HomeMy WebLinkAboutBuilding Permit #773-2017 - 387 MASSACHUSETTS AVENUE 2/15/2017L
LOCATION
PROPERTY OWNER)
MAP �_PARCE
Print
Print / 100 Year Structure
ZONING DISTRICT: Historic District
Machine Shop Village
yes Ono
yes
yes \
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
❑ A ltion
❑ Two or more family
❑ Industrial
Alteration
No. of units.
❑ Commercial
❑ Repair, replacement--
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
)] Septic Well:
'F dpp`1Netlands.
Watershed ®Istnct
DESCRIPTION UI- WUtM I U tst 1-tM1-Urc1wtu:
Identification - Please Type or Print Clearly
OWNER: Name: Phone:
Address:
Contractor Name: A
Email: ZAIJ M01 4`6/ CIE/ a.1,2
Address: _ fit,-� _ Cf11 C i ••
� Supervisor's Construction License:
Home Improvement License:
IW -4
f
SwExp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE. BULDING PERMIT. • $92.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED
,OON,J$`125.00 PER S.F.
Project Cost: $ y � �?0 � •
01z—
Total'FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to�the guaranty fund
J
Plans Submitted 0 Plans Waived El
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Well El
Private (septic tank etc. n
Certified Plot Plan F1 Stamped Plans 1-1
Tanning/Mas s age/B o dy Art ❑ Swimming Pools ❑
Tobacco Sales El Food packaging/Sales n
Permanent Dumpster on Site n
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:
Planning BoaFd Decision:
Comm
Zoning Decision/receipt submitted yes
Conservation Decision: Comments
Water & Sewer Connection/Signature Driveway Permit
DPW Town Engineer: Signature:
PIRV
;7�PWONYMvii # JemPA)urnpsterpnNtp-,Yes
L
,beated at,12-4 q41W`
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.4LV1- intatreet
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Tir al[D -epagment-signAture/date 'h
COMMENTS'
Located 384 Osgood Street
ou
ov
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 lies No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
Doc.Building Permit 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
TOTE: 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
OTE: 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
2012 IECC Energy code
Engineering Affidavits for Engineered products
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 6 1 Ave
No. � 1-5 - 2 CA Date L It
r _-
Check 4t 1 -�
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $��'J
Foundation Permit Fee $
Other Permit Fee " $ '
TOTAL $
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Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
$ 253000.00
m
$ -
$
300.00
Plumbing Fee
$
37.50
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
37.50
Total fees collected
$
475.00
387 Mass Ave
773-2017 on 2/15/17
Kitchen remodel
365 Saewn S;xest
Norih Aii-do 3r, k,1,A 01845
1 *' Ciilll •^•�y
v-.�...4.f:rw3
PROPOSAL 171
Proposal Submitted To (�
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Phone
Date 17
Address
` ' j2
Job Name '
1 p
Job Location
Architect
Date of Plans
Job Phone
we nereby suomit specincations and estimates Tor: {
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WE PROPOSE hereby to furnish material and labor — complete in accordance with specifications below, for the sum of:
Payment to be made as follows:
All material is guaranteed to be as specified. All work to be completed in a workmanlike
manner according to standard practices. Any alteration or deviation from above specifications
involving extra costs will be executed only upon written orders, and will become an extra
charge over and above the estimate. All agreements contingent upon strikes, accidents or
delays beyond our control. Owner to carry fire, tornado and other necessary insurance. Our
workers are fully covered by Workman's Compensation Insurance.
dollars ($ ;? '7— f /" r Cr ).
Authorized /
Signature
Note: This proposal may be withdrawn
by us if not accepted within
Acceptance of Proposal:
The above prices, specifications and conditions are satisfactory and are hereby accepted. '
You are authorized to do the work as specified. Payment will be made as outlined above. Signatureiti
Date of Acceptance
L
Signature
days.
ank ou
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June L. E..`1952'Ddf
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nr�r?zra�ttuecS S nlatioa
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DAVID /MORIN
iDAVID MORIN - - ;�.:.:c•,��'�:��,.
