HomeMy WebLinkAboutBuilding Permit #930-14 - 352 FOSTER STREET 6/20/2014BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#:n 0-k Date Received
Ah_
Date Issued: 1-201 t4 "l< �ACH
1 IM�ORTANT: Applicant must complete all items on this page
LOCATION 5 o� fo_s4 , 9 K , /
/ PrinV",
PROPERTY OWNER
J� V-,
Wck IS
c�5'�
Residential
MAP PARCEL:
0 New Building
Prfnt
ZONING DISTRICT:
100 Year Structure
Historic District
yes
yes
Cno
no
El Industrial
0 Alteration
No. of units:
Machine Shop Village
yes
nq
q
TYPE OF IMPROVEMENT
PROPOSED USE
C17X
c�5'�
Residential
Non- Residential
0 New Building
El One family
I -C\
0 Addition
11 Two or more family
El Industrial
0 Alteration
No. of units:
11 Commercial
N-Ke'Pair, replacement
11 Assessory Bldg
11 Others:
0 Demolition
0 Other
0 Septic 0 Well
0 Floodplain 0 Wetlands
0 Watershed District
0 Water/Sewer
I
OWNER: Name
Addrp-,-,-
DESCRIPTION OF WORK TO BE PERFORMED:
ldentificAion - PI e Type or Print Clearly
7
Contractor Name:
J164 e� L,0r, iW Phone:
C17X
c�5'�
a-33�
Address:
I -C\
ka__
0 711f AFi-cl �� �1(1 L.
Supervisor's Construction License: Exp. Date:
Home Improvement License. (b? Exp. Date:
ARCHITECT/ENGI NEER 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: $ FEE: $ 1 � 2 -
Receipt No.:
Check No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund
_Sb --- ---
,,_gnature of Agent/Owner gnature of contractor/�
Location �6t
No. Date
Check 4t,�—)
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $h;:�L
Foundation Permit Fee
Other Permit Fee
TOTAL $
& Lc-,
t
Building Inspector
r
Plans Submitted El Plans Waived El Certified Plot Plan El Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer 11
Tanning/Massage/Body Art F]
Swimming Pools
Well El
Tobacco Sales 0
Food Packaging/Sales El
Private (septic tank, etc. El
Permanent Dumpster on Site 0
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On
Signature
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH 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 Con nection/Sicinature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signatureldate
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.$100-$l 000 fine
NU i t5 ana UA I A – (11 -or department use
LI Notified for pickup Call —Ema
Date Time Contact Name
Doc.Building Perinit Revised 2014
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
Li Workers Comp Affidavit
Li Photo Copy of H.I.C. And C.S.L. Licenses
• Copy Of Contract
• Floor/Cross Section/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)
L, Building Permit Application
ii Certified Proposed Plot Plan
ij 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
La Mass check Energy Compliance Report
La 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
Doe: Building Permit Revised 2014
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The Commonwealth ofMassachusefts
Deparhne-ntofladustriqlAccidii�ts
0 _flee offfivesfigations
600 Washington Street
Boston., Am 02111
vmmuss.govIdla
Workeirs' Compensaflon bmurance Affidavit: Buffders/Contr.actorsfElectricians/PliO*berg
AnnUcant -bformafion Please Print LegibLy
Name (Businessiorganization&dividual):
Address:
City/State/Zip: t0ge&y-i KAu---- Phone4:
Are you an employer? Check the appropriate bpx-
Type of project (required):
1. rl I am a employer with —
4. Ff I am a general contractor and 1
6. EJ New construction
employees (fall and/or part-tima)-*
2— El I am a sole proprietor or partner-
have hired the sub-confractors
listed on the attached sheet. T
7. El Remodeling
ship an&1avano.employees
These sub -contractors have
8. ElDemoution
7
WoAdng forma la. any capacity.
workers, comp. insurance.
5. E] We are a corporation and its
9. Building addition
[No work -ors, comp. insurance
xequired.]
officers have exercised.their
10.0 Electrical repairs or additions
3. Ell am a homeowner Ung all WO'k
right of exemption p ar MOL
1111 Pluinbingrepairs or additions
myself. EEO workeys, comp.
c. 152, §1(4), andwahaveno
UP RoDfrepairs
insura-acareqa1re4.1 T
employe6s. [No workers'
13.0 other
comp. insurancerequired.]
Mnyapplicautthat checks boxffl must also Moutthe section bef(5wshovingtheirwbrkers'compensatloiLpoliGywonnation.
firomeownerawho submit this affidavit indlcatlnjf�ey Pi� doing aU worX and then hire outside contractors must submit anew affidavit indicatifig such.
