HomeMy WebLinkAboutBuilding Permit #831-15 - 32 STONINGTON STREET 4/22/2015A
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FORPLAN EXAMINATION
Permit,NO#: Date Received
Date Issi "P(i. 1 —.1 11--1 t
T"
ANT: Applicant must complete all items on this
4; v.
0
YPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
Ell w Building
0 One family
R'Atition
El Two or more family
El Industrial
11 Alteration
No. of units:
11 Commercial
El Repair, replacement
El Assessory Bldg
El Others:
-,E1 Demolition
17
ON OR
t�' WC
DESCRIPTION OF WORK TO BE PERFORMED:
IL'e. C. Ill. 1,
OWNER: Name
I'l
Address: i wl
entification Please Type or Print Clearly
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ARCH ITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE, BULDING PERMIT. $1Z00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASEWD $125.00 PER S.F.
Total Project Cost:$ k
6 00 FEE: $
Check No. Receipt No.:
NOTE: PersoArs contracting with unregistered contractors do not have access to the gWrantyfuV
Plans Submitted D Plans Waived Certified Plot Plan St�, Y)ed Plans
TYPE OF SEWERAGE DISPOSAL
Public Sevver El
TanuingfMas s age/B o dy Art El
Swimming Pools EJ%.
well El
Tobacco Sales El
Food Packaging/Sales 0
Private (septic tai* etc. El
Permanent Dumpster on Site
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U F.ORM
PLANNING & DEVELOPMENT Reviewed On
COMMEN-TS
Signature
CONSERVATION Reviewed on Signature
COMMENTS -
HEALTH '%
Reviewed on Simature
COMMENT�
Zoning Board of Appeals: Variance, Petition No: Zoning Decisionlreceipt submitted yes
Planning Board Decision:
Comments
0
Conservation Decision: Comments
Water & Sewer ConneGtion/signature & Date DrivewaV Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
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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 rnin.$1 00 -sl 000 fine
NOTES and DATA — (For department use)
U Notified for pickup Call Email
Date Time Contact Name
Doc.Building Permit Revised 2014
M
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
E: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
4. Building Permit Application
4� Certified Surveyed Plot Plan
4 Workers Comp Affidavit
Photo Copy of H.I.C. And C.S.L. Licenses
Copy Of Contract
Floor/Cross Section/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
OTE: 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
4. 2012 IECC Energy code
,& Engineering Affidavits for Engineered products
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit
In alf 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
Doe: Building Permit Revised 2014
---~---�-~`-- --'r
1.
Location Sz
TOWN OF NORTH ANDOVER
^
Certificate of Occupancy $
Building/Frame Permit Fee :qo�-
FoundaUonPermitFga $_____
OtherPgrmitFee $_____- '
TCTAL $_____
'%IBuilding —Inspector
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IOPOSAL SUBNlrr JOB NAME JOB #
TO: I
)DRESS JOB LOCATION
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DATE DATE OF PLAS
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IONE # FAX ARCHITECT
Ve hereby submit specifications and estimates for: + L4) 0 u e, t V x
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e propose hereby to furnish material and -i labor — complete in accordance wfth the above specifiGabons for the sum of:
nnllarS
with payments to be made as; follows: !,r 07V
IF / A_ft�cal
Anyalteration ordeviationfrom above specifications, involving extra costs Respectfully r
will be executed only upon written order, and will become an extra charge
submitted
over and above the estimate. All agreements contingent upon strikes,
accidents, or delays beyond our control. Note this proval may be withdrawn by us if not accepted within _ days.
01creptance of J)ropozal
The above prices, specifications and conditions are satisfactory and are
hereby accepted. You are authorized to do the work as specified.
Payments will be made as ouffined above. Signature
ate of Acceptance Signature
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Name
The Commonwealth of Massachusetts
Department ofIndustrialAccidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov1dia
Workers' Compensati ' on Insurance Affidavit: BuUders/Contractors/Elqctricians/Plumbers.
TO BE, FILED WITH THE PERNUTTING AUTHORITY.
City/State/Zip- � j4- J( 4 � tP �� ;��. Phone#: 1�, C) _? –2 9.? —.;- 7 –<3r
Are you an employer? Check & appropriate box:
LE!11 am a employer -with __�_�.employees (full and/or part-time).*
2. E] I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3. n I am a homeowner doing all work myself. [No workers' comp. irisurance required.] t
4.F] I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
pro�,iet�rs -with no employees.
5. 1pr� a gpneral contractor and I have hired the sub -contractors listed on the attached sheet.
Theie sub-contrictor's We en�ploye.e's and have workers' comp. insuranceJ
6. We are a corporation and its officers have exercised their right of 'exemption per MGL c.
l52,§l(4),an4wehay.enoe loy��s. [No workers' comp. hisurance required.]
Type of project, (Tpquired):
7. R New construction
8. El Remodeling
9. F! Demolition
10 Building addition
li-E] Electrical repairs or additions
1�-E] Plumbing repairs or additions
l3.FJ Roof repairs
14.EJOthbr
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Romeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the. name of the sub -contractors and state whether or not those entities have
. "; , ". �.. 1: 1! ., - - - - , , 1h , . � I
employees. If the sub-cbrltract6rs ave employees, ey must provide their workers' comp. policy number.
i'd m an employer Mai isproviding workers'compensation insurancefor my emplbyees.'Below is thepolicy andj-o'h site
information. f
Insurance Company Name:
Policy # or Self -ins,, Lic. #: WC -600 L Expiration Date:_
Job Site Address:— ?-?,_ A��_City/State/Zip:
Attach a copy of the workers' compensation' policy declaration page (showing the policy number and expiration &te).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this staternent may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do h erehy certify un der f1i e pains an doenalfies ofpeiju ry th at th e information provided abovXis truepnd correct.
