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HomeMy WebLinkAboutBuilding Permit #742 - 399 MAIN STREET 8/20/2008U) m m m x m YI mm 2 y d C � W O CD n Z y C0rF) C C E c O. = CO) O 0 v CD �� O cr CD CD O CD CCCD CO) �. CD CLO H I CD � v CO) O CD Z CD 0. CDO C CD C O C 2: -1 to N GC ny 5.m O �m m y X09 y O a �. Ci C O d �� tA y ' o w .►= �-►m m did C T T CD CO) o y =r CD m Z oCD o 0 2>4 0 1 M —.CD O Z :9. ED O N Q � O m W CA a � cCL ?� "7 C.)= CLmi CA CL d C7 C � O �c o to N �m fid o �o GC O ?1 w 0 '� m ^D II ' ( O tG CZ, „� ' o w O t"J '0 ^ moi (� :� a� :- � a 0. W d r �^ CO) 9 7d O 'C O mcl —.CD ED H W Co dm; CL -S: nC 0 0; oo: moo: co Co: 0 Y#* C )Mi 0 9 'Y fid o �o GC ro ?1 w 0 '� m ^D II ' ( O ►� ' o w 70 OGro '0 ^ 'T? w (� O d crn z"� o GC ro ?1 w 0 '� z w ( O ►� ' o w 70 OGro QJ M 'T? w (� :� a� :- � a 0. W d r �^ oGL 9 7d O b�R O C The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street tl�tis ; Boston, MA 02111 Y' ; ' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: ,S O �e i N11 Phone #: (�'6 3) Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I e ployees (full and/or part-time).* 2. LZI am a sole proprietor or partner- ship 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 have hired the sub -contractors listed on the attached sheet. I These sub -contractors have workers' comp. insurance. ❑ 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): 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 -tiny appneant inat cnecKs box # I must also fill out the section below showing their workers' compensation policy information. Homeowners who submit.iinis aiidavii indicating they arc duing aii wuix and hien 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 their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Job Site Address: Expiration Date: 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 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 certifyZunr the pain,�/ nd penalties of perjury that the information provided above is true and correct e Siartature: Date: Phone #: 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. 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 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. # 617-7274900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia Homeowner Information Contractor Information Name: Company Name: Jerry Bateman Mannion Contracting & Home JerryBateman Improvement CSL #95277, HIC #145628 Street: Business Street Address 399 Main St. 34 Matthias St City State Zip code City State Zip code N. Andover, Ma 01845 Salem, NH 03079 978-688-2446 Business phone: 603-321-2570 Work to be Performed and Material to be used: Removal of existing roof and installation of ice shield along the perimeter of the roof. Installation of IKO Aristocrat AR shingles. Materials Expected to be used: Ice & water Shield, 30# felt paper, 8" drip edge and IKO Aristocrat AR Dual Black Shingles. The following schedule will be adhered to unless circumstances beyond the contractor's control arise: Work Schedule to begin: 8/18/2007 Expected Date of Completion: 8/30/2007 Total Contract Price And Pavment Schedule The Contractor agrees to perform the work, furnish the material and labor specified above for the Sum of $6000.00. Payment will be made according to the following SCHEDULE $3000.00 to be paid when material is delivered to site and work begins. Balance is to be paid upon the completion of all work to the satisfaction of both parties. Do Not Sign This Contract if There are any Blank Spaces This is I of 3 copies Homeowner Contractor Town Copy Homeowner's signature Contra