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HomeMy WebLinkAboutBuilding Permit #731-2017 - 4 BRIGHTWOOD AVENUE 1/23/2017j,i.' TOWN OF NORTH ANDOVER 4:APPLICATION FOR PLAN EXAMINATION Permit NO; 3 % - — ?V q Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page v ..t,.. -. LOGATION - �` - P` PROPERTY OWNER m S f) 5100�Year,Old,Structure yes . MAPrNO: PARCEL:ZLtON1NGSTRT HistoneDistrct yes _Machine Shop {Villa e _ —' g _ y -yes o TYPE OF IMPROVEMENT PROPOSED USE Non- Residential Residential ❑ New Building One family ❑ Addition El Two or more family [I Industrial ❑ Alteration No. of units: ❑Commercial Repair, replacement ❑ Assessory Bldg El Others: ❑ Demolition ❑ Other _ ' �;. CJ Water -died Distract Septic ' ' NVell, ❑ Floodplain..-E],Wetlands 11 Water(Sewer DESCRIPTION OF WORK TO BE PERFORMED: ,. �7 5 / Please Type or Print Clearly) OWNER: Name: ry� r2 Add C�3Y/� ress. r .�3 �hone FJ.3 CONTRACTOR . Name _ . ' t. 'P t�4 , .��. p�✓ ,� _ -'1. ..«�.� SCJ �'♦ �/_.`� / (/ �. } ' 1 � a Pry ' .eV, i t .Y r�7H%+NC- 3 • ... F - _� �• nr ♦ a -c ' b r2•. .,f � y a, �,.1: � Y .A• a y r '` O i `� Ex Date `(✓� ! a t Supervisor's Construction License _l"J'..� p a- ;�; +�. '��;t t b '1' .rT'� Sr` r,}'1�+'r'i r F. ; rr:,- r �r' _ _ . { Exp Date Horne Improvement L'icense:� �` 7" ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT. $12.00 PER $,100,0.00 OF THE TOTAL ESTIMATED COST BASED ON $925 R S. F. Total Project Cost: $ "Z :�— © FEE: $ Check No.: l 7 —Receipt No.: NOTE: Persons contractin with unregistered contractors do not have access to the guaranty fund Signature of_Agent/.Owner: > i nature: of:.coritractor.:....;_ Plans Submitted ❑ Pla s Waived Certified Plot Plan ❑ Stamped Plans ❑ Plans Submitted ❑ Plan s Waived❑ Certified Plot Plan ❑ Stamped Plans F1 TYPE OF<SEwERAGEI}IS�':OSAL ❑ Swimming Pools Public Sewer ❑ Tanning/Massage/Body Art well 11Tobacco.Sales ❑ Food Packaging/Sales 0 Private (septic tank, etc... ❑ permaneint Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY IMTI=RnEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENT .DATE REJECTED: DATEAPPROVED ❑ ❑ CONSERVATION Reviewed on Si nature COMMENTS HEALTH Reviewed on Signature COMMENTS, Zoning Decision/receipt submitted yes Zoning Board of Appeals: Variance, Petition No: Planning Board Decision: Comments conservation Decision: Comments - Driway Permit Water & Sewer Connection/Si nature « Date ve ]DPW Towi! Engineer: Signature' Located 384 osgood Street FIRE i?PARTiI.Iy`T --Temp Dumpster on site yes.. no Located at U4 Mair, Street Fire ®epartmer'itsignatureldate` U-UlvilvI.tIN 1 0 Dimension Number of Stories: Total land area, sq. ft.: Total square feet of floor area, based on Exterior dimensions. 