The URL can be used to link to this page

Home My WebLink AboutBuilding Permit #681 - 345 CHESTNUT STREET 6/9/2009TYPE OF IMPROVEMENT PROPOSED USE Residential _ Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial X' Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: ��A�2 �c� LiNO� �o� /�-DD N� �-�c'K:.✓t EI ,�-�ciN! . �-rZ�si�vw� Identification Please Type or Print Clearly) OWNER: Namejogr 4 S uN L16Xy7,1-r- Phone: 1 F7 Address: 3g�" ehi4q77y-,-T ST CONTRACTOR Name: W,tqyr 7' Phone: �r7V7?/ � Address: Z I)VIOA4o at,iy Supervisor's Construction License: OV02Z -3 Exp. Date: t /1-0/ 4) Home Improvement License: f 113 if4�13 Exp. Date: 2 L�-7 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: $ FEE: $ UD —� Check No.: 311 Receipt No.: —Tsoli NOTE: Persons contracting with unregisjere#,coAtractors do not have access to the g#aranffr,#4 co 22U>9 Building Inspector �L`" � ,v,/ Sf" Location No. (� 01- Date NOR7H TOWN OF NORTH ANDOVER Oft„•° '',�O • • Ow O? F 9 Certificate of Occupancy $ �� ;'•�°';c�' +cMus Building/Frame Permit Fee $ Foundation Permit Fee $ —, Other Permit Fee $ TOTAL $ Check # 22U>9 Building Inspector 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/SA40 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 HEALTH Reviewed on Signature COMMENTS V 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: -Si Located 384 Osgood Street FIRE DEPAR Tri Temp Dempster on site yes no Located a 124 Alai Fire Department 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 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 2008 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) ❑ 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 m m m m YI �m v/ m v■ F d C � d � o CD az CA CCD O a r FF c .L ?' CO) O O v CD CD o CL CD Er mo C CD y� d cz O CA CD I � v y O 'C CD z oCD t CD L6 N il r 2 Cr\ 0 VI C 0 CD 0 • O _ m 0 c d _ V2 m m c O OCCL CAN N z O m o Vl ^y a1 h7 DJj N .0 O , I� ^D i• m o Vl ^y a1 h7 O CD: :L _ a� i• Cl) CM, O O tw rl O CD (n Vl ^y a1 h7 O O i• O O O tw rl O `� o ^ � 7 Z t" z !"1 o 0 0 � � O qo onq 0 The:_Com»�onwalth of Massachusetts Department of Industrial Accident -- OffIceof. Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contrwetors/Electriclans/Pltlnihers nnlica.n:t -Information PleaseTA& Le!?lbly Name (Business/Organization/Individual): /"I f C /MQ Address: u u M A- 0?fi11) Phone Are you an employer? Check the appropriate box: 1J91_1 am a employer with 1 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ 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. employees and have workers' [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § l (4), and we have no employees. [No workers' coma. insurance required -1 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 V~4 .Any applicant that checks box #1 must also fill 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 state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. . Insurance Company Name: 5AIe -9 logo -PC" 4' aJJV79-e_M 60 Policy # or Self -ins. Lic. #:1'- i? a S(z(,/O 7 Expiration Date: ( 6 /1 Job Site Address: CA�M`7' S-7— City/State/Zip: ND Avo O V git-, !/t , d?r 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. I do hereby certify under the,pains avid penalties ofperjury that the information provided above is true and correct Official use only. Do not write in this area, to be completed by city or town official 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 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-contractor(s) 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. or 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 of stamped or marked by the city or town maybe provided.to the. applicant as,proof:that..a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each year. Where ahome, 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, please do not hesitate to give us a call. The.Department's address, telephone and fax number: The Commonwealth of Massachusetts J2epartrrtent of Industrial Accidents Office of Investigations 600 Washington Street Boston; MA 02111 Tel #' 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617--727-7749 Revised 4-24-07 vry r,mass.govfdia aNGM INSURANCE COMPANY INSURED West Street, Keene, NH 03431 Telephone: 1-888-646-7736 CONTRACTORS POLICY DECLARATIONS Named Insured and Mailing Address ANDOVER RENOVATIONS 2 DUNDAS AVENUE ANDOVER, MA 01810 Agent: BYETTE INS AGENCY INC AGENT PHONE : 978 851 6678 POLICYHOLDER INFORMATION Policy Number: MPJ0418M Account Number: CACP 13969 Producer Code: 200113 Named Insureds Business: CARPENTRY RESIDENTIAL Entity: INDIVIDUAL Policy Term: 12 Effective: 03/06/09 (12:01 A.M. Standard Time at the address Expiration: 03/06/10 of the Named Insured stated above) In return for the payment of the premium and subject to all the terms of this policy, we agree with you to provide the insurance as stated in this policy. See the attached schedules for Description of Premises, Property Coverage, Optional Coverages, Forms and