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HomeMy WebLinkAboutBuilding Permit #687 - 393 MAIN STREET 5/22/2008BUILDING PERMIT o�tt,�o ,b TOWN OF NORTH ANDOVERh..�6 o APPLICATION FOR PLAN EXAMINATION to rJ Permit NO: Date Received SSACHUS� Date Issued: 4 �� IMPORTANT: Applicant must complete all items on this page LOCATION _ �'3 n cS 71 ,.. Print PROPERTY OWNER /a wt e <r_ wev? Print MAP NO: GSI Y PARCEL: i ZONING DISTRICT: Historic District yesn Machine Shop Village yes(no�) TYPE OF IMPROVEMENT PROPOSED USE Resi Non- Residential New Building Addition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain ` Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: `�, �/4�� O-elle7' S1oue_ I<j ; lV Z, // /,',-7-el— OWNER: Nam Address: 353 Identification A" Tr,' e 71 Type or Print Clearly) CONTRACTOR Name:_ e-�Z A& ,„,f r- 1 Phone: b ei3 6 prls Address: ! 3 e,-,8 /Qc Supervisor's Construction License: C S Exp. Date: // O Home, ImprovementLicense: Exp. Dater ARCHITECT/ENGINEER Phone: Address: Reg. No 30 FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ 5'6 0. 6 6 FEE: $ 80 Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 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 CONSERVATION COMMENTS HEALTH COMMENTS DATE REJECTED DATE APPROVED Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition N Planning Board Decision: Comments Conservation Decision: Comments Zoning Decision/receipt submitted yes Water & Sewer Connection/signature & Date Driveway Permit DPW Town Engineer: Signature: Locatea sts4 uS ooa 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 MGL Chapter 166 Section 2 1 A —F and G min.$100-$1000 fine NOTES and DATA — For department use ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 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/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 Location ti� A_/i%_ No. e;t 4— Date '60 NTOWN OF NORTH ANDOVER 0.�.�,0 o 1t{.O • . OL A Certificate of Occupancy $ P Y �� t•t�ii�• 4 E<� Building/Frame Permit Fee $' Mus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check #(w C 21, 4 73 _ Building Inspector 9 O z W co c o `m c o o C N O C .3 C3 .p, -I;a CL C W O ; D O (� H A •�o ..4D �oc E_ nom ccc+ w :mom •� N W �mo c=:, � CD vN ' C � C cmm �O N W N D mo aC3 y O m yL.. O w c :cya acz IS y O c_ C O` O v O. m m CD H p w mom~ W C OrL.,�L O F– •fyq dt O C ac E N_ a m� Cl = ee to H 0 a�-•m a N M O zipN C cm m C3, c m O cm C_ �C N m s O Z 0 O i oil u 0 C a " 2 O 0 0 0 L 0 V Z 0 CL 0 h o c 0 0M 0 �— 0 0 .coE ao m CD H= CL CD 0 CDCJ LO M0 a- =a CO) = c v J •0 0. C Z CD 0 CL V y c C — C_ C _c _ 0. COD D v o O w � ) a v cn. O w O w U G w � O � °�° O w m G w" AG O W °�° O r� c1 G iw � O a m O w" w A O m U) O U) c o `m c o o C N O C .3 C3 .p, -I;a CL C W O ; D O (� H A •�o ..4D �oc E_ nom ccc+ w :mom •� N W �mo c=:, � CD vN ' C � C cmm �O N W N D mo aC3 y O m yL.. O w c :cya acz IS y O c_ C O` O v O. m m CD H p w mom~ W C OrL.,�L O F– •fyq dt O C ac E N_ a m� Cl = ee to H 0 a�-•m a N M O zipN C cm m C3, c m O cm C_ �C N m s O Z 0 O i oil u 0 C a " 2 O 0 0 0 L 0 V Z 0 CL 0 h o c 0 0M 0 �— 0 0 .coE ao m CD H= CL CD 0 CDCJ LO M0 a- =a CO) = c v J •0 0. C Z CD 0 CL V y c C — C_ C _c _ 0. COD D �. Sun-Raa P.O. Box 3217 Manchester, NH 03105-3217 Tel. (603) 300-6915 Fax (603) 622-0658 SUBMITTED TO STREET__ r CITY, STATE AND PAGE NO. OF PAGES PHONE ,4 G DATE 1 G� i . G EMAIL ADDRESS JOB NAME JOB LOCATION JOB PHONE r <.� _. �_._ 7`l tom_ ff • � - _. _.� _.__ _r_...____ WE PROPOSE HEREBY TO FURNISH MATERIAL AND LABOR - COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS, 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 Workmen's Compensation Insurance. DOLLARS ($ AUTHORIZED SIGNATURE ACCEPTANCE OF CONTRACT -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. I, SIGNATURE t.� �\ ; , Y1lX DATE0 SIGNATURE DATE Boardof �u'irdmg zCegu ai�o s artd Sta¢�dart3s;;{ .F, Construction Supervisor License License: CS 86380 Expiration: -11/3/2009 Tr# 10573 Restriction: 00 JASON A TARDIFF 15 NOTRE DAME AVE ALLENSTOWN, NH 03275 Commissioner Board of Building Regulations and Standards = HOME IMPROVEMENT CONTRACTOR Registration: 141507 Expiration: 4/26/2010 Tr# 265184 Type: Ltd Liability Corpor SUN -RAY BUILDERS JASON TARDIFF 15 NOTRE DAME AVE<&^�a'"`°� ALLENSTOWN, NH 03275 Administrator 05/21/08 ConfirmNet -> 16036220658 Pg 2/3 ACORDT. CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYYI MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH 05/21/08 PRODUCER 1-617-723-7775 Hays Companies of New England THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 133 Federal Street 3rd Floor HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. POLICYEFFECTIVE