HomeMy WebLinkAboutBuilding Permit #652-13 - 330 MIDDLESEX STREET 4/9/2013TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit N0: J I Date Received
Date Issued:
IMPORTANT: Applicant must complete all items on this page
- ---. -•_- - --- --z.___._
PROPER; OWNER --- -
f"' Print' 100 Yearriold structure _ yes` no., .
MAP NO:._. PARCEL:_�ZONINGiD.ISjTRIGT. HistoricDistrict yes no:
Machine, Sliop Villages yes, n02
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
R -One family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
"epair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
11 Septic,, ❑0e1l
❑ Floodplaih. ❑ Wetlands
❑ WatershedbDistrictil
❑°Water/S:ewer
DESCRIPTION OF WORK TO BE PERFORMED:
Identification Please Type or Print Clearly)
OWNER: Nam
AddrP-qG-
7�-'R-07 _2 q zk
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CONTRACTOR? Name: W Phone-.,�o
Address:..lt? v.. _�r C _
`Supervisory'slC_onstruction;License:,(t� 4 9 Exp., Date:
Home lmprovement;License:: l/ 3_51 3 Exp. Date;
ARCHITECT/ENGINEER
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: $ X 3 FEE: $ 3n�
Check No.: / ���� Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
'Signature�ofAgent/®wner ... : '{ :. Signature+of,contraetor�;.-_ v:. .�- :' �+'
Plans Submitted 0 Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
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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
u Building Permit Application
u Workers Comp Affidavit
Li Photo Copy Of H.I.C. And/Or C.S.L. Licenses
u Copy of Contract
u Floor Plan Or Proposed Interior Work
u Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
u Building Permit Application
o Certified Surveyed Plot Plan
u Workers Comp Affidavit
u Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
u Mass check Energy Compliance Report (If Applicable)
u 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)
o Building Permit Application
o Certified Proposed Plot Plan
o Photo of H.I.C. And C.S.L. Licenses
u Workers Comp Affidavit
u Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
u Copy of Contract
Li Mass check Energy Compliance Report
u 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 subm;tted with the building application
Doc: Doc.Bui!ding permit Revised 2012
-V
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
PLANNING & DEVELOPMENT
COMM
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE REJECTED
DATE APPROVED
El
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes .
Planning Board Decision:
Conservation Decision:
Comments
Comments
e Water & Sewed" COnnectiOn/Signature & Date Driveway Permit
I., DPW Tows Engineer: Signature:
Located 3M Usg000 Street
FIRE DEPAftfMENT - Temp Dumpster on site yes no
Located at'124Nain'Street
Fire Deparfinen -signature/date
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
DATER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A -F and G min.$100-$1000 fine
NOTES and DATA — (For department use
EJ Notified for pickup - Date
Doc.Building Permit Revised 2010
Location 4F I -J AA—
No. �G,� Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy
Building/Frame Permit Fee
$ '76—
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Foundation Permit Fee
ok.
Other Permit Fee
TOTAL
Check#
26262
Building Inspector
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DOB NVOICE
TO
ADDRESS
t
DATE ORDERED
ORDER TAKEN BY
PHONE NO.
CUSTOMER ORDER #
JOB LOCATION
JOB PHONE
7� 777'q9 �-25,"
STARTIN DAT
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TERMS
CUSTOMER APPR
SIGNATURE
AUTHORIZED SIGI
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TOTAL LABOR
TOTAL MATERIALS
TOTAL MISCELLANEOUS
SUBTOTAL
TAX
GRAND TOTAL
CERTIFICATE OF LIABILITY INSURANCE
03-11/-2013
THIS CERTIFICATEIS 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 HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONALINSURED, the policy(les) must be endorsed. If SUBROGATIONIS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statementon this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER
EASTERN INSURANCE GROUP LLC/PHS
087059 P:(866)467-8730 F:(800)308-5459
CONTACT
PHONE FAX
(AIC No Ext): (866)467-8730 (AIC,No): (800) 308-5459
301WOODS PARK DRIVE
ADDRESS:
INSURERIS) AFFORDING COVERAGE NAIC #
CL INTON NY 13323
INSURER A : Hartford Fire Ins Co
INSURED
INSURER B
INSURER CINSURER
WEITZ CONSTRUCTION
D
1605 ANDOVER ST a
TEWKSBURY MA 01876
INSURER E
INSURER F
CLAIMS -MADE U OCCUR
X General Liab
COVERAGES CERTIFICATE NUMBER: 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. 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.
