HomeMy WebLinkAboutBuilding Permit #932-14 - 33 UNION STREET 6/23/2014TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: 0 Date Received
Date Issued: (A —,X —I
LOCATION -
PROPERTY
-IMPORTANT: Applicant must complete all items on this page
-QA
.R PO it I r -
Print
MAP NO: PARCEL:7
Print
ZONING DISTRICT:
100 Year Old Structure
Historic District
no
yes
Residential
Non- Residential
0 New Building
Machine Shop Village
yes
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
0 New Building
VOne family
[I Addition
0 Two or more family
[I Industrial
0 Alteration
No. of units:
[I Commercial
El Repair, replacement
El Assessory Bldg
El Others:
0 Demolition
El Other
0 Septic 0 Well
0 Floodplain 0 Wetlands
0 Watershed District
El Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Vr',p + Re-JkA/e f0e
Identification Please Type or Print Clearly)
OWNER: Name: Poh1c!c; 1'445on Phone: Y79, 3 ? 7 T(k (v 0
ab
Address: 3 3 U 'ok 5�-
CONTRACTOR Name: 00.4'd 0/ V e--, rc. Phone: i 7a- 66 41-5-6 3 3 -
Address: P-0 0,?Y, 1,5-G AI-Af-4;4�, No, 096it-1
.1
Supervisor's Construction License: 63!�/3 Exp. Date: 3&-6-2-7-1!y
Home Improvement License: 11M2 -
Date:
ARCH ITECT/ENGI NEER Phone:
Address:
Reg. No.
FEE SCHEDULE: BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ %Y00 FEE: $
Check No.: � ( 2--0 Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund
N.
8igna ture of A . ent/Owner Signat ure of co ntrac tor
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
Plans Submitted -0 Plans Waived Certified Plot Plan D Stamped Plans F1
.-TY-PE�'OF�SEW-ER-A-GEDISPOSAL-
Public Sewer El
Tanning/Massage/lBody Art
Swimming Pools 0
Well
Tobacco.Sales
Food Packaging/Sales 0
Private (septic tank, etc.._
Permanent Dumpster on Site F1
THE FOLLOWING SECTIONS FOR -OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED:
PLANNING & DEVELOPMENf
COMMENTS
CONSERVATION
COMMENTS,
HEALTH
COMMENTS
DATEIAPPROVED
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decisionfreceipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
�Comments
Water & Sewer Connection/Signature & Qate Driveway P rmit
DPW Towo Engineer: Signature:
Located 384 Osgood Street
-DIEPARTMEN'T' - Tem'p- Dumpster on site yes no
Located -at 124 Mair, Street
Fire DL-part-merit!§ignatu'reldate'-'
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 21 A —F and G min.$100-$1000 fine
NOTES and DATA — (For deDartment use
El Notified for pickup - Date
Doe.Building Pennit Revised 20 10
Building Department
,�.The foll,:,)wing is ---a list of the required forms to be filled out for the appropriate. permit to be obtained.
Roofipg, Siding, Interior Rehabilitation Permits
Lj Building Permit Application
u Workers Comp Affidavit
u Photo Copy Of H.I.C. And/Or C.S.L. Licenses
Ei 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
c3 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 casi�s if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the apu%,al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be subm.tted with the building application
Doc: Doc.Building Permit Revised 2012
Location 5?D U A)l ovi
No. Date
Check #
TOWN OF NORTH ANDon
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $-
Other Permit Fee $-
TOTAL $
4 ���
Building Inspector
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office of Consumer Affairs& Business Regullation
0 E IMPROVEMENT CONTRACTOR
M
e Istration: 1�3852 Type:
g
4/15/26-15� DBA
xPiration:
Oliveira Construction
I
Daniel Oliveira, Jr
10 Mill street
I N. Reading, MA 01864 Undersecreta i ry
11M Massachusetts - Department of Publi.c.safety
Board of Building Regulations and Standards
Supen-isor
Construction
License: CS -068413
DANIIEL OLIVE113X JR
10 NML ST k
N READING MX --01864
w Expi ratiory
Commissioner 06.1A20.14
0
6/9/2014 12:24 PM FROM: Fax M.J. Foster Insurance Services, Inc. TO: 19786645633 PAGE: 002 OF 002
OP ID. PS
CERTIFICATE OF LIABILITY INSURANCE
—DATE (MMIDONYYY)
F AT �'1111
06/091201�
OS
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY 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 HOLIDFR.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED. the pollcy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this cenIficate does not confer rights to the
certificate holder In lieu of such endorsernent(s).
