HomeMy WebLinkAboutBuilding Permit #695 - 410 BEAR HILL ROAD 5/23/2008BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued:
16
IMPORTANT: Applicant must complete all items on this page
LOCATION�1t� 3Ar*v0.._ , 4,61, �
Print
PROPERTY OWNER At.tlUel
MAP NO:y PARCEL: ZONING DISTRICT: Historic District yes
2_/0 v G t/ / / :'� Machine Shop Village ves
TYPE OF IMPROVEMENT
PROPOSED USE
Residential v
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 Well
Floodplain Wetlands
Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
Identification PIT Type or Print Clearly)
OWNER: Name: C wpz . r_.!:ICKA Phone: R"1 L
Address: `ft 6
CONTRACTOR Name _✓�!w l/, ,,� t3 � Phone: 906&q4417-6,
Address: `7r L rev,. -r-u7 -�- ,LPy
Supervisor's Construction License: c> 5'3 c ci o Exp. Date: (g 17- -J a�
Home Improvement License: i o sa Exp. Date: -7 t o g
ARCH ITECT/EN01 N EEF Pi. _ L PA Phone: g-00 6 QG 6 Q7 --t
Address:
. 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: $_ R/, s"� o FEE: $1d'���
Check No.: 190 /) Receipt No.: oJ i4-�;1—
NOTE: Persons contracting with unregistered contractors do not have ayeess4,o the guaranty fund
Signature of Agent/Owne _ ignature of contract_..
(a
Location
No. r Date
NORTh TOWN OF NORTH ANDOVER
_ _ O
Certificate of Occupancy $ �T
Building/Frame Permit Fee $ J
s�CHus
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # boo
2 1 1 82 Building Inspector
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 OG2
COMMENTS a (,- w/lrrr� 5 l,vi C 00
HEALTH Reviewed on Signature
COMMENTS
e
L
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:
t_ocatea 364 Usgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
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 21A —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
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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 -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 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-# 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26-05 www.mass.gov/dia
0-101-
The
.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/El p'P cpaps ntmbers
Legibl,
I
Name (Business/Organization/Tndividual):
its vY (Z"
40
Address:—
a ne#:
City/State/Zip: Phone #: d (� 4
Are ou an employer? Check th�ppropriate box:
Z� 4. ❑ I am a general contractor and I
1. I am a employer with
employees (full and/or part-time).*
have hired the sub -contractors
listed on the attached sheet
2. ❑ 1 am a sole proprietor or partner-
These sub -contractors have
ship and have no employees
capacity.
working for me in any capaci
workers' comp. insurance:
5• E] We are a corporation and its
[No workers' comp. insurance
officers have exercised their
required.]
3. ❑ 1 am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
C. 152, § 1(4), and we have no
employees. [No workers'
insurance required.] t
comp, insurance required.]
Type of project (required):
6. ❑ New construction
7.. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or addition:
11.❑ Plumbing repairs or addition:
12.0 Roof repairs
13.❑ Other,
*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.
tContractors 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:
ov C> Expiration Date: �y � Z° o �
Policy # or Self -ins. Lie. #: �! e_ GT �I //' ,,/ _
N� /3 es -r �j�y City/State/Zip: ! , o ma✓ e'er -
Job Site Address: of $yv-
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 ascivil penalties in the form of a STOP WORK ORDER and a fir
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 c�er It painspens tte perjury that the information provided above is true and correct.
Phone #:
Official use only. Do not write in this area, to be completed by city or town officid
City or Town:
A th rit (circle one):
Permit/License #
Issuing u o y
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
Environmental
POOLS
Des ign E.-Veellence It, M7
1 84P, Riverneck Road - C"heIrrisfof-d, MA 0 1824
BOARD OF BUILDING REGULATIONS
License CONSTRUCTION SUPERVISOR
K. Numb -, yr
Number o
Birthdate: 06/28,11,964
Expires: J6/28/2009 Tr. no: �9
Restricted: 00
DAVID BRABANT
54 MCDONALD ROAD
MI-MINGTON MA z
Commissioner
8C ; 6-6
-"-')-69976
078-256-0200 0
978-256-6620 FAX
1848 Riveinneck Road
Chelmsford, MA 01824
—aar,d of3u:klngRegulafions and Standards
License or registration valid for individul use
HOME �t OVEMENT CONTRACTOR
before the expiration date. If found retu.— to:
72
pwgis
Board of Building Regulations and Standards
08
One Ashburton ]Place Rm 1301
Y a"ie CO'P01-2tOn
Boston, ML 02108
B
Not valld.withont sl ure
MA 0, 82G'— Deputy Administrator
BOARD OF BUILDING REGULATIONS
License CONSTRUCTION SUPERVISOR
K. Numb -, yr
Number o
Birthdate: 06/28,11,964
Expires: J6/28/2009 Tr. no: �9
Restricted: 00
DAVID BRABANT
54 MCDONALD ROAD
MI-MINGTON MA z
Commissioner
8C ; 6-6
-"-')-69976
078-256-0200 0
978-256-6620 FAX
1848 Riveinneck Road
Chelmsford, MA 01824
05/12/2008 22:11 19782560200 ENVIRONMENTAL POOLS PAGE 02
ACORDTM CERTIFICATE OF LIABILITY INSURANCE
5/1gi o e '
PRODUCER (602) 635-4848 FAX: (866) 696-4918
AIMS Insurance Program Managers
15230 N. 75th Street, Sten: 1002
Scottsdale AZ 85260
THIS CERTIFICATE 18 ISSUED AS A MATTER OF INFORMATION
OKY . AND CONFERS NO RIONTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POUCIks BELOW,
INSURERS AFFORDING COVERAGE NAIL t
INSURED
Environmental. Poolas, Ino.
184R Riverneak Road
Chelmsford MA 01824
INSURER A: Aroh Insurance Company
INSURER B:
INSURER I'
INSURER D.
IN$URERE:
6G6S
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING AN
REQUIREMENT, TERM OR CONOrrION OF ANY CONTRACT OR OTHER DOCUMENT NTH RESPECT TO WHICH THI6 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 LIMaS SHOWN MAY HAVE BEE 4 REDUCED BY PAID Q1 AWA
INSR
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POLICY NUMBER
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LIMITS
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MED EXP $ 5,000
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AUTOMOWLE LIACIUTY
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EMPLOYERS,uASKITY
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5/1.4/2007
08/14/2008
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13"cRipum OF OPBRAnoHSILOCAFIONSNEHICLEs7ExCLUS1oWs ADDED BY ENDORSEMENTISPECIAL PROM N"
*Except for ten (10) day* C4111*611*tion notice applies for non payment of premium.
EVIDENCE OF INSURANCE
SHOULD ANY OF THE ABOVE DESCRIOCD POLICIA$ 0 cANdffLL.EO WORE THE
EXMTH)N DATE YHEREOF, THE ISSUING INSURER WILL ENDEAVOR TO NjPK
*30 DAYs WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO 7HE LEFT, BUT
FAILURE TO 00 30 anALL IMPOSE No OBUQATMN OR UAMLTTY OF ANY KIND UPON THE
AUTHORiZM REPRESENTATIVE'
Pater Codfrey
ACIDRD z5 (2001108) 0 ACORD CORPORATION 1888
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