INSR
LTR
TYPE OF INSURANCEPOLCY
INSR
WVD
POLICY NUMBER
(MMIDDIYYYY{
EXP
(MM/DDIYYYY)
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,000
PREMISES (Ea occurrence) 5 300,000
COMMERCIAL GENERAL LIABILITY
A
CLAIMS -MADE U OCCUR
X General Liab
_
I__I
_
H
08 SBA KJ4015
03/24/2013
03/24/2014
MED EXP (Any one person) $ 10,000
1 PERSONAL &ADV INJURY $ 1,000,000
GENERAL AGGREGATE 5 2,000,000
FENIT AGGREGATE LIMIT APPLIES PER:
PRODUCTS
PRODUCTS - COMP/OP AGG S 2,000,000
POLICY U PRO
u U( LOC
S
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT $
(Ea accident)
ANY AUTO
BODILY INJURY (Per person) $
INJURY (Per accident) $
ALL OWNEDI ISCHEDULED
AUTOS 1I AUTOS
HIRED AUTOS I NON -OWNED
u AUTOS
L I
HBODILY
PROPERTY DAMAGE
$
(Per accident)
$
UMBRELLA LIAB U OCCUR
EACH OCCURRENCE $
EXCESS LIAR CLAIMS -MADE
IJ
U
AGGREGATE $
DEDI I RETENTION $
$
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBEREXCLUDED7
NIA
u
I WC STATU• 0TH -
TORY LIMITS ER
F.L. EACH ACCIDENT v
E.L. DISEASE - EA EMPLOYE $
(Mandatory In NH)
If as, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE -POLICY LIMIT $
uu
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required)
Those usual to the Insured's Operations.
CERTIFICATE HOLDER CANCELLATION
ACORD 25 (2010/05)
0 1988-2010 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered matl(s of ACORD
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
Wells Fargo Bank, NA #k936
BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE
Its Successors and/or Assigns
DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZE R PRESENTATIVE
a'z--
PO BOX 100515
FLORENCE, SC 29502
ACORD 25 (2010/05)
0 1988-2010 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered matl(s of ACORD
The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
600 Washington Street
Boston, MA 02111
av www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):,
Address:
City/State/Zip: %� Phone #: �' 7 2 G s�
axe you an employer? Check the appropriate box:
❑ I am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
® I am a sole proprietor or partner-
listed on the attached sheet. #
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
❑ 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.❑ Roof repairs
13.❑ Other
iy applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information.
omeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
ntractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
►n an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
brmation. /n n
urance Company Name:
.icy # or Self -ins. Lid. #: Expiration Date: 3/ 2 1 tot q
Site Address: 3 3yk City/State/Zip: I�
:ach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
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
ip to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
estigations of the DIA for insurance coverage verification.
i hereby cert tinder the pains and enalties ofper�jaiar/y t/hat�the information pro vi eed abov is true and correct
nature: l 1 Date: `it�-3
?fficial use only. Do not write in this area, to be completed by city or town official.
�ity or Town:
Permit/License #
ssuing Authority (circle one):
. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
i. Other
1_4_ .,, --_.. '01,....,.44.
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 -contractors) 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.
he Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 021.11
Tel. 0 617-727-4900 ext 406 or 1.877-MASSAFE
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i - C6nstruction Supervisor License
`-cense: CS 12649
IVA h,
.?GERALD LtWEITZ {
1605 ANDOVER ST
TEWKSBURY, MA 01876. U1,
'
Expiratioh: 9/8/2013
'trnurn.ci Nice Tr-#- 1332
Ite
' OPrce'of Consumer r' hairs & Bdsiness R
r' HOME -IMPROVEMENT CONTRACTO
� Reg istratio n:.-,113513
'E.xpirkion: .6%24%2013 P.riva `t
W fi Z COIVSTRU - ION II
i_
GERALD WEITZ
a `16.05 AND 'ST. — ,
! N TEWKSBURY; MA01876 Undersecre '
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