TContraotors; that cho6k this box must attached an 9dditional sheet showing tho name of the sub -contractors and their -workers' comp. Policy information.
lam an employer that lsp�ovldlng WoAfers'com m erq s el w v lie an
pensation insuraneefo y loyee . B o is e o y i1joh site
Nformation. L—
Insuxance Company N
/'t- r'- U--)
Policy # or Self . ins. Lio. 9: /,A)fp F> /Y 3'T 0 1 Expiration Data.
lob Site Address-,— pity/state/zip: YJ A-4(30
Attach a copy of the workers' compen�atlon-pollcy tleclaration page (showing -the policy number and expiration date).
Failure to secure coverago.asre I dunder Section 25A ofMGL o. 152 can lead to the imposition of criminal penalties of a
- Tune.
flue up to $1,50 0.00 andlor one�year Imprisonment, a� well as civilpenaltias in the form of a STOP.WORK ORDER and a flne;
ofupto$250.00adayagabistthavi,Dlator. Be advised ffiat a copy of this statement maybe forwarded to the Office -of
investigations of the DIA for insuranco coverage verification.
I do hereby thepains andpenaftles ofperjury that the inflormationprovided above is true and correct.
Official use ayi4l. vo not write in this area, to be com
pleted by clify or town official
City or Town: Permft/License#
Issuing Authority (circle One):
1. )3oard of Health 2. Buildingf) epartment 3. Cftyffown Clerk 4. Electrical Inspector 5. Plumbing hispector
6. Other
CoatactPerson: . Phone
Information and Instructions
Massachusetts General Laws chapter 152 req-uires all employers to provide workers, compensation for their employees.
Parsua�t to thIsstatute, an ernVoyee is deflned as "...everypersonhi. the service of mother under any c6tract oThixo,-
express or implied, oral or written."
An empfoyWls defined as "an hadividualpartnorship, association, corporation or other legal entity, or any two or more
of the f6r�jo��uj engaged in ajoint enterprise, and includingtho, legal representatives of a: deceased emplpyg, or . the
xedelv&r oitaistee'of` aniudividual, partnership, askolation or other legal entity, employing employees. )Sv�averth6
owner of a dwallirig hous a having not more, than thre a ap artments and who res id us thoroh4 or the o coup ant of the
dwaag house of another who employs persons to do maintenance, construction or rep air work'on su�h dwcDhg house
or on the groua ds or building appurtenant thereto shall not b e c a as a of such employment b a do ome d to b a an employer.
MGL chapter 152, §25C(6) also states that "every state or lo'cal lie-ensing 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 15�, §25C(7) states'Weithor the commonwealth nor any of its political sub(ivisions shall
enter into quy contract for the performance ofpublic work until acceptable evidence of complipace, with the insurance
requirements of this chapter have beenprosented to the contracting authority."
Applicants
Pleas,e,flll out the workers, componsaRon affidavit completely, by checking the boxes that apply to your situation and
if
.U6c0jsarY., B"applysab-contrartor(s)name(s), aftess(es) and phone number(s) along with their coMcato(s) Of
insurance. Limited Liability Companies (LLQ or Limited Lf abilitY Partnerships (LLP) with no employees other than the
members or p�a�ars, aronotroquiredto carry workers, compensation insurance. If mL1_C orLLP does have
employees, a policy is required. B a advised that thi� affidavit maybe submitted to the Department of ludustrial
Accidents for confitmation. of insurance c
overage. Also be sure to sign and date the affidavit. 1ha affidavit should
be returadd to the city or town that th'a applicatim for the permit or license is being roqaaAoq,)aot the Dep'artmont of
Industrial Accidents. Shouldyou have any questions regarding tho law orif you are xeq*ed to ob'taia a*arkorsl
compOnsationpolicy, please call the Department at the, number listedbelow. Self-h2sured companies should enter their
self-insuran ca license number on the appropriate lfrio.'
City or Town Officials
Please, be sure that the affidavit is complete, andpriatchogibly. The Department has provided a space at the bottom
of the, affidavitfoxyOuto fill out in the event the Off cO Of Investigations has to contactyouregairdingffie applicant.
Ploasle be -sure to flu in the permit/license, number which will be used as a reference number, 1haddition_,mappi1cant
thatm-astsubmitmultiplopolmit/license applications in any giyenye I ar, need only submit one. affidavit indicating cutr&.nt
policy inforruation (if necessary) and imde.r "Ibb Site, Address" the applicant should write "all locations in
tow1r)."A:6o' ---_,.(c1ty or
py ofthe affidavit that has been officially stairiped or marked by the city or town maybe provi&,d to the
applicant as proof that a -valid affidavit -lion fflo�or Unro permits orlicerises. Anew affidavitmu'stbo fiffeLd6ut each
year.'Whera a home owner or citizen is obtaining a license or -permit not related to any business or comm venture
(i.e. a dog license orjJormit to bum leaves oto.) said -person is NOT required to complete this affldavit.