Official use only. Do not write in this area, to he completed hy city or town ofJ11cial.
City or Town: Permit/License #
Issuing Authority (circle one):
1. 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 emplo ees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contrdA_�O`Iffire,
expres's or implied, oral or written."
An employer is defined as "an indiviidual. Dartnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer, or the
receiver or truitoe of an individual, partnership, association or other legal entity, employing empl6�ees. 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 wh6 employs persons to dom�intenarrce, construction'br repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment b6 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 commohiyealth.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-contractoi(s) name(s), address(es) and -phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLQ 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 Depattment of Ifidustrial
Accidents fbi 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 requ�red to obtain a workers'
compensatioti-'policy, please call the Department at the number listed below. Self-insured companies sh,ould'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 Depa rtment has pi6vided'a space at the bottom
of the affidavit for you to fill'but in the event the Office of Investigation's has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a referenceriumber. in addition, an applicant
that must submit multiple permit/license applications in any given year, need only subipitm 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 pennits or licenses. Anew 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 Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
I a
ACCORV CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDDIYYYY)
1
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
04/14/201'5
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGA71VELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. IfSUBROGATION IS WAIVED, subject to the
terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsement(s).
PRODUCER
-CONTACT
NAME: AL MATTHEWS
AX
(PAH12INLEA: 781-872-1813 CAIC' No): 781-872-1813
MATTHEWS INSURANCE AGENCY
E-MAIL
182 PARKER ST
-ADDRESS:
INSURER(S) AFFORDING COVERAGE NAC#
LAWRENCE,MA
INSURERA: MERCHANTS 23329
01843
INSURED
INSURERB: LI BERT MUTUAL 19624
ALL IS WELLS CONSTRUCTION
17
288 NO END BLVD
INSURERC:
SALISBURY,MA
INSURERD: —
A
01952
INSUREIRE:
BOP1047700
INSURERF:
rnvrPanPA CERTIFICATE NUIVIRER! REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTAN DING 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. LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
TYPE OF INSURANCE
ADDL
AM
SUBR
ima
POLICY NUMBER
POLICY EFF
(MMIDDIYYYY)
POLICY EXP
[MMtDDIYYYYI
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $ 1 000000
AGE IQ HEN ILL)
=ISES (Ea occurrence) $ 1,000,000
COMMERCIAL GENERAL LIABILITY
_7 CLAIMS -MADE X1 OCCUR
F
17
MED EXP (Any one person) $ 15,000
-PERSONAL & ADV IN,1URY $ INCLUDED
A
BOP1047700
04/14/2015
04/14/2016
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
- COMP/OP AGG $ 2.000,000
-PRODUCTS
$
F—] IRI-
POLICY JECT 7 LOC
AUTOMOBILE LIABILITY
COMBINE13=17PIT
(Ea accident) $
BODILY INJURY (Per person) $
ANY AUTO
BODILY INJURY (Per accident) $
ALL OWNED SCHEDULED
AUTOS AUTOS
NON -OWNED
HIREDAUTOS AUTOS
PROPERTY D AGE
Cper ac TY
accident)
UMBRELLA LIA B
H
"cc UR
F.
F
EACH OCCURRENCE $
AGGREGATE $
EXCESS LIAB
CLAIMS -MADE
DED F:FR7ETE7N1
$
B
WORKERS COMPENSA71ON
AND EMPLOYERS'LIABILITY YIN
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICE/MEMBER E)(CLUD FN—]
(Mandatory In N"
NIA
17�
VVC00035222065
02/10/2015
02/10/2016
ORY LIM T� I 'ITH
I TIC STATU
I ER
E.L. EACH ACCIDENT $ 100,000
E.L. DISEASE - EA EMPLOYEE $ 100,000
E.L. DISEASE - POLICY LIMIT $ 500,000
If yes. describe under
I DESCRIPTION OF OPERATIONS below
L_
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required)
GENERAL CARPENTRY
rPPTI;:irATf;= wni nFzR CANIC17ILLATION
TOWN OF NO ANDOVER
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
1600 OSGOOD ST
ACCORDANCE WITH THE POLICY PROVISIONS.
BUILDING 20,SUITF2035
AUTHO ED ESE TIVE
NOANDOVER,MA01845
I
..� I - (9) 1988-2010 AC C;QKFQKATIQN. All rignts reservea.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACOF ro
Office of Consumer Affairs
10 Patk Plaza,
Boston, MaskIr-.'
N
Home lmproveinenit�,ji
WINDOWS BY WELLS
RANDALL WELLS
181. MAST RD.
EPPING, NH 03042..
'Commonwealth of
chysetft-
Department of Labor stanaarcis
h�l�rE �or�, 1)#KW
1361ijid
I , Eq isuPervisor
RANDY d.,
Eff. Date o2til/15
E_V. Date 02/
10/16
DS000783
*MbOrof C.O.N.E.S.7,
16
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6in'ess Regulation
,1470
'�62116
ir Registration
ReaWdon: 125503
DBA
ExP'mgcn: /08/20108 293210
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.14date Addrew and ratalro card. Mjwlt rvM" Jbr Osige.
C] Addren 0 Renewal. C] 1n;
Massachusetts - Department of Public Safety -
Board of Building Regulations and Standards'
Construction Su*.r�isor
License: CS -078046,
Randall G WeUs
PO Box 246
Salem NH M9
'01 Ex piration
09/08/2016
Commissioner