or's S' ature JerryBateman James Mannion Date: er— SIS Date: — n You may cancel this agreement if it has been signed by a party thereto at a place other than an address of the seller, which may be his main office or branch thereof, provided you notify the seeler in writing at his main office or branch by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third buiness day following the signing of the agreement. °�f�i< Boar of w mg. egulatio sand Standards Construction tuOdmisor License Licenser", CS 95277 Expiration x3/7/2010 'Tr# 17665 ��J�eSt�laiion DO t � �I i JAMES MANNIOW '� 7�k , t 34 MATTHIAS STRiEET y �i'y SALEM, NH 03079 Commissioner aoaeaas!ulmpd 60£0 HN 'lN3lvs j 1S SVIH.Lt/W b£ lN3WJA08dWl 3go)©z '8+"Ni Jb2 NOO 0 NNdW i. yl ;9,OEti9Z #il 60OZ/9l/Z oe3'dz3 E 8Z99b1 r uoi>>;p�;si6a xYi 21,0131Y21J N0O J N3W3/1'O.bdWlWOH S Pae suo!aef"aH gu'!RI!a.8 Jo p.ieo8 f �'� �jrrtaouauco�i �� � r i Permit NO: 7 / 2 Date Issued: LIS o2 BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received to 10 - DESCRIPTION OF WORK TO BE PREFORMED: C- ) Y d o ov 3 Identification Please Type or Print Clearly) OWNER: Name: (;,erg Id .C3-�,g wo-A Phone: 6&K-2g4I Address: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ X201 (1y FEE: $ /, QQ Check No.: y 3 -22- Receipt No.: -� ©2 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signatu�e�of Ag�rtt/Qwner �� _ �'�`� � Mature of �dntractor � ��� ��: N, DESCRIPTION OF WORK TO BE PREFORMED: C- ) Y d o ov 3 Identification Please Type or Print Clearly) OWNER: Name: (;,erg Id .C3-�,g wo-A Phone: 6&K-2g4I Address: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ X201 (1y FEE: $ /, QQ Check No.: y 3 -22- Receipt No.: -� ©2 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signatu�e�of Ag�rtt/Qwner �� _ �'�`� � Mature of �dntractor � ��� ��: N, 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS rt HEALTH COMMENTS ❑ ❑ IN] I. DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED ❑ 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 Located at 384 Osgood Street 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 2007 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 2.2007 Location No. % Date S /S NaRTh TOWN OF NORTH ANDOVER G��t.o ,•,ti 9 Certificate of Occupancy $ HusEtA Building/Frame Permit Fee $ ' Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 9372 y 2U1UN 4 4 e6liding Inspector . k� 0 z h W O O■ � O ts Z a) Oo O y cm o c CO) 10 An O O 'E- m m O O O CL_� _... imp% CD C o M o a a. o,¢ c_ o =� ♦, C O V C9 'fl •C O Z ts O 0 CL V h O C C c CA Cl LLI CA 19 W W ix W U) 4j bch >. �?. a 5 �° 7 v Uw -- est a a � a�' eti w' a (ii � a°' eti w � w�' w ►. rA z � cn c o cn O O■ � O ts Z a) Oo O y cm o c CO) 10 An O O 'E- m m O O O CL_� _... imp% CD C o M o a a. o,¢ c_ o =� ♦, C O V C9 'fl •C O Z ts O 0 CL V h O C C c CA Cl LLI CA 19 W W ix W U) The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 o www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): t iia n 6ah,( Lee -Z_ ef Address: City/State/Zip: Phone #: 602 .302, J -6X0 I Are you an employer? Check the appropriate box: 1.02 am a employer with f 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. I ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] 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 *Any applicant that checks box #I 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 their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees!. Below is the policy and job site information. r Insurance Company Name: JP45 � &Udr ;itsQ M16t — G' Ad v it> Policy # or Self -ins. Lic. #: ;bU �� 4/ `% ,� y Expiration Date: 4J10 Job Site Address: 3Sq wain �t City/State/Zip:__ _"M� "acn�_- fiias� 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 of perjury that the information provided above is true and correct. Signature: Date - Phone `D 7 r 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 #: tLl�,htt'dX O/ 1'f/ GVV ! 