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 2008 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 o 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 o Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses o 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 o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o 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: Doc.Building Permit Revised 2008 Enter construction cost for fee cal - Construction Cost $ 4,200.00 $ _ North Andover Fee Cakulat%on m $ 50.40 Plumbing Fee Gas Fee 100 comm. Electrical Fee Total fees collected $ $ $ $ 6.30 100.00 6.30 163.00 4 Brightwood bathroom remodel 731-2017 on 1/23/17 CD 0 Z C O Cr a) Q. 2. O < 0 CD CL a� CD O CD O CCD� U) CD O c v_ z z a < C �'a�r O W _ c0 � � � �' < U)CD -a CD 0 O z o ? = � 1%4 _I W T O v► oO �, CLm �' -n O (D (D CDO �S CD h CD 03 WCD -a -- > J 3 N o CD D CD _ : M C _CL sm =c n cc CL O C S —Di "6 n Ln N O ca .O '-r n '. CD O o = CD V D '^ y m � CL n Z m to Z m --1 0 r v z m O (D 3 co D ;o OT 2 m D = CD --, ZCD °, a O N CD N Ci < Q O Q= N �0,<� N =0 =� :f y �.p CD r N rt a1 � OD U) **: �D •d VI U) W 0 o c0 � � � � sr• 1 f '1PE- wx CD CD 1%4 n W T N T O (D (D CDO �S (DD N > J 3 N O < O OO C - D CD N : M C D :F = O C S C a- O "6 n Ln N O \ n m v 0 � o D '^ y m � CL n Z m Z m --1 0 VI U) W T .0 T N W T w T n W T N T O (D (D CDO (DD) C (D > O C =rn 3 N O < O OO C - N O C S 7 N :F = O C S C a- O "6 n Ln N O \ n m v 0 D '^ y m n Z m Z m --1 0 r v z m O (D 3 co D ;o OT 2 m D = ISI Ate 110TIR, iii i -V iS' WCe, iL(..' c,ems! I [K.e' •. iL - �4if=/xrat.,,'j 6 `L PO i`K b Q(V ( / e r�. aC �L G "bz S a '�i2 t i y'^ 4, �K.CI�CI it eZ S/ /i IC lrdC 4:[�% %C i (l eT 7 -6za 6, •.y $L C- �o a i i -O- j"' d ice 11 teikL4Pc r m `I- ' =4 0 C% Slt; ice:./ % •7-j �e ` s ` e ' ✓ c•i% ALL fltGU%,, 7-k- 7-,, 4/Z)O 0e rs(I' FGArl ltil�2t e�z, mix `, Chi ' �lY�u CV7 hi /,v I All Material is guaranteed to be as specified, and the above work was performed in accordance with the drawings and specifications provided for the let and was comKted4P a substantial womanlike manner for the agreed sum of /`this is a ❑Partial ❑Full i(ivoice due an(rpayable by: Month Day in accordance with our [:]Agreement ❑Proposal No. Dated 4adamr TC8122 Month Year Day Year 11-12 +, yhe Commonwealth of Hassachuseds _ Department o flndusifialAceldents M - i I Cong-ress Street, ,S`tiRt 10 0 tV.�%.,� 02114 2017 �- Fn YoAi www.mcass go-pMa • VPt3Tkers' Compensatioz<7nsux'ance Affidavit: B>xildens/COA'pTSOStI�-�cians/gXumbers. TO BE FILED WXTHTBE Name(BusznesslOrgazaiiontlndividual): f9 dC� %l/ l Address: `o- City/Stata)Zip: /4 g2 q. e Are you an employer? ljiecictlre approp�date box: Phone #: 7�- 1.Q I aemployerwith employees (o andlorPart-time)., Z- a sole proprietoz or partnership and have no employees working for me m any capacity. [NOw0lkem' comp* insurance required ] 3.0 I am a homeowner doing all work myself: LNo workers' comp, insuranceregrr oen 4.Q Jam ahomeowner and wilt be hiring coairactors to conduct allwork onmy prert oppy- I vM ,,,,,that all coldraetb3s q herhave workers' compensation insmance or are sole proprietors with, employees. 5.❑Tama general contiacto , and leave hn edthe snb confractors listed on the attached sheet These sob -contractors have employees andhavewmkD& comp. fimnanee: (,❑�e are a corPorauon and ?t , offices have ex dsedtheir rigist of exemPtion per Md c. 152 i(4) andvte has& no employees- [No woziors' comp. insurance required-] Type of project (required: 7. ❑ Ne 'con&ddiiou 8. QR.emode&P; 9. ❑ Demolition 10 ❑ Building addtfzon 11.❑ Electrical repairs or additions 12. Urpra—mbirig repairs or additions 13•.[�R�ofrepaars 14.0 Other § illf - *Any applicaut that chgoks bbx#1 must also fill. o e a fall Vo k d henhue outside cmontractors must submit a new aftdavit mdica�ng such Homeowners who submit tins a Fdavit indicating ey _ Contractors ±at checkihis boxznust attached au additional sheet thea tworkers'oco�mp. policynn �bemn�d statewhe�er ornotthose entities have employees. ifthesub-cD0t=torshave emgloyees,they must Pr. X am an employer that is.Providing-woTkej,s' compensation �supancefor° my employees. Below � tliepolicy orzd job site information. Innsmaace Company Name: ExpirationDate' Policy # or Self -ins. Lic. #:. •-- ,r- City/State/Zip: /i/ I d /.t/l �VeV /k k lob Site Address: "V /Sy64" ` uW"c., Attach a copy of the workers' compensation policy declaration page (showingis a the police nu:azber and expiration date). a ffie UP to 5 00-00 Failure to secure coverage as requiredumderM nalllxes2z, §2 f of TO-violation WOE O DF Z d a o to $250.00 a and/or one-year imprisonment, as well as czvzl p of this statement may be forwarded to the Office of Invesixgations of the DIA for insurance day against the violator. A copy coverage vezifica#ion- c v ragekerei�y certify ramaciem tiaepains and penaldes ofperju-ry that the information provided above is tune and correct- A� Date - Ph one #: ©ff�cicrl rise onry. Do not7vvrite lino this area, to he cor,�preted by city or town of_ftdaL • Permit/License # City or Town' issuing Authoxdty (circle one): ector 1.. Board of Real& 2- Building Department 3. e ty/Town Clerk 4, Electrical Inspector 5. Plumbing Insp b. Other Phone #- Contact Person: 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 o€bite, express or implied, oral or written." An employer ig defined as "an individual; partnership, asso ciation, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enfeiprise, and including the legal representatives of a deceased employer, or the receivbfor trostde 6f an individual, partnership, association or other legal entity, employing emplbyees. -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 b6 deemed to bean employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shalt withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicaAtwhio has not produced -acceptable evidence of compliance with the insurance coverage requiked." 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 affdavit completely, by checking the boxes that apply to your situation and, if necessary, supply s-db=contractors) name(s), address(es) and phone ni mber(s) along with their certificates) 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 d663 have employees, a policy is required. Be advised thatthis affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be suxe 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 Iudustrial:Accidenis. Should you have any questions regarding the law or if you are required to obtainn a workers' compensatiori policy, please call the Department at the number listed below. Self-insured companies should enter their self insuurance 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 fel out in the event