HomeMy WebLinkAboutBuilding Permit #701 - 4 TYLER ROAD 5/12/2010Permit NO
76/
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
Date Issued: � - (D �—
I IMPORTANT: Applicant must complete all items on this pate
LOCATION e' . _ rt y le yr f�� � /ytl `'LC�1 .�t'� c�ae
Print
PROPERTY OWNER 4 I -A I i Q (� (}/2
Print
MAP 210?2PARCEL: ZONING DISTRICT: Historic District yes
Machine Shop Village yes (no�
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One family
Addition
Two or more family
Industrial
-- ; �,
No. of units:
Commercial
Repair, replacement
Assessory Bldg
Others:
Demolition
Other
Sep is well--
Floodplain Wetlands
Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
Address:
CONTRACTOR Name: t„� 0rPh�ne: - S 7 SOS
Address:SQ. 4 1 c olC
Supervisor's Construction License: $S3 i S Exp. Date: ! .2,01,
Home Improvement License: IS -9 71 -7 Exp. Date: �/ '9-0 1 b
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: $V FEE: $_
Check No.: 1'�lp Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner Signature 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
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
Y
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comments
Conservation Decision: Comm
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
FIRE DEPARTMENT - Temp Dumpster on site yes,
Located at 124 Main Street
Fire Department signature/date
COMMENTS
t_ocatea :364ysgooa Street
no
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 2010
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: Building Permit Revised 2008
Location 7 7/et ,�(
No. Date
.01
TOWN OF NORTH ANDOVER
f°- '' OL
Certificate of Occupancy
$
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swC"Ust
Building/Frame Permit Fee
$ PS
Foundation Permit Fee
$ f
Other Permit Fee
$
TOTAL
$
Check # I
231 i,7
Building Inspector
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The Commonwealth of 112assachusetts
Department of rndustrzal Accidents
lily Office of £nvestigations
600 Washing- ton Street
Boston, 1124 02111
`ww.mass.gov1&a
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
�plicant Information
"T___. T . _ __ -
Name (Business/(>rpnization/Individual):
'Ar -
Address:
City/State/Zip: ,-t g
Phone #:
Are you an employer? Check the appropriate b x:
1. ❑ I am a employer with I
employees (full and/or part_time).*
2 El
am a s
Deneral contractor and I
have hired the sub -contractors
• am a sole proprietor or
Partner-
ship and have no employees
These sub -contractors have
working for me in any capacity.
[No workers' comp. insurance
workers' comp, insurance.
5. ❑ We are a corporation
❑required.)
I am a homeowner doing
and its
officers have exercised their
all work
myself. [No workers' comp.
right of exemption per MGL
c. 152, § 1(4), and we have
in required.] t
no
employees. [No workers'
comp. insurance
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building- addition
10.❑ Electrical repairs or additions
11. ❑ Plumbing repairs or additions
1) Roof repairs
required.] I 13 ❑ ther
`: ray a::p?icaat that ch=elz box -1 mnv! _1st, ui c¢c c sece� ce op V^o! n.* r
Flomeowners who submit this affidavit indica , - Workers' cOWY....s.iOe Y c; Y r : yon
+Contractors that the ro'uhis box must attached an additional sheet shower and then hireoutside contractors must submit a new affidavit indicating such,
a the same of the sub -contractors and their wnrk�
` o Urirmation. empeoyer that is provufing
infoworkers' compensation insurance for my employees.
Insurance Company Name:
Below is the policy and job site
Policy # or Self -ins. Lic. #: r7 a K 3 16�7yS^
Expiration Dz
Job Site Address:
C'
5-1119
Attach a copy of the workers' compensation policy declaration page (she I�/State/zip.
Failure to secure coverage as required under Section 25A of MCL c. 152 can lead to ththe e imposition
bof crer iminal matron date).