1G 1G eel et%uz G/ vva L o.n .�ca vtii Eaten :19227 JOHNHORA .w a &50%r- DATE OUVWYYYY) ACORP. CERTIFICATE OF LIABILITY INbUKANt-oc 1 05/14/07 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION PRoou�R ONLY AND CONFERS NO RIGHTS UPON THE CERTIRCATE M USI New EngG�nd HOLDER.THIS CERTIFICATE DESS NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. PO Box 6360 Manchester, NH 031084360 INSURERS AFFORDING COVERAGE MAIC 0 603525-1100 INSURER Hartford InsuranceCompany 29424 INSURED John Horan Construction LLC INRER a Ea8t9uard Insurance Company 14702 SU 21 Evergreen Ofte INSURER C Hampstead, NH 03841 INSURER D: INSURER E COVERAGES NAMED ABOVE FOR THE POKY PERIOD NO THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED E ISSUED OR KATE MAY WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT i QCT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH MAY THEINSURANCEAFFORDEDBY THEPOLICIESRI E PES. HEREIN EEN REDUCED D LIIMITS SHOWN VE POLICAGGREGATE EFFECT PODA� EXPIRATION LABTS LIRTYPE aFINSURA NCE POLICY MAKER 04SBAGCOMB DATE 04101/07 04/01108 ooCu �� $1000,000 A GENERAL LIABILITY Tm000 X COMMERCIAL GENERALUABIL17Y CLAIMS MADE QX OCCUR MED EJp wn one pamun) $10,000 PERSONAL&ADVINJURY $1000000 CEN ERAL AGGREGATE S2 OOO 000 PRODUCTS -ELMfIOPAGG $Zw0,0W GEM AGGREGATE LIM APPLIES PER: POLICY LOC A AUTOMOWLELIABLI Y 04UECTU4440 12130/06 12/30107 SiNGLELIhMT 5500,000 (CME Esaccidan X ANY AUTO ALL CONNED AUTOS BODILY INJURY $ (Per P--) SCHEDULED AUTOS X HIRED AUTOS BODILY INJURY $ (Pet ao�itlad) X NON -OWNED AUTOS PROPERTY DAMAGE 5 {Pet aoddenf) ALSTOONLY-EA ACCIDENT 5 GARAGELIABLITY OTHER THAN EA ACC $ ANY AUTO AUTO ONLY. AGO S ECCEMUIIA6IRELLALIABLIrY EACHOOWRRENCE S AGGREGATE S OCCUR FICLAIMSMADE S j DEDUCTIBLE S 8 RETENTION S OERS COMPEIMTION Aro WRX JOWC804724 04101/07 04!01!08 WCSTATIU- OTH- X EL. EACH ACCIDENT $100,000 81IIPLOYERCLIABLITY EL DISEASE - EA EMPLOYEE $70,000 ANY PROPRIETQUPARTNER/EXEQ1TIVE OFFICEiifiEMBER EXCLUDED? ut a es, daIALMo EL DISEASE - POLICY LIMB 1 $500 000 o trofow OVL910NS OTHER DESCRIPTION OF OPERATIONS ILOCATIONS /VEHICLES/ECCLU810M ADDED BYENDORSEMENT/ SPECIAL PROVISIONS Gerald Bateman 399 Main Street North Andover, MA 01845 LD ANY OF THE ABOVE DESCRSED POLICES BE CANCELLED BEFORE THE EXPIRATION n *MOF. THE ISKIING INSURER WILL ENDEAVOR TO MAL fit- DAYS WRITTEN E TO THE CEINTON TE HOLDER NAM® TOTTE LEFT. BUT FAILURE TO DO 80 SHALL IE HO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER. ITS AGENTS OR —.—nu 4000 ACORD 25 (2001=)1 of 2 NS15799711MI154744 174wA -----•-- -- O CW9 ' L: � E AZO � v 1 Q Z 2 .J m WO _ E �% . . >w WQ. ` 1 0 N Z, ,,7-hn -7foran Construction, L. L. C. Buifding and Remodefing 21 Evergreen Drive Hampstead, NH 03841-2342 April 3, 2007 Gerald Bateman 399 Main Street North Andover, MA 01845 Dear Mr. Bateman: tel. (603) 329-6209 fax (603)329-6209 This is a contract to replace seven windows (six in sun porch and one in upstairs closet) as described: 1. Remove existing weights and insulate pockets. 2. Install window unit provided by homeowner. 3. Caulk exterior window frame. 4. Reinstall existing interior stops. 5. Disposal of sash, weights and storm windows included. 6. I will apply for building permit. Cost: $925.00 gnatur f Home Owner S-ilo- Date Si tune of Contractor s-A1a Date/