the Office of Investigations has to contact you. regarding the applicant. Please be sure to fill in the p ermit/license number which will be used as a reference number. In addition, an applicant that must submit multiple pemiitllicense 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 b e provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filed out each year. Where ahome owner or citizen is obtaining alicense or permit notrelated 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-AJASSAFE Fax # 617•-727•-7749 Revised 02-23-15 www.mms.gov/dia 01/24/2017 15:54 9786886398 MW 66M "t v MARC RINALD ,4 T `1 t ie16,y7-zvoo4 #11e , PAGE 01 ACC?RDCERTIFICATE OF LIABILITY INSURANCE 0112312017 M001C� 978$880828 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION JOANNE K MILLS INSURANCE AGENCY ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 158 HAVERHILL ST HOLDER. THIS CERTIRCATE DOES NOT AMEND, EXTEND OR METHUEN, MA 01844 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. ............. —INSURERS AFFORDING COVERAGE -.. . ._.._._..�..,-..,.-..,_..—.-..._.. .. _. NAIL ! RING CONSTRUCTION IMURER A: QUINCY MUTUAL GROUP iNsuaea e: ' MARC RINALDO/ 12 KENSINGTON AVENUE INSURER °' METHUEN. MA 01844 u�uRER ns"ER E f :AVCCl/SeQ _ THE POLK3ES OF INSURANCE LISTED BELOW HAVE; BEEN ISSUED TO THE INSURED NAMED ABOVE ANYREQUIREMENT,TERM CONDITIONANY n NUT SCCRIIBBEDD FOR THE POLICY PERIOD INDICATED NO IINTHSTANDING E INWRANCICIES Ds EE SlACT � Bair THE POLHEREIN IS SUUWINT RCT TH O ALFLCTHE WRNIS, D(C TMS cONa TE S �OF POLICIES. AU3CiREGATE LIMITS SMOtNN MAY HAVE BEEN REOUCED BY PAID CLAIMS AND s11G1 mwioUcv POLICYMu�1 �oLUCY aIQIwIA6 LIALITr DAM A X � EACH Ww „ENCE s ib COMMERCW GENEO@ RAL LUIBIUTY 802060Q1 05-O'1-16 CLAWS UhMAM 06-07-17 . PRENIM (ea o= "w) 'S 300,000 MAOCCUR MED ERP (An/ one Oweeltl 5 5m PERSONAL A ACV INJURY f GENERAL AGGREGATE 7 1 MILLION CAWAGGREGATEAPR,E6r PRODUCTS-OOMPIOPAGG 3 1MILLION POLICY LOC pf AUT0111011{tLIASMJIY ANY AUTO (CE011>ItMED 8MIDLE UNIT I KE OVM41ED AUTOS ' SCHEDULEDAUTOS ( MpV�) INJURY i wRED AVFO5 MONO M D AUTOS w�Leed 3 PROPERTY aMU►Ge • , GARAW ►IAMUrY AUTO ONLY - EA ACCIDENT I ANY AUTO On€R THAN EA AOC 3 AUTO ONLY: Atr. 1 VIAS Y EACH OCCURRENCE 6 OCCUR CLAWS MADE AGGREGATE _ DEDUCTIBLE 1 RETENIION $ _ MOeMNMG011fi1SATI0MAND9TATU � rLo�YwLM�ItY rl.Mll.IsI 101w ER._._.._..... . ANY PROPRIETORPARnEUEXECUTNE EL EACHACGIOEN1 1 OFFTCERM1*111 REXULIDEm M a>on F L 0'W- E- EA EMPLOYEE f PROVISIONS hllttr EL DIGEAGE - POLICY OMIT f o111■1 aNSGMIPIIDM Ot 0/e11ATIDIAB LOCAT101p/ vSISCLSI! S>trlJ►SIOwt Aoow My ENooR@ M W I MiSLYAL pm&jgW & JIM LYONS 4 BRIGHTWOOD AVE NO ANDOVER MASS 01845 AGORD 2512001M1 .wTea.r-.. A I RJM SMDIRD ANY OP IME ASOMS eNSCROM POL O n Sa CANCFIIED Sarallc TW 6fDRUtTow OAT% THE WW. TNS JIMOO MSS X= riRL OIOSAVOM TO N ML DAYS M1�1TMM owl TO THE C11"WWATS MUM AAM® To THA Lrr. Mur MARIISM To DO 80 SMALL raAE 110 OWU0A"= oM LMJIKITY OP AIIY MM UP= THE NMWSA. ITS AGENTS OR C9 5; 0 m) u m u U) X Lij O-c 0 � c (a c 0 13, .0 lu Iz c 0 (L) m o IS < 9.(n W co c 0 0 CIS C-4 z 0 2 c :, z �: 55 uj E 0u to c zM 0 ui m Y�� 0 0 It u�6� { C9 5; 00 0 (L) m o IS < CIS C-4