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HomeMy WebLinkAboutBuilding Permit #741 - 33 WOODCREST DRIVE 6/30/2009Permit NO: Date Issued:"���� rG BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received �''�t�-eD �67•�C q 1• TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building <0One family Addition Two or more family Industrial Alteration - No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other L,, LAJ! 9i41N5 "A 4Se, ptic Weil$ °. s Floodplain Wetlands Watershed District Wates/Sewer. 6 DESCRIPTION OF WORK TO BE PREFORMED: �v�lyfl� irk ra i/ �v1,G- 66 kele .1 ��/ Ji5-1141 -0�7 Identification Please Type or Print Clearly) Y� OWNER: Name:4'- Rt`ci� QY, L.-r'aA Phone: Address: 33 Ag b d Q,12� CONTRACT3RNmePhone:L . F r / s Address:= ay .. I _. 'Supervisor's Constru t fln License: L'��'136, V Exp. 'Date: � 2' , t _ Ffome_tmprovernent License:.lf�b Exp. Date: -T - ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COSTBASED ON $125.00 PER S.F. Total Project Cost: $ / j 9L' - ° FEE: $ b J Check No.: J r Recei t No.: Z ' NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 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 b _' EALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street F!RE DEPARTMENT Temp Dumpster on site yes no .Located -at 124 Main Street Fire Department 1gnature/date R COMNNTS Dimension Number of Stories: Total land area, sq. ft.: Total square feet of floor area, based on Exterior dimensions. 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 NOTE5 and DATA — (For department u ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 F Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. I_ 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 s ❑ Engineering Affidavits for Engineered products .r 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 ❑ 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 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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 Location 3 S�Ce� 77— No. Date 4�r 0 _a l TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check #� 22'163 cl::,_ Building Inspector T,p A% �i Y r Ar .M 4 74, O z � � W " w a o. a v .� �7 p v p p G o Gp G p G ` w cn w w U w a' w w c� i�. r 4 w C O d C ct5 O � C ` O N CS O V V : C O � y V EQ m c L t5 : +I V 0 d H 7 m 4 ' ; oma,•, CM li w c _ E �m O �m 3 Ag s cm m N �o = m . H O O Ey m �mo av m N O cm C y Q luwa r m Q S Z o` ' . c � o c co ts a CD :cmc •o = m CCOD cc C N �0.. H m Z F.. uiw at c Z U= •E5 vsci o COD a g cz r 4-aSm F. w w a A co z O U tqll 4 O O W O EA, W ts CD Z a O H G C I C� ,wCD O •� Y/ Q •� m CO CD 0 co CL CDL env o CL. CL. CL �a ca C CD C co CL C.3 y C O C C y is r j 1 Ina c 44�ji The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washinatnn Street Boston, MA 02111 c www nwQss.gov/din . Workers' Compensation L:siu ante Affidavit Builders/Contractors/Eieotricians/p�umbers Viicant Informsitinn Name (Business/Organizadon/Individual):_ fZ Address: 7 City/<State/Zig:p���2� Phone Are you an employer? Chwk.the appropriate box: I . a employer with 4. _ 1 ❑ I tun a general contractor and I Type of project (requites: employees (full and/or partr part-time).* have hired the sub -contractors 2. ❑ 'I am .a.sole proprietor or listed �. []New construction partner- on the attached sheet I 7• Remodeling ship and have no employees' These sub-contractors have 8. Q Demolition workingfor me in . airy capacity. workers' comp. instuance. (No workers comp. insurance . 5. P ❑ We are a corporation and its 9. M Building addition 3. ❑required.) officers have exercised their I am s homeowner doing 10.[] Electrics] repairs or additions all work. right of exemption per MOL myself. [No•workers' comp, c. 152, § 1(4), and, we have no I I.Q Plumbing repairs or additions insurance ired. t �N ] .employees. [No workers' 12.0 Roof repairs comp. insurance required..] I3.[].0ther ;Any 'Airy appiietmt that tdreeica bo�f! t must also fi[t out the section below showing their workets' bompenution policy information who submit this affidavit indicating they am doing all work and than has outside contractors most submit a new affidavit indicating ;Contractors that check this box reust such attached an additional sheat showing. the name of the sub -contractors and their workers'ccr»�ti r Fc• ; tntimnation. art an empkyer that is proW47g:workerscompensation insurance or information. } m1'P�y Below is the policy audyob site .. . lj{ r /�� Insurance Company Name: 43-r )1P ai40, �y.