The Office of investigations . would Eke to thankyou in advance for your cooperation and shouldygahave myguesjio�s,
please do not hesitate, to give us a call.
The Department's address, telephone and fax number:
Tho Cm-MOU
WGaft� Of Y_;9��Sq C�,A-U
Offloe Of Imstigatiolm
6b 0 Wnbingt(a 8 -(Te, ot
B oston, MA 021 If
617-7-2,Z4900 o A 406 Qx- 1-877�MAS
SAF
Revised 5-26-05 Fax # 617-727-7749
_WWW=w,g0V1(Rd
A CERTIFICATE OF LIABILITY INSURANCE
F777DDIYYW)
3/6/14
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CE9rIF1CATE 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 CE91'IFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) 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 thiscertificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER
A -Costa Insurance Agency, Inc
2 Franklin Commons
Framingham, MA 01702
CONTACT
NAME:
FAX
(508) 875-3488 A . No): (508)
Ir 875-9388
E_MAJL
ADDRESS: jon@a-costains.com
ATE $ 2,000,000
GENT AGGREGATE LIMIT APPLIES PER
17 POLICYF PRO -
ECT LOC
INSURERS) AFFORDING COVERAGE NAIC #
INSURER A: Travelers Insurance Company
INSURED
INSURER B: Western World Insurance
JD GENERAL CONSTRUCTION INC
INSURERC:Ace American Insurance Co.
1001 WAVERLY STREET
FRAMINGHAM, MA 01702
114SURER D:
114SURER E:
INSURER F:
BODILY INJURY (Per accident) $
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 ANDCONDITIONS OFSUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR AM—LISUB. - POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE WV� POLICY NUMBER (MMIDD/YYYY1 (MMIDD/YYYYJ LIMITS
B
GENERAL LIABILITY
MERCIAL GENERAL LIABILITY
CLAIMS -MADE F—IOCCUR
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISO NS.
DBA EXPRESS ROOFING
NPP8183801
8/15/13
8/15/14
EACH OCCURRENCE $ 1,000,000
DA"'A GE TO RENTED
,EM ES (Ea occurrence) $ 50,000
Pp IS
MED EXP (Arry one person) $ 51000
PERSONAL& ADV INJURY $ 1,000,000
ATE $ 2,000,000
GENT AGGREGATE LIMIT APPLIES PER
17 POLICYF PRO -
ECT LOC
-GENERALAGGRE
PRODUCTS - COMP/OP AGG $ 10,000,000
$
AUTOMOBILE LIABILITY
ANYAUTO
ALLOWNED SCHEDULED
AUTOS AUTOS
NON -OWNED
HIREDAUTOS AUTOS
Co T.INED SINGLE LIMIT
(E, � rt) $
'6'
BODILY INJURY (Per person) $
BODILY INJURY (Per accident) $
�_PROPERTY DAMAGE
I (Peracciden') $
$
UMBRELLA LIAB
EXCESS LIAB
�_ OCCUR
CLAIMS -MADE
EACH OCCURRENCE $
$
DED RETENTION $
-AGGREGATE
$
c
WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY Y/N
ANY PROPRIETOR/PARTNER/EXECUTIVE —
OFFICERIMEMBER EXCLUDED? Y
(Mandatory in NH)
Wescribe
Ifrs under
I D RIPTIO N OF OPERATIONS below
N/A
9972L68813
9/25/13
9/25/14
—TT w5cR —YsTLAmT, 7,T 1oTH
E.L. EACH ACCIDENT $ 100,000
E.L. DISEASE - EA EMPLOYEE� $ 100,000
E.L. DISEASE -POLICY LIMIT I s 500,000
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Rermrks Schedule, if more space is requi red)
L;t:K 111- IL;A I t HULDER rANrF1 I ATIn1J
Q0 1983-20 10 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
Phone: Fax: E -Mail:
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
MICHAEL CORTNER
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISO NS.
DBA EXPRESS ROOFING
AUTHORIZED REPRESENTATIVE
16 JONAS RD
PEBRA DALLA COSTA
Q0 1983-20 10 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
Phone: Fax: E -Mail:
Of CO�E��X,'ARZgdl.tai,.a
T1
Z ZN Office
ME IMPROVEMENT CONTRACTOR
Registration: 108126 Type:
Expiration: 8/13/2014 DBA
MI HAEL L. CORTNER-EXPRESS ROOFING
Michael Cortner
16 JONAS RD
WESTFORD, MA 01886
Undersecretary
Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
Construction Super% isor SpecialtN
License: CSSL-099497
\\�'% 1 1% "',
NUCHAEL L C04-tNE
16 Jonas Road I k' f di
Westford MA 01986
Expiration
Commissioner 0412412016
REM PitopouL
www-,"Pressroater.com
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781-820-1600
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