PRODUCER
North Andover Insurance Agency
M.J. Foster Insurance Services
163 Main St.
5%"TE�C' PETE SULLIVAN
FAX -686-6410
P14ONE 978
Av5gg%s: psuilivanCcDfostersullivangroup.coT..
North Andover. MA 01845
Pete Sullivan
PRODUCER OLIVE -1
I
INSURERJS) AFFORDING COVERAGE NXC#
A
INSURED DANIEL OLIVEIRA JR.
INSURER A: TRAVELERS INSURANCE CO 119046
INSURER 8: MERCHANTS INSURANCE GROUP 123329
OLIVEIRA CONSTRUCTION
INSURER C ..........
INSURER D:
P.O. BOX 156
NORTH READING, MA 01864
INSURER E:
INSURER F t
Or-%-nQIr)?1J KII IaA;:kr-P.
THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
INSRI 6�–U-'- - FOUCYFXP UwrS
W""�—Mm I
VR TYPE OF INSURANCE M".9 NUMBER IMMf00IYyY`YI (M1wDDrrffyI
- -
GENERAL LIABILITY
El
---E—
EACH OCCURRENCE 6 1,000,0001
A
X 1 COMMERCIAL GENERAL LIABILITY
X
�
0610112014
06101/2015
1 DAMAGE TO RENTED 3N,60d
PREMIUS 1115"t"n0G) $
i 1 CLAIMS4AACE 17X OCCUR
51
_!�ER_EXP
1'000'00
PERSONAL& ADVINJY!�q 0100
GENERAL AGGREGATE $ 2�000100..
GEN'L AGGREGATE UWT APPLIES PER:
�7
PRODUCTS - COMPIOP AGG S 2,000,00
POLICY F-1 Prgcoi F--1 LOC
I ALITOMOSILE LIABILITY
COMBINED SINGLE LIMIT $ 1,00io'000
1
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B 71 AUTO
MCA7015598
TIO/2512DI3
10125/2014
ANY
BODILY INJURY (Par parson)
ALL OWNED AUTOS
LIOD�LY 1NA-IRY (PLI,11,16-1-11
SCHEDULED AUTOS
P p 0 E Is
X HIRED AUTOS
i IPER ACCIDENT)
X NON-OWNEDAUTOS
is
:$
UMBRELLA LV 10 1 JOCCUR
EXCESS LIAS
ILI�—GG R E GAT C
is
DEDUCTIBLE
is
RETENTION A
WC A OTH.
X
WORKERS COMPENSATION
1DRY-LNITS- ER
A
AND EMPLOYERV LIABILITY YIN
ANY PROPRIE11ORIPARTNER/EXECUTWE r---1
6OUB-SB50092-6-13
0712312013 07123120`14 L EACH ACCIDENT is i'000'(10(
OFFICERMEMSER EXCLUDED?
NiA
�ISEASE - EA EmpLoYEE11 1100100(
(Mandatory In NH)
11 da=tbo unclef
E L DISEASE - POLI 1,000,00(
CY LIMIT 1
rs,
D SCRIPTION OF OPERATIONS bolow
DESCRIPTION OF OPERA'nONS I LOCATID"I VE"Ir�LXU (AUSCn P.6VKU IVI.
EVIDENCE
ACORD 25 (2009109)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUIHORLZED REPRESENTATIVE
pli7�. 'gi 11 .1 17�
(D 1988-2009 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
The Commonwealth ofMassachusetts
Department oflndustriqlAccldi�ts
Office of Investigations
600 Washington Street
Boston., MA 02111
www.mass.gov1d1a
Workers' Compensation Insurance Affidavit: Builders/ContractorslElectricians/.Plumbers
Applicant Information Please Print Ledb
NaMO(Busine.ss/Organization/Individual):
Address: P. 0 A, c,)(
City/Stat0/Z`iP:1V.fteQJ.AJ ffll,.019-6�t Phone #: q Ttr - q - 5-(, 3 3
Are you an employer? Check the appro&1ate box: Type of project (required):
1. 91 am a employer with 4. D I am a general contractor and 1 6. n New construction
employees (fall and/or part-time),* have hired the sub-contractoys 7 . . E] Remodeling
211 1 am a sole proprietor or partner- listed on the attached sheet. T
ship and'have no employees These sub -contractors have 8, 0 Demolition
working for me in any capacity. workers' comp. insuranc . a.
9. E] Building addition
[No workers' comp. jnsurance 5. El We are a corporation and its 10.[] Electrical repairs or additions
required.] officers have exercised their
3. D I am a homeowner doing all work right of exemption per MGL I LD Plumbing repairs or additions
myself. [No workers' comp. c. 152, § 1 (4), and we have no 12.�oofrepalrs
insurance required.] t employees. [No workers� 13.Fi Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section bel6w showingtheir workers' compensation policy information.
T Homeowners who submit this affldavitindioatingthoyaic doing all work and then hire outside contractors must submit anew affidavit indicating such.
tContractors that check this box must attached an additional sheet sliowingthe name of the sub -contractors and their workers' comp. policy information.
I am an employer th at is providing workers I com
pensation insurancefor my employees, Below is thepolley andjoh site
information
Insurance CompanyName:. 1V0rJA 11&dc-ef- T45, *#qeAry
Policy 4 or 8 elf -ins. Lic. Expiration Date: 7-ZL11-
JobSiteAddress: 33 un,&ix Citv/statelzip: /1/, 194 4oe At-,
Attach a, copy of the workers' compensation -policy aeclaration page (showing the policy number and expiration date).
Failure to secure coverage as requiredundor Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or oiie�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 ofthis statement maybe forwarded to the Office uf
Investigations of the DIA for insurance coverage verification.
I do hereby cXfify under�epalns andpenattles ofperjury thalthe information provided above is true and correct.
I 1� Date: (b - 7-3 -
Phone 4: q —,5-( 3,3
Official use only. Do not -write in this area, to he completed by c4 or town official
City or Town:
Permit/License
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone 9:
Information and ffustructions.
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their ernployees.
Pursuant to this statute, an employee is defined as "....every person in the service of another under any contract. ofhiro,.
express or implied, oral or written,"
An em
ploydis defined as "an individual, partnership, 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 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 6e
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 ofpublic work until acceptable evidence of compliance with the insurance
requirements of this chaptorhave beenpresented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the
, boxes that apply to your situation and, if
neccssar3� supply sab-contractor(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 anLT—C orLLP does have
employees, apolicyis required. Br. advised that this affidavit maybe; 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 ratumedto 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 to appropriate Eno.
City or Town Officials
-Please-be, sure that -the affidavit is-complete-aad-printed"legibly. ThEiDbp-aM�ntliCspf6vid6da'FpEFcc�it-ff&b6-tEom-
of the, affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Pleas * e be sure to 0 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 ye ar, need only submit one, affidavit indicating current
Policy information (ffnecessary) and under "Job Site Address" . the applicant should write "all locations in—(city or
town)." A copy ofthe 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 ii on file for firture permits or licenses. Anew affidavit must be filleLd out each
year.'Where a homeowner or citizen is obtaining a license cip-ormitnot related to any business or commercial -venture
(i.e. a dog license orpienuit to bum leaves etc) said person is NOT required to complete this affidavit.
The, Office of hivestigations' would like to thank you in advance for your cooperation and shouldyou have any questions,
pleas a do not hesitate to give us a call,
The Department's address, telephone and fax number:
Tho Commonwealth of
Dopafte.ut offadustdal Accidoilts
6W Washiugtou Strea
Boston,MA02111
TOU 617-7274900 at. 406or 1-877�UARSAFF,
Revised 5-26-05 Fax # 617-727-7749
4M E it,
04 Rooftg 9 Gufters
CONSTRUCTION
P. 0. Box 156
North Reading, MA 01864
(978) 664-5633 Fully Insured
Lic. #68413 Reg. #123852
STREET 7 -'� (-) rl'i 9 �-
CITY h, I STA3,44t ZIP
CertainftedM
PHONE 91S, -3T7 -c((,(00 I DATE
JOB NAME
JOB LOCA11ON 33 uyl,%, s-11
We hereby submit specifications and estimates for:
cc, A? le -4- to v dvWi-sl 11V16ce
ro 0 d ecl-l"I'l ee-de W. /?Wv(" re lace'WeAl;�'
/1 0"14 / P
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YyAtAld,-C
e -le
r4,��c. It A Z u%, ve-,a / P�oe ey -/-4 /c) r
A an J 1115 J., tt r�; dy e V e -A too 1 tocce k,
PA,'-'�te- cid ro-it., ce,4,q;-n1ee,,1 1,a,1dA4v,( A- Q.�r C 6 e r- le
&�em "-A
/4�v U
Price Includes removal of all job related debris.
Tlease note: All items in attic should be covered during roof tear -off.
We Propose hereby to furnish material and labor — complete in accordance with above specifications, for the sum of:
dollars
Payment to be made as follows:
This proposal may be withdrawn by us if not accepted within days.
Acceptance of Proposal: The above prices, specifications and
conditions are satisfactory and hereby accepted. You are authorized to
do work as specified. Payment vjill be made as outlined above Z— �kltev vev_a
�i ii, - �-/� �
Note: Unpaid bib over 30 days subject to
1-1/2% finance charge per month (18% annual).
orq_ VA -CAA-)