Loading...
HomeMy WebLinkAboutBuilding Permit #506 - 4 WALKER ROAD 12/28/2011BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: (o Date Received Date Issued: /' // IMPORTANT: Applicant must complete all items on this page rviaui ui is �i ivN vi rOl h'� o /NORTk� ��S,�LEO /6 q/VO ` TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic®�V11ell ❑Floodplain f7 Wetl`and's ❑: Watershetli©istnct OWNER: Nam Address: 4- t'q DESCRIPTION OF WORK TO BE PREFORMED: iop Please Type or Print Clearly) !m, q'1u- t(Q'�" GONa !RACTOR Name Phone .. Address=© Supervisor's(Construction'License <Exp {Date t, 1 L (Z �IJiirridilrrs'r"rnvcmcri+!�:inaneA• ARCHITECT/ENGINEER N Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT. $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cost: $ ®p FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund rSignature:�of Agent/Ovvner _. �� a ::._. Signature ofccontractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan [I Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art E] Swimming Pools Well ❑ Tobacco Sales ❑ Food Packaging/Sales""" ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ • r THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH COMMENTS c Reviewed on Signature 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 DPW Town Engineer: Signature: Located 384 Osqood Street FFIRE(DEPARTMENT - Temp�Dumpster,on site yes _ .y no. tLocatedtat 124►MainjStreet - ` Fir Departmentsignature/date . -- 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 IYes No DANGER ZONE LITERATURE: . Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine 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 ❑ 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 o 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 DEPARTMENTMFORM07 Revised 2.2008 Location No. Date NORTTOWN OF NORTH ANDOVER 3 O F R A Certificate of Occupancy $ JAcNustt�' Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 5 t S- 2 4 9 ! 3 Building Inspector to a) ;00 O b C . C O m cd O o w O y CD w W co w y m m ■ate w W CL o cn cn . C O zCL m O o O y CD C V V y m m ■ate -CO3 :r � CL O C=c CDo� y C cc Z C=uO ;= O ,� � CDN, CD y O O CD go m N omom, .y c.. O EQ 'a= C r .y m c CL Cos A L y•O $ a. q m o c. Eca 0 CD c� O O cm CD' a . ori CD -3 r o NCD 3 � �p zCL g O 5 z 0 w w P-4 z s v 2 O E L 0 :.s Z 03 0. O CO) � C CD I Com_ CD._ y � � cc CD cam m � H Z _m d CL CM< co C ,� o � � ev ev CJ C Z0 CL d C.� N2 � C C■� ■ C H LLI 0 U) W w LLIW 0 m N �p CD m o 1 y m m -CO3 :r � cm- mOo CDo� N.O. -.2,' cc Z C=uO ,� CL C CDN, CD y O go m M CD omom, .y c.. O .E 'a= C r .y IS go CL Cos A L y•O $ a. q m g O 5 z 0 w w P-4 z s v 2 O E L 0 :.s Z 03 0. O CO) � C CD I Com_ CD._ y � � cc CD cam m � H Z _m d CL CM< co C ,� o � � ev ev CJ C Z0 CL d C.� N2 � C C■� ■ C H LLI 0 U) W w LLIW 0 lU/20/1Ull 2:Jz:0y FM W UO/U4 CERTIFICATE OF LIABILITY INSURANCE n"')'1012512011 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 HOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. ItiPORTAtIT] If tha certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies my require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). Y110110M CONTACT Mi1M Insurance .Associates %rl,C 575 Chickering Road _.......--_�._-^._. ..�._____._ ""'E` P)1011F: FA% Y.