Boston, MA 02110 ' INSURERS AFFORDING COVERAGE NAIC# INSURED Sun -Ray Builders LLP INSURER& Liberty Mutual I NSURER B: PO Box 3217 NSURERC: LIMITS INSURERD: Manchester, NH 03105 INSURER E: COV 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR LTR DD'L INSRD POLICYNUMBER POLICYEFFECTIVE POLICY EXPIRATION ' REPRESENTATIVES. North Andover, MA 01845 USA P 0 T M !YYDATE(MM/DDNYI LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIAB ILITY DAMAGE TO RENTED - PREMISES Ea occurence$ CLAIMS MADE FIOCCUR MED EXP (Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ POLICY PRO- JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALLOWNEDAUTOS BODILY INJURY $ SCHEDULEDAUTOS (Per person) H IREO AUTOS BODILY INJURY $ NON -OWNED AUTOS (Per accident) PROPERTYDAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY -EAACCIDENT $ OTHER THAN EA ACC $ ANY AUTO AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ AGGREGATE $ OCCUR 17 CLAIMS MADE DEDUCTIBLE RETENTION $ $ A WORKERS COMPENSATION AND WCS-31S-360214-097 10/01/07 10/01/08 XWCSTATU- OTH- TORYLIMITS ER EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? X E.L. DISEASE - EA EMPLOYEE $1,000,000 If yes, describe under E.L. DISEASE -POLICY LIMIT $1,000,000 SPEC IAL PROVISIONS below OTHER LI DESCRIPTION OF OPERATION S I LOCATIONS/ VEHICLES f EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS This policy covers those employees leased by Sun Ray Builders, LLP through Surge Resources, Inc., Manchester, NH 03109 CERTIFICATE HOLDER CANCELLATION *10 Days for Non Pa ent of Prem i ACORD 25 (200 1108) mvaughn2 8831905 Certificate Delivery by CertificatesNow - www.ConfirmNet.com - 877.669.8600 ©ACORD CORPORATION 1988 ym um SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Thomas Teichman DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL *30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL 393 Main Street IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. North Andover, MA 01845 USA [AUTHORIZED REPRESENTATIVE ACORD 25 (200 1108) mvaughn2 8831905 Certificate Delivery by CertificatesNow - www.ConfirmNet.com - 877.669.8600 ©ACORD CORPORATION 1988 05/21/08 ConfirmNet -> 16036220658 IMPORTANT Pg 3/3 If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. 25 (2001108) The Commonwealth of Massachusetts J Department of Industrial Accidents J Office of Investigations J =; d 600 Washington Street eWt Boston, MA 02111 V www.mass.gov/dia ' Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers pplicant Information Please Print Levibl' Name (Business/Organization/Individual): Address: / 3 G ��e a kS�P �K �-71 City/State/Zip: Q s r V a 31 a A Phone .#: 3 G a Type of project (required):.~ 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10_7 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs // 13. Other W j 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: L Policy # or Self -ins. Lic. #:'_ w (� �j ' 3ZJ — 4 6,R/Y- O f 7 Expiration Date: G / — o g Job Site Address: City/State/Zip:_4j AyJg, 114" 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct Phone #: '60,03 300 l 4/, c not write in this area, to be completed by city or town official, City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other ContactPerson: Phone #: Areyou an employer? Check the appropriate box: 1 a employer with ' 4. ❑ 1 am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.$ 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, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required):.~ 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10_7 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs // 13. Other W j 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: L Policy # or Self -ins. Lic. #:'_ w (� �j ' 3ZJ — 4 6,R/Y- O f 7 Expiration Date: G / — o g Job Site Address: City/State/Zip:_4j AyJg, 114" 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 and penalties ofperjury that the information provided above is true and correct Phone #: '60,03 300 l 4/, c 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 ContactPerson: 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." ' i 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 appurtenani 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,opera'te�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 -contractors) 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 maybe 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. 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 110T 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 Department 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 11-22-06 www.mass.gov/dia