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the foam of a STOP WORK ORDER and a fine
penalties of a
of rap to $250.00 a day against the violator. Be advised that a copy of this
Investigations of the DIA for insurance coverage verification statement maybe forwarded to the Office of
I do hereby certify
perjury thIrt the information provided above is tr
eye ang' correct
/lam//(�
Official use only. Do not write in this area, to be completed by city or town officraL
City or Town:
PermitUcense #
Issuing Authority (circle one):
1. Board of Health 2. Building- Department 3. City/Town CIerk
6. Other 4. Electrical Inspector 5. PIumbine Inspector
Contact Person:
Phone #:
Inforrmation an- d 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 en- - in a joint enterprise; and including t -L 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 apartzoL eats and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintem2ance, 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 a onstruct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of co=mpliance 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 unvil 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 may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be stare to si=gn and date the affidavit The affidavit should
be returned to the City or town that the application for the pmmwtor l:cen..e iS beta-fi requested, not d-e—De-part—m-ett Of
Industrial Accidents. Should you have any questions regardirig the law or if you are mT' aired 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 ofInvestigations 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 than 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 Investiaat Gas
600 Washington Street
Boston, MA 0.2111.
Tel. #1617-727-4900 east 406 or 1-977-MASS:AFE
Revised 5-26-05
Fax # 617-72.7-7749
vrvrw,.Inass.. aov/dia
ACORa CERTIFICATE OF LIABILITY INSURANCE
`�
DATE (MMIDD/YYYY)
1 10/13/2009
PRODUCER 781-395-3030
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Pasciuto Insurance Agency
84 High Street
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Medford, Ma 02155
POLICY NUMBER
POLICY EFFECTIVE
INSURERS AFFORDING COVERAGE NAIC #
INSURED
Ryan and Son Roofing Inc.
13 Sunset Drive " $
INSURER A: Tower. Group
INSURER B: AIG e" "
INSURER C:
INSURER D:
Wakefield MA 01880
INSURER E:
PREDAAMISES AGE ToEa occurrRENTEDence$
A16111:4 -#11t7 =!!Z,
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 LAIMS.
INSR
DD'
hm
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
POLICY EXPIRATION
05/12/10
LIMITS "
AUTH ;R ES ATIVE
ACnRrf 9S /9nn0/n41
GENERAL LIABILITY
8203169745
05/12/09
EACH OCCURRENCE $ 1,000,000
PREDAAMISES AGE ToEa occurrRENTEDence$
rA
X COMMERCIAL GENERAL LIABILITY
CLAIMS MADE FXXI OCCUR
MED EXP (Any one person) $
PERSONAL & ADV INJURY $
_
GENERAL AGGREGATE $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG $ 1,000,000
XX POLICY PRO LOC
in F
AUTOMOBILE
LIABILITY
A
COMBINED SINGLE LIMIT
ANY AUTO
(Ea a!r (, t)
ALL OWNED AUTOS
BODILY
P D�rson) " { $
SCHEDULED AUTOS
HIRED AUTOS
BODILY INJURY $
NON -OWNED AUTOS
(Per accident)
PROPERTY DAMAGE $
-
(Per accident)
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT $
OTHER THAN ACC $
ANY AUTOEA
AUTO ONLY: AGG $
EXCESS / UMBRELLA LIABILITY
EACH OCCURRENCE $
OCCUR CLAIMS MADE
AGGREGATE $
DEDUCTIBLE
$
RETENTION $
B
WORKERS COMPENSATIONXX
WC STATU- OTH-
AND EMPLOYERS' LIABILITY Y / N
0405025
05/12/09
05/12/10
E.L. EACH ACCIDENT $ 100,000
ANY PROPRIETOR/PARTNERIEXECUTIVE
OFFICER/MEMBER EXCLUDED? a
NO eXCIUSIOr1S for owner
E.L. DISEASE - EA EMPLOYE $ 500,000
(Mandatory b Ad
Des, describe il�der
_
E.L. DISEASE - POLICY LIMIT $ 100,000
SPECIAL PROVISIONS below
OTHER
Lj-
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
f�C�TI Cl/�ATL- IJ/1, e��e�
V — W 79tfS-ZUU9 AGORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION RLIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REAP ENT V_ S:-
AUTH ;R ES ATIVE
ACnRrf 9S /9nn0/n41
V — W 79tfS-ZUU9 AGORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
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