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HomeMy WebLinkAboutBuilding Permit #268 - 410 BEAR HILL ROAD 10/15/2008 PERMIT of N°oT" q TOWN OF NORKH ANDOVER 4...,., APPLICA t" i AN.EXAMINATION " D Permit NO: Date Received &�- d '9SE� Date Issued:J0 SgCHUs IMPORTANT:Applicant must complete all items on this page PA 'PROPER OE s P-nn't IA 'l iD; 1='A G Z-Ol ll G DISI"RiC7 His#oc�c Dis�r�c# +es n Machine Shop al:illa aG dao 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 S pl ie We)l �Floodplaaain Wbflands /� rsta 3 D"a tract -a -r -,e alaeT DESCRIPTION OF WORK TO BE PREFORMED: �v 1, oQ x d"t6 ?o-a L CA J3 AAI,A- All) f W6V 6' alt &--oy — Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: C0�1=: TOlael a pe tory Gabstr-c ony;Lipenset %c .. Date: l:! I. 1 � lapra� r�ara#1anse; . Date----, 91. ARCHITECT/ENGINEER 5a5�P �-� S A T-A- -J-ri Phone: I�� Gly 3313 Address: �o i �'(,A�ler�il� S 6l8Gy �, iz- L=NG Reg. No. 317519 FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. �• cs O Total Project Cost: $ tE,(�1 DO O FEE: Check No.: (���5 !� Receipt No.: NOTE: Persons contracting with unregistered contractors 416 no ave access to the guaranty fund y --- Q r� #ure of A ev�t/�Oaner �l a ure•o#contractflr 3 —777`17777 Location - No. Date hl)-Ir- ya NpRTh TOWN OF NORTH ANDOVER � 9 � s • , . Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ /TOTAL $ Check # 21tl,- u � 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 1` Si nature ,��",I.U - 0 COMMENTS hA) a"�- r "712 (�U� C LTH Reviewed on Signature COMMENTS z 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 Osgood Street iIREE ►`i T Te uxr ps#er r: it+e o Lo�tetl�t-'1���l�in Etre�# Mare Dj 'jan 'i kivel ate 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 0 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 ❑ 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 DEPARTMENTWITORM07 Revised 2.2008 NORTH Town of No. o dover, Mass., A-0 ' O LA1. COCMICHEWICK V RATED p'PG,`�5 ri BOARD OF HEALTH Food/Kitchen PERMIT T D.- Septic System ��� � � Ai BUILDING.INSPECTOR THIS CERTIFIES THAT........... ................... r'f .#.. .r....:........ . Foundation has permission to erect........................................ buildings on .... 1 .....:... /�j.... ...... 1►... Rough .4pA )e..2 co... . .............. Chimney to be occupied as ..... ... .............. .... provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final v so PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU S TS . - Rough .......... ..... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR - Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. 10/09/2008 THU 15:11 FAX 781 581 7200 BENEVENTO INS AGENCY 1a001/001 MOND. CERTIFICATE OF LIABILITY INSURANCE oP ID BB DATE(NMMONY" PETRO-1 10/09/08 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Benevento Ina. Agenay, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 497 Humphrey Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, Swampscott, MA 01907- Phona:781-599-3421 Fax:781-581-7200 INSURERS AFFORDING COVERAGE NAIL# INSURED 04URERA LIBERTY MVTVAL INSURANCE PETROSINO CONSTRUCTION INSURER 8; NORFOLK 6 DEDHAM INS. CO. 23965 rm ne Petrosino INSURER C: Hort Rea�dDriveng 01964 INSURER& - INSURER E, COVERAGES 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 POUCES.AGGREGATE LIMBS SHOWN MAY HAVE BEEN REDUCED BY