,m License or registration valid for individul use only
wgjg—.,.&
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration: 101730 Office of Consumer Affairs and Business Regulation
91t Type:
6126/2012 10 Park Plaza - Suite 5170
Expiration: Private Corporation
Boston, MA 02116
HA
William Hope
57 CHASE STREET-,,
4�
METHUEN, MA 01844..
Undersecretary Not valid without signal