-NA1L y North Andover, MA 01845-- O:rth»MYY> rnnwrn:N CDSTOlIF.R TDA. GENERAL LIABILITY TNSiP"IS) AriMr-011; COvt.Wr. nAlf 0 North Andover Building Corp 70 Pillon Road A. I .M. Mutual Insurance Co — ~� 33758 -- - . _-_ --_- nISNA:R x: _ IRSIMER T: p/ Milton, MA 02186 111SOA;N D: �❑CIJtTlKi I1LAE ❑n:rUF COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OP INSURANCE LISTED BELOW HAVE BEEN ISSUED 70 THE INSURED "AM 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 iNSORANCE AFFORDED BY THE POLICIES DASCRIBED HEREIN IS SUBJECT TO ALL THE TEMIS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOIS I''MY HAVE BEEN REDUCED BY PAID CLA7199_ ]nar POLICY HUMBER POLICY EFF POLICY cNe y r L*r TYPE OF INSURANCE I=xAnl/rms O:rth»MYY> EACH OCCURAICE GENERAL LIABILITY ❑CF.44SF.PC IAL ,EAEPAL �❑CIJtTlKi I1LAE ❑n:rUF PMA IS1.5lY.A.DCtYItrCnMl $ N"ED 1.EI' lAnY unr pi•�—xtlonl_ 8 El❑ PEN5011A1. H ADV )WORY-- - _ __.._ GP.fi'L ACfiPC4ATE LIMIT AFULi R:i i!P: GCJIED)11. AUGOF.fiATP. S r`RODnCTS - C.nxP/OP AUU S --_ n,,.,.. OWN.... aL<.+: $ AOTOISOBII.E LIABILITY s 1•+• m•r1arA1) nAAY ADro DUDILY ImtonY ]Per Irorson) - —..— S v8011,Y FlYCIIEOULLP 1161°RY(Wr ArCldmq $ AIJT,<5 I'RIVERlY DI°IA(q: n VIPIt, Alr= iPrr —14-1) S _ S �14,T•APbLA LING sf_GUS __— ._.._.__.._......_...... _ __._...._._.—.... .._.".-.--`. FACII DrttmNl:IICP. 5 E]EICESS LIAL Q CLANS ;ADE AUGREGATI: S _ ❑DF,DIiCT7 BLE _._.._..___.—__......«._ - '___..___._.__..........._._.. S._..._____.-____.._.._.. aFF.TERTltf1 6 $ WOR RERs cOMPENsnmioli_ M EMPLOYEES LIABILITY +PIRrlRnT )°.el- �..__._..___._.I_...._....-_ .__.��_-_....._.___...`. THF. PR5PP.1F,T F..,'PARTl1ER5l$ r.Arn ACCIM:IO 100,000 FY.ECIITIVF OFFICERS AREe.r.. a I'IIf 2 Cr. ('1 7023267012010 R.L. DTS7:ASE -POLICY 1.1hil S 500,000 11/11/2010 11/11/2011 _ r..r.. Dl>vASP. - CA ryn+l.nwN $ 100,000 en7ml:Ars ( DI:SI'N.ti'770A m nrlxmnxxs An L9fAT1DI1Sa �a GERT_IFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EF.PIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE 111711 THE POLICY PROVISIONS_ � AnnnxlzeD nPPnrsranA�Tw----1 , 12, Zip 2011-10-2514:51 DTF Fax Machine ID — Page 3 iA H9 69 4A � E9 69 co r <O r M m nxEd� M O eco C .0 m OD a 00 O^° c m c EA 69 I i I 69 E9 E9 O O O M r 69 fA EA 6ri EA 69 69 69 Vi 69 69 69 69 E:3 09 69 69 E9 O O O O O O O co M r 9 E9 fA 69 EA O O O O O O) O CO M r- 69 69 69 6% 69 69 69 i I I i i 6A 69 69 69 69 69 619, 69 69 69 69 69 69 69 69 69 69 69 vgi 69 69 69 69 69 O O o U') M r 69 EA 69 E9 69 E9 (!? E9 69 ffl 69 d9 E9 69 69 E9 69 to O O O n 69 O O O o LO M 6A 69 6fl 69 69 69 o` C m >a) Co O C O O .O �p O Q U yOE d m mOL Ya) C '2f2 Lama>i ) M- U a) O '6_O O O N >C tml V O y. cis _O U) C uO 0�ee' Fu_m �a— Q o u(6 U w iv t O v U m Y m C 69I c � O m c c a c m E o v a> o .0 m E y -v E 7 VO N a) C L CL O CO C c O o r c N N c c c >>CoocoO O O N' O O.Q•-•-��� V', C C I O U) .+ •� a0+ i To l0 O EA V3 V3 V! V3 V9 V) V) V) d9 'Vi Vi V3 Vi !0 O r+ ul V) V) V) V) 619,03-619, Eft V> 649 69 613 Vi fA N O C') y X E N N O O C ; O O O Q .o C t0 C y , F» 61 Vl Vs 69 V) Vl 63 EH 63 6%6s V) V! Vl V) V) Vi Vi V) 1 1 1 1 1 1 1 1 1 1 • 1 1 1 1 1 va Vl 6-3 Vi tft 61 V3 fR V3 Vl fA 619 619 tH V) 619, 1 1 1 1 1 1 1 1 t 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 I 1 1 Vi V! Vi V) V) 613 Vi V) 03 69 641,40 6%03164 40 Vf V! 63 V) V) 613,613, Vi V! Vi V) V> V3 y a+ O) y += N N p C C C c 0 N d 0 0 U)O m d v) Q 5 C O y y C d C p� 0 ?i t O O o o Q E m« m io 3 c m� c dIE c o c 0 cm vOcE>, oCL om o•N° 3>o4) V vc6 HEm«mc'ri Eo p_�o Qm c��., �o'»- 3 H � 0,2 o N m ea 3 y�� _ O� y 3 y a o - 3 E � Sc m QQ - o � �51.N��arint,cttr - {)�•lutrintcnr r�i•t'Ultlic ,��tfr.t Board of.1 llilti +t;; Re'-,t,larionq,tt1 I �tttrjtf�tt-41• '�. Construction Supervisor Li"eris,e License: CS. '82816 Restrid'ed To: 00 JOHN R LEEMAN JR 70 PILLON ROAD MILTON, MA 02186 . i ..nuni"i"ller ` Expiration: 6/16/2012 Tr": 27393 - - - Office of Consumer A.ffai�-s and , uszness Re ulation g 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvej*nezlt Contractor Registration Registration: 137552 Type: Private Corporation NORTH ANDOVER BUILDING CORP. Expiration: 11/26/2012 Tr# 205622 JOHN LEEMAN P.O. BOX 132 N. ANDOVER, MA 01845 DPS-CAI 0 0 50M•04104•GIO1216 Update Address and return card. Marls reason for change. (_( Address 0 Renewal 0 Employment ❑ Lost Gard The Commonwealth ofMassachusetts Department, of Industrial 4,cidents Office oflnvestigations 600 Washington Street Boston, MA, 02111 S't www.massgov/�'ica 'Workers' Compensation Insurance Affidayxt; Builders/Contlractors/, + leciricians/Plumb licant Information ers • P1iaeoU�.