Endorsements applying to this policy and Mortgagee Schedule if applicable. BUSINESSOWNERS LIABILITY COVERAGE LIMITS OF INSURANCE Liability & Medical Expenses - each occurrence S 1 1000,000 Personal and Advertising Injury Limit S 11000,000 Products -Completed Operations Aggregate Limit S 2,000,000 General Aggregate Limit S 2,000,000 Fire Legal Liability - any one fire or explosion S 500,000 Medical Expense Limit - per person S 10,000 Business Liability and Medical Expense. Except for Fire Legal Liability, each paid claim for the above cover- ages reduces the amount of insurance we provide during the applicable annual period. Please refer to section DA. of the Businessowners Liability Coverage Form. For policies subject to premium audit: Annual Audit Applies. Commercial Inland Marine Coverage Part $ 63 Estimated Annual Premium: S 1,570 TOTAL PREMIUM AND CHARGES S 1 633 , �i Countersigned: __ t ; By: 64-5470(9/00) 03/19/09 NEW BUSINESS DN �J SAVERS _] Workers Workers Compensation and PR PERTY Employers Liability Insurance Policy --CASUALTY INSURANCE 11880 College Bvld, Suite 500 COMPANY Information Page Overland Park, Kansas 66210-1224 —A, JrronAC lnvrvar GrniiV _ Policy Number Renewal Of Policy Period Agency AR0426107 New 10/01/2008 to 10101/2009 0000750 Item Named Insured and Address Agent 1. Scott, W Michael Byette Insurance Agency, Inc. 2 Dundas Avenue 853 Main Street Andover, MA 01810 Tewksbury MA, 01876-1854 FED ID Number: 042915070 NCCI Carrier Code No.: 31771 Risk ID No.: 0201186 Other workplaces not shown above: None Entity: Individual 2. Policy Period: 10/01/2008 to 10101/200912:01 am standard time at the insured's mailing address. 3A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation law and any occupational disease law of each of the states listed here: MA 3B. Employers Liability Insurance: Part Two of the policy applies to Employers Liability Insurance for work in each state listed in Item 3A. The Limits of Liability are: Bodily Injury by Accident $100,000 Each Accident Bodily Injury by Disease $500,000 Policy Limit Bodily Injury by Disease $100,000 Each Employee 3C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: All states except ND, OR WA, WV, WY and states designated in Item 3A of the Information Page. 3D. This policy includes these endorsements and schedules: See attached schedule. 4. The premium for this policy will be determined by our Manual of Rules, Classifications, Rates and Rating Plans. All Information below is subject to verification and change by audit. Adjustment of premium shall be made at: Policy Expiration Classification of Operations: See attached schedule Minimum Premium: $500 Expense Constant: $338 Deposit Premium: $2,788 Total Estimated Annual Premium: $2,788 Countersigned 09/26/2008 By DATE Authorized Agent This Information Page with the Workers Compensation and Employers Liability Insurance Policy and Endorsements, if any, issued to form a part thereof, completes the above number policy. Date of Issue: 09126/2008 Insured Copy RENMB001 WC 00 00 01 SV (12198) v� Boa'ilyr iiYlOi�� it ffo`n n an la�'ifs -`�=— HOME IMPROVEMENT CONTRACTOR Registration: 113863 Expiration: 7/19/2009 Tr# 130331 " Type: Individual W MICHAEL SCOTT W MICHAEL SCOTT 2 DUNDAS AVE ,Q , ANDOVER, MA 01810 Administrator BT�o�m mg eg� uTaho+Cs an tan arc s Construction Supervisor License '/ License: CS 44723 �s Expiration: 1/11/2010 Tr# 12250 Restriction: 00 W MICHAEL SCOTT 2 DUNDAS AVE ANDCAIER, MA 01810 Commissioner o N 5 T R -v C:r t ern i 4 q,7 2.3 - it T":77t. # i J 3 Fb 1 2 DUNDAS AVENUE ANDOVER, MA 01810 470.2640 We Michael Scott Andover Renovations Additions d Carpentry o Remodeling Page _4 of L PROPOSAL SUBMITTED TO PHONE DATE ,�Os 7j STREET J00 NAUE 35F c i4&s7wyr ST CITY. STATE AND ZIP CODE JOB LOCATIO93 A/ 0v yog rel ev r ARCHITECT DATE OF PLANS I – — - - _t JOB PHONE We hereey 0r000" to furnish metsrlale and labor necessary tot the completion of. 17 riL ��ri� uIc D�iZ /,S fru Alda lv AC cTr ►' w g/M00w o✓ifnT �XTL d2�n2. WE PROPOS_Ehereby to furnish material and labor — completo in accardarim with above specifications. for the turn of: Arw 1-7 ve, vi3 '47� A'to Payment to oe mace as follows: dollars ($ All material Is guaranteed to 00 as specified. All work to to completed In a sub- stantial workmanlike manner according 10 specifications Submitted, per standard Practices. Any alteration Or deviation trait above specifications involving extra costs will be executed only upon written orders. and will become an extra charge over and above the estimate. All agreoments contingent upon strikes, accidents or Celayf beyond our control. OvNner to Carry fire, tornado and diner necessary in. suranca. Our workers fire fully covered by Workmen's Compensation Insurance. Awhonad SIptalun gate: This proposal may be mtadaat by ea if not accepted ettAm r days. ACCEPTANCEaresatisfactory OFaPROPOS ey The above You are authO izeas. tosdo hcondi- tions r as specified. Payment will be mace as outline above. SitMtere J