HomeMy WebLinkAboutBuilding Permit #679 - 34 SAUNDERS STREET 4/23/2007Permit NO:
Date Issued: 'd
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
DESCRIPTION OF WORK TO BE PREFORMED:
2-z-95-729211 z/F_ ma(./
OWNER: Name:
Please Tr or Print ClearIA;)
7 J Phone:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE. BOLDING ERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ �� D U FEE: $ Q
Check No.: (9 � - Receipt No.: a /�
NOTE: Persons contrac4ng,4vith unregistered c"ractors do not have access to the guaranty fund
nafd of co' ntrac or
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/ ates-,-, D'
Private (septic tank, etc. ❑
Permanent Dumpster on Site ❑
`
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED
PLANNING & DEVELOPMENT ❑
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE APPROVED
11
DATE REJECTED DATE APPROVED
❑ ❑
DATE REJECTED
El
DATE APPROVED
11
r
Zoning B6ard of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
Located at 384 Osgood Street .
FIRE DEPART AEN�� � W T Du #e sits y
t �
feted a# 124[Frt=
Dimension
Number of Stories:_
Total land area, sq. ft.:
441
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
NOTES and DATA — For department use
❑ Notified for pickup - Date
.................................................................... ....................... ...................................... ............... .............
..........._
Doc.Building Permit Revised 2007
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
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)
Li 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 2.2007
Location
No. �7 Date
I
f
gCRTh
TOWN OF NORTH ANDOVER
f 9
'
Certificate of Occupancy
$
�'� s'••° E<�
Building/Frame Permit Fee
$ �—
AGMus
»
Foundation Permit Fee
$
Other Permit Fee
$�
TOTAL
$
Check # ")
20►;,
"%6 Building Inspector
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
'_i� www mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: 2045AC D 4 iV
City/State/Zip: Aee_ 7% g92/yY Phone #: v"'*11-j2V5'y`� -
Are ou 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. ❑ 1 am a sole proprietor or partner-
listed on the attached sheet. t
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
3. El 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
-Any appncant tnat cnecKs box; i must also till out the section below showing their workers' compensation policy information.
t 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 -contractors 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:
Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address: City/State/Zip:
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.
1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Sienature: l/ zyF1= Date _� �• 3 • o .Z
Phone #: 6 ;t 4 / Sy �S
Official use only. Do not write in this area, to be completed by city or town ofeiaL
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 #:
DATE 0WAX IYYMY)
A-CORD,� CERTIFICATE OF LIABILITY INSURANCE 04123/2007
THIS ERTIFICATE IS tS3UED ASA MATTER F INFORMATION
PRODUCER i781� 438-6070 ONLY AIS CERTIFICATE s "I
ND CONFERS NO RIGHTS UPON THE CERTIFICATE
R.L. ZiSta zaourancs Agency, xpc. H 7LEpRERTM� COVERAGE AFFORDED BY THE POL•ICIkS OT MEND BB�•ND OR
501 main Street
P.O. box 80032NAIC4
Stoneham MA 027.80- INSURERS AFFORDING COVERAGE
INSURED INSURERA;Granite State xnauraaCe
Benjamin Construction Company INBURBRB'Preferred MutuaL Znsuranc
i79 Reed Avenue 1
:OVERAGES 5N ISSUED TO AB FOR THE POLICY PERIOD IIIN
THIS OUIREMENT�iERM OR CONDITION OF ANY CONETRACT OR OTHER DOCUMENT WITH RESURED ESSPEC TO WFtICH THIS CERTIFICATE MAY BE�SSU DOR MAY PERTH NY
THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUB.IECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.
AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, pDLICV EF GYNE LIMITS
IBR POLICY NUMBER DATE M DATE MMIDA
iYPEOPINSURANCE 08/10/2006 08/10/2007 tsACHOCCURRE s 1,000,000
$ GENERAL LIABILITY CFR 0100558419 GE T011,2120L—
ENTED 50,000
PRF -MIS , u encs s
COMMERCIAL CRNERA LIABILITY / / $ 5,009
/ / MF.D ExP OnOgMn
CLAIMS MADE X OCCUR PERSONAL 8 ADV INJURY $ 1,000,000
G ERAL AG TE s 1,000,000
S 1,000,000
DEN -L AooRFcATE LIMIT APPLIES
POLICY 13SE OC
AUTOMOOLF LIABILITY
ANY AUTO
ALL OWNED AUTOS
sc"EOULED AUTOS
HIRED AUTOS
NON-0"FO AUTOS
oARaGE LW8IUTY
ANY AUTO
EMESSIUMBREU A UABILITY
OCCUR CLAIMS MADE
OEOUCTBLf
RNTION 5
a WORIO:RS COMPENSATION AND
RMPL.OYERW u"XiTY
ANY PROPRIFTORIPARTNFRMMUTIVE
OFFICOWEMBER FXCLUDEDT
F Yes, rk:senbe under
SPECIAL PROVt3(ONS balew
OTHER
DESCRIPTION OP
GOMBn+Eo SINOLF- LIMIT I s
(Fn weldent)
BODILY INJURY
S
(Per P—)
BODILY INJURr
$
(Per etcldMI)
aROPERTY DAMAGE
$
(PeracddeM)
AUTO ONLY -EA ACCIDENT $
OTHER THAN
EA ACC S
AUTO ONLY:
Ann i
NC 574-10-16 03/15/2006 03/JS/2007
03/15/2007 03/15/2008
sraIGLU MONS AVOID BY ENDORSIRMENTMPECIAL PROVISIONS
S.L. EACH ACCIDENT Is 1,0 9,0001
EL, DISEASE • EA EMPLOYEES 110001 000
c, ryefflh&c.VMLICVLIMrT s 1,000,000
CERTIFICATE HOLDER CANCELLATION
( y _ SHDULD ANY OF THE ABOVE DESCRIBED POLICIES BR CANCELLED BEFORE TT+E
OPIRATION DATE THEREOF, THE ISSUING INAURER WILL ENDEAVOR TO MAR
10 )Aye WPJTTEN NOTICE To ME CERTIflCATE HOLDER NAMED TO THE LEFT, BUT
PAILURE TO DO 80 SMALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY MND UPON THU
TOWN Of Ai®OVTR INsJ" rrs AGENTS ESENTATIVES.
AUTNORMED REPRBSENTATIYE
ANDOVER VIA - A ACORD CORPORATION 191
ACORD 25 (2001108)°op I a
�_.- INS025 (otoa).as ELECTRONIC LASER FORMS. INC • (800)327•�IS
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r�r.nnn At L-fioIAITTCr)Tr)-
NAME
kA-
ADDRESS
'' A _
& j? M,4
PHONE NO. 6 710 1,12
DATE
tAIOQV Tri RF PFRFORMED AT:
We hereby propose to furnish the materials and perform the labor necessary for the completion of - — -
A 7e
e/z �`
6 ra?, Ile AI- Z 0 �) 5
T,q - =
At : i� J i,I X10 7 -lir 6 keV i
All material is guaranteed to be as specified, and the above work to be performed in accordance with the drawings and specifications
submitted for above work, and completed in a substantial workmanlike manner for the, sum of
Dollars
-e (7
with payments to be made as follows:
-Respectfully submitted
Any alteration or deviation from above specifications involving extra costs.
will be executed only upon written order, and will become an extra charge per
over and above the estimate. All agreements contingent upon strikes, ac-
cidents, or delays beyond our control. Note - This proposal may be Withdrawn
by us if not accepted within - days.
ACCEPTANCE OF PROPOSAL
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 outlined above.
Signature .r"o <�V
Date
Signature
D8118 PROPOSAL
ad— MADE IN USA
NORTH ANDOVER BUILDING DEPARTMENT
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
at: sis that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
C 11, S 150 A.
Also, note Permits are required under Fire Prevention laws Chapter 148 Section
I OA.
The debris will be disposed of in:
Fire Department Sign off:.
Dumpster Permit
(Location of Facility)
�_/ �� 3z_zeQ�
Signature o Permit Applicant
Date