�..a.T __��_� Name Address: Q 6 i�j "(,- ,City/State/Zip: vu Ak A— Phone #: Are you an em I p oyer. Check the appropriate box: I.0 T am a employer with ( 1 4. a general Elemployees (full and/or par * 2. El am a sole proprietor or actor and I have hired ,the ub s partner ship and have no employees lontracisted on the attached shee working for me in any capacity. These sub -contractors have workers' comp, insurance. [No workers' comp, insurance 5. ❑ We are a corporation and its required'] 3. T am a homeowner doing all officers have exercised their work Myself [No workers' comp. right of exemption per MGL c. 152, §1(4), and we have insurance required.] i no employees. [No workers' Com Type of project (required): 6. El New construction 7. &I"M' odeling 8. El Demolition 9. El Building addition 10. El Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.0 Roofrepairs p, msnrancerequired.j A 13 ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy mfoimahon. 1 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicatingsuch. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their wart -P , "ii enty[OyBY Z/Z[lIZsIJYOyl[ling lyorjCers' cOPl2pensation insllpancefoYYily eyyiplOygeS Below is thepolicy and job site information. Insurance Company Name:. Aim mmi-x— Policy # or Self-in.s. Lie. #: '% ( , z 7 1 --1 (p 1 zo 1() ExpiratlonDate: 'lilt .!I Job Site Address: Yc QA / City/State/Zip: �n,� 6�-J ll, Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration Failure to secure coverage tion date. as required under Section 25A ofMGL c.152 can lead to th fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the foe imposition of criminal rm of a STOP WORK ORDERation d t a Of up to $250.00 a day against the violator. Be advised that a copy ofthis stand a fine Iztvestigations of the DL9• for insurance coverage verification. statement may be forwarded to the office r do Hauer zitepatns and 6� nrr_ that the information provirdecd above isue and correct. Date I-1, 7i% `1 ✓�" �«' uYL oncy. Lo not Write an this area, to be coinpreterd by city or town official. City or Town: Permit/License F Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical inspector 5. Plumbing gInspector 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 aparti ants 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 o'r permit to operate a business or to construct buildings in the commonwealth for nny 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 far 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 Plesse 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) andphone 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 !s 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 (ifnecessary) 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. Anew 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 NOTrequired 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: `he C013I uoa-tea , ofSVITassadame-tts Department Qf Industrial Accidents Office of I[nveolgafiqus 600 Washington Street Boston; MIA. 0211 X Ted. # 61.7-727.4900 ext 406 or w7.7-mAsSAFE Revised s 26-05 Fax # 617-727-7749 www.mass.govaa.