���✓,���,C Policy # or Self -ins. Lie.J/ Expiration Date: /2i kA'; Sob Site Address:_ 33 i Z-11f%rte City/State/Ztp:_�✓�% �.�/� 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 5250.00 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. ! do hereby certify under the pains and penalties of pedwy that the information provided above is true and correct ficial use onfy, do not write in this area, to be completed by city or town officio! City or Towyn: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Cleric 4. Electrical Inspector 5. Plum 6. Other bing Inspector LOn Person• Phone #: Information a nd Instructions Massachusetts General Laws. chapter 152 requires all emp Ioyers 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 legai`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 apaxtments 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 appurtenarit 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.oC 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 perfomrasuce of public work raitil-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 compimtely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es),a=ud phone number(s) along with fiheir certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to cavy 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' oompensation policy, please -call the Department at the nurnber iisted below. Self-insured companies should enter their sett=insurance license number on ihe' appropriate Tine. 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/Iicrose 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 band affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. When 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, pimse do not hesitate to give us a call. The Departmont's address, ieiephone and fax number. The Commonwealth of Massachusetts Department of lmdustrial Accidents Office of Envssti ations 600 Washington Street Boston, MA 02111 TeL # 617-727-4900 ext 406 or 1-8.77-MASSAFE Fax # 617-727-7744 Revised 5-26-115 www.mass.gov/dia Client#• 537006 _ ACORDTM CERTIFICATE OF Mtu... IN1 LIABILITY INSURANCE T-0D4AjT0E7(mj2m0/D0Dq"yy) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION USI Ins Serv., of MA Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 12 Gill St., Suite 5500 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P O Box 403 - ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Woburn, MA 01888 INSURERS AFFORDING COVERAGE NAIC # INSURED Medford Roof dba Medford Vinyl Products INSURER A: Hartford Underwriters Insurance Co 30104 INSURER B: 45 Tyler Ave. COMMERCIAL GENERAL LIABILITYDAMAGE CLAIMS MADE FlOCCUR INSURER C: Medford, MA 02155 INSURER D: MED EXP (Any one person) $ PERSONAL & ADV INJURY $ INSURER E: COVERAGES 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 (MMIDDIYY POLICY EXPIRATION DATE MMIDD/YY LIMITS GENERAL LIABILITY _ - -- EACH 1 CH OCCURRENCE $ COMMERCIAL GENERAL LIABILITYDAMAGE CLAIMS MADE FlOCCUR TO RENTcc.ED"an $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ POLICY JEC LOC AUTOMOBILE LIABILITY - - ANY AUTO - - _ COMBINED SINGLE LIMIT $ (Ea accident) ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per person) $ HIRED AUTOS NON -OWNED AUTOS BODILY INJURY $ (Per accident) PROPERTY DAMAGE $ (Per accident) _ GARAGE LIABILITY - AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO AUTO ONLY: AGG $ . EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ - AGGREGATE $ OCCUR FICLAIMS MADE $ DEDUCTIBLE $ RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY 08WEIF6665 - 12/08/08 12/08/09 WC STATU- OTH- E.L. EACH ACCIDENT $100,000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? If yes, describe under E.L. DISEASE - EA EMPLOYEE $100,000 E.L. DISEASE -POLICY LIMIT $50U,000 SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS EVIDENCE OF INSURANCE-insured's Operations: Roof/Floor Contractor Town of Stoneham Building Inspector 35 Central St Stoneham, MA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL _3 n DAYS WRITTEN 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 ���� '1-1 1 OT Z 9bJ37Z83Z/M337Z801 MECCD © :CORD CORPORATION 1988 \ % \ ■ O \ CA ; 0 ) § \ $ / CO, 2 / u \ I- =, o $Fm . ■ % c ©: 4 \» c ra ��c7°@—«.��«« . k 2< \ � f�~ k= m<� � m. ± o ...w. w< ¥ - - - & L Lu / u 0 _ k k 3 \ j ■ O \ CA 2 �Rrg� \ § o $Fm ©> t� , : ic k 2< \ d k= w �' a kx ■ 0W ,Wy & This form satisfies 90 basic renerk. See ofthe state's Home lmprovmneut GmtraMWL4w (MGLchapter)42A)• but docs not Include stattdnrd laoguageto protect hottteownets Stxlc•tegai advice if necessary, q . lzrsonplttmtittg home atptwemcoc should first obtain l copy of •'a Masmcltaseps C0Da11Oq guide to h°°m msPrm'tmlcat" bcforc OM -9 to any wort on yourresidcnce. You may obmina irce copy by calling the Ofittx ofCoasumerASttns andBvsiltrss RepiadonsConsum:rinformtitionHotlinear617-973-=7ar1_aae_na, •, _ Homeowner information not us:a Contractor Information .css ndoress (most indude a sur_t address) 3D-Aaa�a5eaj'7� 47�r ao�_7rsP, 1 ro _/ Evmtttgl'hoae �fd�t � jS�S ty/Tnwa State Zip Cod: ►,tm+infi Address p, tbrfcate fiat. alcove) -�3s7 o aG y�7Ss in>Soes, Pimne edcal 6oplaye ID or s -s. Nu >+.•.evua,vanoau�o. ��PDYp�hc^,.timoa �..amcx,t mm,emnbre. I The Contractor agrees to do the fallowing -work for the Homeu ern`�� ZTiGGClI'-tai-SfE77"r1RiTir _ 4/X1zojd � iii �0� Required permits e dy►D L .Q ( � �P 7i� folia �� i 6 C+� iO rtr% °� building p�hs arcrequired Proposed Start and Comdidetion Si )hernia . LL y t!m conuacrorac tie hatueowace eget., be adhered ro The following schedule will ure-fbt:ir own permits >10 be 1Olett "'c"'"s�'as beyond the conna tuns control arise re Guaramtlr.Fttni3 provitsions oI 2A..j ao Date when contractor will begin wnuacted wort• d a Dao wnca contracted work ,rill be substantial)• completed Total Contract Pratt and Payment Sebedule Tne Cantmemr agrees To Perform the wad,, famish the mnraial and labor spc^i fed above forth-- total sum of S aV Paymenu will•bc rhotic aceo�ins to rim foli s Sbbo `� u S owiag schedule; rAnr��� upoa sitmiug cotutsct (-1 m extra d 113 of frac tutu' contract Price or the � cast of spxiel order items, whichever is S bOb act or upon Completion of /� _ �,/f Fteator) 'oe,—� orupaoePmPierionof !i/J6IV je--l-IOty s 90 upon completion of the eounua (I.aw forbids dmanudtag full Tac tollowittE mnrw iaV Payment thrid Contract is completed to.both•pam•'s satist�_rion) orttecd h,farc tbaeaatraaul rnt taestda soxial S .. tvor's•'bepins in order S'- to be paid for to ut='be eompledtm sdt_wwe.(•) to ba paid for NOTLrS: (•) Including a0 famta c6atFe Yom,) )M renal that nm cceeed the pdcedepomar lbf or iLepaymcm rog-t6 b)• the cant aarr before,rad; bpas arcane of (al onoUtird aftim total coaaaq whicia must br spxcal ordered in advmmto mat be I oeatal mst of soy spQni can. 00111PICOM schedule. rpmmtor auTam orad materia! G W vro-Isft" retsw rim bd dadBvtb Sahcnnirnetars - I7ea eontmexor agrees m be SOlely responsible forco� No ec 11 r M of the era w m o eked r contra Padyfsubconuactor uWiwd b)• the eommemr. The caauntaor further omplesdoa of the work described r ordlexs of the oetioas of on. third feria and e rnr Lis ro i>c sdleiy tcsPonnbic for all P837"cUts to all subcontractors in, c0ntMMCOMMct not implmcey - upon signing, this doaunem becomes a binding contract shad not imply that may Gen or other � coaaaet arida dew. litdtss mhenvisc noted within _ carefullyon before si sx�4' inmost has bene Iaccd an flee rcsittacc Review the following cautious and nnucns Loring Ibis contract. Doan bnPtctsured-inta signing the contract Take tithe to tend and fitti Niiika m tttn err s - Y understand iL Ask questions if something is unclear. v as n Thte law ltewt'on by to be tee—red acd tcc the O --Director ofHome It. *aN anon 4o. unr"vcrncnt contractors and rci�nation by tvtitiag ro'the flircctorat On-- Ashbttrmn place, Prot�eat ConuactorRegisoatioa You may inquire about contractor 1-800-2?3 0433. Roam 1301• Baswn, MA 02108 or by calling 617-727-3200 Does the contractor have ' v to ''.now your lights fetal tru9ttarta Chttl ro r= that your enaa'aetor is ProP�l)' iasuted respati9iolCon Read t>sr. htrpotmnt lofotmedon on tit ret txsc side of this form sad Guitb ro aha Home Contractor get a copy of rho Corttuma You may -acei this agmement if h bas beam sidpted at a plttcc odea than the co comtaetar in writing at hu/hameio office err m actoes normal lace, orb ' hirdbminrss day falimvirt the s' branch office by utnta� mail Posted_ dry. yl P "nO�. Provided you notify the g tgtiutg o£tbis aloce'" l Se" the ottaebed notice of t. sent or d--"vcry, not later than midnight of the DO NOT SIGN THIS CO �ror�edinrioa form Toren. acpiaaation of Ibis right Two idanealtopiC afatcamwaq tmgtrK NTRACT IF TIEiEREr ARE 4,Ny BL rat �vxtaeaaauaoa. oa:aprmoraas,eeemaa�„ra�. rntaa� ANK SPACES_.. covrsaruta x rpt tr eh. mnaeuar. Hatroow err-S..signnmm �/ % /l� %