365 SUTTON ST
1 MA 01845 � Undersecretary
} N. ANDOVER,
Massachusetts Department of Public Safety
rBoard of Building Regulations and Standards
-License: CS -040898
Construction Supervisor
DAVID M MORIN
365 SUTTON STREET.n � 'y
NORTH ANDOVER MA 0184 �A
lam- Expiration'
Commissioner 0710412017
+ The Commonwealth of Massachusetts
z . Department of IlndustrialAccidents
1 Congress Street, Suite 100
Boston, MA 02114-2017 ;
,-` www mass govfdia
,y.
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plimbers.
TO BE FILED 'WITH THE PERVJJT TNG AUTHORITY.
Name (Business/Organization/hdividual):
Address:
City/State/Zip: _ N
Areyou an employer? Check t& ap�xopriatebox:
Phone #:
1.Q I am ployerwith .:.. ! employees (full and/or part-time).*
am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3-F] I am a homeowner doing all work myself. [No workers' comp. drisuraace required.] ?
4.01 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— employees.
5. Q I am ageneral contractor and I have hired the sub -contractors listed on the attached sheet.
These sub-contractorsliave employees andhave workers' comp. insurance.T
6.0 We are a corporation and ip o£ficers'have exercised their right of 'exemption per MGL c.
152, § 1(4), and we have na. employees. [No workers' comp. insurance require(L]
Type of project (xequired):
7.. Q New cozisituction
8. j�'�Remodelirig
9.%❑1 Demolition
10 [] Building addition
11.❑ Electrical repairs oradditions
12: [( Plumbing repairs or additions
13: Roof rep airs
14. Q Other
`Any applicant that checko box #1 must also fill out the section below showing theirworkers' compensation policy information.
T Homeowners who submit tTvs affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
lContractors_ that check this box must•attac1aed 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, ley' must provide their workers' comp. policy number.
I aim an employer that ispiovidiilgworaketrsI compensation insurancefor my employees ' Beloip is thepolicy acid job site
information.
Insurance Company
Policy1# or Self -ins. lir,.
Expiration Date;
Job Site Address: _�S)! M — 'U e, City/State/Zip: A4/�
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 tine 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.
Ido hereby ce nder the p ` landpenal ' ofperju.-y that the informationprovidedabove is true and cor; ect
signafore: / Date:
Phone #: '?) d —Z—
Official use only. Do not -write in this area to be completed by city or town off ciaZ
City or Town:
PermitEicense
Issuing Authority' (circle one): i
1. Board of Health 2. Building Department 3. City/Town. Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact
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 bf bnre,
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 commonwealtlq for any
applicant who lias 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=contractox(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 - 7industrial
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-iin'sur6d 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 bum 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•-MA.SSAFE
Fax # 617•-727-7749
Revised 02-23-15 www.mass.gov/dia
a CERTIFICATE OF LIABILITY INSURANCE
Qti;7//2017DmYY1
THIS CERTIFICATE IS 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 ADDITIONAL INSURED, the policy(les) 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 endorsement(s).
PRODUCER
PAYCHEX INSURANCE AGENCY, INC.
150 SAWGRASS DRIVE
ROCHESTER, NY 14620
CONTACT Paychex Insurance Agency Inc
PHONE
. 877-266-6850 FAX 585-389-7426
E-MAIL Certs@paychex.com
INSURER(S) AFFORDING COVERAGE NAiC III
INSURED
INSURER A: AmGUARD Insurance Company
INSURER B:
David M. Morin
365 Sutton Street
INSURER C:
North Andover, MA 01845
114SURERD:
INSURER E:
INSURER F:
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.
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TYPE OF INSURANCE
DDL
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POLICY NUMBER
POLICY EFF
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WORKERS COMPENSATION AND
EMPLOTERS' LIABILITY
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DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, H more space Is required)
CERTIFICATE HOLDER
TOWNOF NORTH ANDOVER
CANCELLATION
0HVVWAAT VtIncAtlVVCUCYLKtlCYrVL1{iltJtlt AnLtLLCVtlCPVltr111GeAn lIVN
DATE TNEREDF. NOTICE WILL BE DELIVERED IN ACCOROA�CE WITH THE POLICY
ACORD 25 (2010/05) @1988.2010 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD