HomeMy WebLinkAboutBuilding Permit #533-2016 - 381 MASSACHUSETTS AVENUE 10/29/2015C /CAv Al -,O /t - Y- /.f
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: �� Date Received
Date Issued: �tl wl l�
ANT: Applicant must complete all items on this
LOCATION 3,& /1?rt.�yv�c-
Print
PROPERTY OWNERA141
MAP � I �� PARCEL:e0a(y
Print 100 Year Structure yes no
ZONING DISTRICT: Historic District yes no
Machine Shop Villaqe ves no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other a�
Cl Septic ❑ Well
❑ Floodplain ❑ Wetlands
❑ Watershed District
❑ Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
±� A 12 P --P r; s'flu o f rlys fid // Af f u-) 4 9 4` a�6,h f S k I n.r l� z -
n 2 i r r4e - (S �-e If - KCe/heUe .be.ka' .5
a
Identification - Please Type or Print Clearly '
OWNER: Name:, �( &A&1<'u-c Phone: -7 -.
Address: r*l4S5 0 ti M�Dyrk
Contractor Name: 4 k l . Phone:
Email,-
Address:
mailAddress:
Supervisor's Construction License: 0 70 4:21 Exp. Date:.J
Home Improvement License: f 7G Exp. Date; /d%i fPi//
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: $�,57jd Oo FEE: $ %Q-�—
Check No.: Receipt No.: C2q 511
NOTE: Persons contractin with u egis eyed contractors do not have access to the guaranty fund
Signature of Agent/Owner ignature of contractor
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
COMMENTS
Reviewed On
Signature.
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
it
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 OsgoodStreet
FIRE) DEPARTMENT Temp Dumpster on• site yes _ no. _
Located at 124 `Main Street
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
MGL Chapter 166 Section 21A -F and G min.$100-$1000 fine
IVU I tJ ana WA I A - (t -or department use
❑ Notified for pickup Call _ Emai
! Date Time Contact Name
Doc.Building Pennit Revised 2014
No
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/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)
❑ 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
VOTE: 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: Building Permit Revised 2014
Location 3J I
Date
No..6 3 3
TOWN OF NORTH ANDOVER,
Certificate of Occupancy $ ,
Building/Frame Permit Fee $a --
Foundation Permit Fee $_
Other Permit Fee $
TOTAL $
Check # P20-511(,o6&Z2—
Building Inspector
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Joesph Banko
11 Ocean Terrace
Salem, Ma 01970
Phone # 978-855-1696
Name. / Address
massbaybuilders@juno.com
Estimates
Date
Proposal #
10/17/2013
291
Project
e 10_�
Terms Terms
Description . Total
Any alterations or deviationsfrom above specifications involving extra costs will be executed only upon written orderand will become an extra charge over and
above the original proposal. Persons oth4r�than Joe Banko. employees and authorized agents of Joe Banko. are expressly forbidden on any ladders, scaffolding or
use of any tools owned or operated byJoe BaNko--or authorized dgents of •Joe Banko. Joe Banko shall be entitled to charge a one and one half percent(1.5%)
r 2.. g
monthly finance charge for all fn`voices on which p'`ayment isin". reckiyed within (30) days. The customer agrees to pay all cost of collection, inluding but not
limited to reasonable attorney's fees`iri regards to any and idl pgst due"a#rounts.
Quote pricing valid for 45 days . ,**All;special bider materials a nbn=iefitndable
Please do not hesita a tocontact us with any questions 'tconcerns-' r ��
$0.00
�- , �, . • _ � " ... , '_ „-, Total 1
Respectfully submitted by: Joe Banko CUstomerSlgnature/Date: kw
� `
The Commonwealth of Massachusetts
Department of IndustrialAccidents
I Congress Street, Suite 100
t
Boston, MA 02114-2017
°" www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): a S
Address: 0 A,a, �G G
City/State/Zip: 514
Are you an employer? Check the appropriate box:
Phone #: � %_14s
1.❑ I am a employer with employees (full and/or part-time).",
2.01 am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t
4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insruance.1
6.FJ We are a corporation and its officers have exercised their right of exemption per MGL c.
152, § 1(4), and we have no. employees. [No workers' comp. insurance required.]
Type of project (required):
7. ❑ New construction
8. Remodeling
9. ❑ Demolition
10 0 Building addition
11.0 Electrical repairs or additions
12. F1 Plumbing repairs or additions
13. Roof repairs
14.0 Other
*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 pioviding 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 MGL c. 152, §25A is a criminal violation punishable by 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. 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 tAe pains and penalties of perjury that the information provided above is true and correct.
Phone #: V F7k 'lS S� ��
��
Official use only. Do not write in this area, to be completed by city or town official'
City or Town:
Permit/License
0
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'
compensatioii'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 Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
EMPLOYER:
Joseph J Banko
11 Ocean Terrace
Salem, Ma 01970
NOTICE OF ASSIGNMENT
The Waiver of Our Right to
Recover from Others Endorsement
Is available on Pool policies.
Contact your agent for details.
AGENT David E Zeller Insurance Agency Inc
OR David E Zeller
PRODUCER: 370 Lynnway
Lynn, Ma 01901
COMBO I.D. STATUS OF EMPLOYER
00026997 Individual
Coverage under this assignment
applies to Massachusetts
operations only. For coverage
outside of Massachusetts, contact
the appropriate Pool or Plan for the state
INSURANCE COMPANY:
American Zurich Insurance Company
Jonathan Schamberg
P O Box 3556
Orlando, FL 32802-3556
(800)453-9843
CLASSIFICATION OF OPERATION CLASS ESTIMATED RATE ESTIMATED
CODE TOTAL ANNUAL PREMIUM
REMUNERATION
CARPENTRY -DETACHED ONE OR TWO FAMILY DWELLINGS 5645
CARPENTRY -DWELLINGS — THREE STORIES OR LESS
5651
ROOFING -ALL KINDS EXCEPT FLAT
5551
EMPLOYERS LIABILITY 100/100/500
9845
STANDARD PREMIUM
LOSS CONSTANT
0032
EXPENSE CONSTANT
0900
TERRORISM CHARGE
9740
RISK MINIMUM PREMIUM
0990
TOTAL ESTIMATED PREMIUM
DIA ASSESS. 5.75%
TOTAL EST. PREMIUM PLUS ASSESSMENT
INSTALLMENT BASIS: ANNUAL
COMMENTS
COVERAGE EFFECTIVE 12:01 AM ON 10/08/15
$0 8.06 $0
$0 8.06 $0
$156,000 41.56 $66,056.36
$0
$150
$259
$0
$500
$65,742.60
$0
$65,742.60
DEPOSIT PREMIUM: $3,500.00
THIS IS NOT A BILL
CARRIER NOTE: The Bureau reviewed the classifications and descriptions provided with the application and determined that a change to the
classes provided on the application was warranted.
DATE OF NOTICE: 10/19/15 PREPARED BY: Joanne Shea
EXT 530
The Workers' Compensation Rating and Inspection Bureau of Massachusetts
101 Arch Street • Boston, MA 02110
(617)439-9030 • FAX(617)439-6055 • WWW.WCRIBMA.ORG
NOTICE OF ASSIGNMENT
LETTER ID: ** VOLUNTARY DIRECT ASSIGNMENT **
4473573
The Workers' Compensation Rating and Inspection Bureau of Massachusetts
101 Arch Street • Boston, MA 02110
(617)439-9030 • FAX(617)439-6055 • WWW.WCRIBMA.ORG
Feb. 24. 201 1p .CFAIti(I ��. ;931 i',
I
�-- MAS13AY B-01 S.L RSEN
DATE (AIKDD!YYY1')
_ �wCERTIFICATE OF LIABILITY INSURANCE _ 2124.(2015 --
THIS CERTIFICATE IS iSSUED ASA 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 ADDITIONAL INSURED, the poiicy(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 this certificate does not confer rights to the
certificate holder in lieu of such endorsemert(s), _
PRODUCER (License # 1001090-�
Commercial lnsurance.NET aH ri -- ---------- -- _ —._ . �_.----.----___._--
2420 Springer Drivear� Flo Fat1;Eg7) 907-528'7 -- - --------�.IN.tc.N(091 366-8817 --
Suite 100 I Ao mss_certs commem aUnsurance.net
Norman, 014 73069 — ---- -- ----- -----
INISURED
I PJSL'RER(Sl AFFORDING COVER:4GE __ tJAiC_R__
;NSURERA : United Specialty insurance Company 12537
Mas Bay Builders INSWtERC: _ — --
11 Ocean Ter NSURER D:
Salem, MA 01970 PNSURER
----
�INSi1RER---------
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COVERAGES CERTIFICATE NUMBER: _ REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POL!CIES OF INSURANCE LISTED EELOWHAVE BEEN ISSUED TC THE INSURED NAMED AEOVE 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.
--Mucy EXP—I
LTR_TYPE OF INSURANCE -- —_ INSDiWVD POUCYNUMBER — —1(NIMA)M'YYY) (MMrDDtrYY1� _ L114I7S
Al - X COMMERCIAL GENERAL L IABILITY i----- - --T------
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DESCRIPTION OF OPERATIONS! LOCATIONS I VEHICLES (ACORO 101,AddMonal Remarks Schedule, may be attached Y more space Is required)
Please call 877-907-5267 to confirm coverage is still active.
Insureds Copy
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
fiiCCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
@ 1988.2014 ACORD CORPORATION. All rlahts rc-,�rvprt
ACORD 25 (2014/01) The ACORD name and logo are registered marks o'fACORD
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Insureds Copy
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
fiiCCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
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fairs &Business Regulation
Office of Consumer Af
OME IMPROVEMENT CONTRACTOR i
sRegistration- ''176831
Type:
Expiration: :101%2017 Individual
JOSEPH J. BANKO
JOSEPH BANKO '
11 OCEAN TERRACE !1 ~ • '
SALEM, MA 01970 r t 'ti `. `"`•_" �= i
Undersecretary
License or registration valid for individul use only
before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, MA 02116.
of vali w"t2na e
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
r Construction Supef—so i
License: CS -070671
JOSEPH J BANK¢ ,
11 OCEAN TERAMO
! Salem MA 01970 �
commissionTer' Expiration
01/06/2017