PAD CLAIMS, p�► p(� y� LTRINSRC TYPE E POLICY NUM02R DA E DATE IlaAlb -- UNITS GENERAL LIABILITY EACH OCCURRENCE $300,000 MU TORMIE13 8 X COMMERCIALGENERALLIABILITY R0207052 08/01/08 08/01/09 PRSMISES(EN oaa,ronea 350,000 CLAMS MADE Q OCCUR MED EXP(Any ens penes) 15,000 PERSONAL a ADV INJURY $200,000 GENERALACCREGATE 5600,000 000 GENL AGOREOATE LMT APPLEtS PER: PRODUCTS-COMP/OP AGG 7_606_" 000 X POLICYESC 17 LOC AUTOMOBILE LABILITY COMBANY AUTO A&WINS SINGLE LIMIT 3 ALL OWNED AUTOS BODILY INJURY 3 SCHEDULED AUTO$ (Per Person) HIRED AUTOS NON-OWNED AUTOS BODILY( seCtl PROPERTY DAMAGE (Per QWdgnq GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S ANY AUTO OTHER THAN EAACC 3 -B AUTO ONLY: AGO 3 EXCE331MBRELLA LABIUTY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE 3 3 DEDUCTIBLE 3 RETENTION 3 3 WORKERS COIRPENsATION AND R Y qV UMIT8 ER- A PMETOEW CITY WC2-313-361492-017 04/17/08 04 17/09 E,L,EACHACCIDEN7 sID0,000 A ANY PROPRIETORIPARTNER/EXECUTN& I OFFiCERIMEMBEREXCLUOEDT IEGIELDISEASE_EAEMPOVE 00j.000 S� Yu IAL E.L.DISEASE-POUC0' 000 OTHER DEBCRNrTiON OF OPVAT'IOms!LOCATwms I YENK LES I EXCLUGON6 ADDED BY ENDORSEMENT I SPECIAL PROVISIONS JOb:Pool Home CERTIFICATE HOLDER CANCELLATION TOiONAND SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED MORE THE UFIRAT10N DATE THEREOF.THE ISSURM INSURER WILL ENDEAVOR TO RIAIL 20 DAYB wRTITEN Town Of Andover NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAIWRE TO DO SO SHALL Brooks Residence 410 Bear Hill Rd 11APO6E NOOBLIGATION OR LABIUTY ANY KIND UPON THE INSURER.ITS AGENTS OR Northe Andover MA REPRESENTATIm. ACORD 25(2001108) ;9=29�4ACORD CORPORATION 1988 Tlie Commonwealth of Massachaseltr ;5 Department of Industrial Accidents . i Office of Investigations 600 Washington Street �; a;" Boston, AIA 02111 r www-morass gov/dia Workers' Compensation Insurance Affidavit; Builders/Contrsetors/Eiectricians/Plu»ben Applicant Information Please Print Legibly Name(aosgtesrrorganiaonAndiviei,all:_ yst 1�et os,ivr1 Address: )-N C.'rc.lt` City/SUte/Zip: M- A-ee,..L,=4 \96'L( Phone#: T7V-6Cy-�a3o Are you an employer?Cbeck tate appropriate box: Tyle of project(required): I.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. ©Nom,„construction employees(full and/or part-time).* have hired the sub-contractors 2.91 1 am a sole proprietor or partner- listed on the attached sheet= ?• ❑Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition working for me in any capacity. workers' comp. insurance. g, ❑Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised.their 10:0Electrical repairs or additions 3.0 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 13.❑Other *Any applicast amt chocks box*1 must also fill exa the Section below showing their workers'conte,policy information. Homeowners who suhmil.this Oriidavii indicating the y ere doing all work air then hire outside.oumiredm must submit a new affidavit indualing suck. tComtrnetors the:check this boa mot attnclted to additional sheet showing the name of the sub•cotrtraenxs and their warkers'comp.policy infmination. I am an eMloyer team is providing workers'conipensadon u+swance jor my etaployees Below i8 the info�� policy and job site Insurance Company Name: \ore,. /"%,-ICV 0-1 Policy#or Self-ins.Lie.#:_ C_ --3 S - 3b�y�� - a{ 7 Expiration Date: i( - 1 -©cl Job Site Address: "10 H t ll City/Stateziv: lV• A w2 MA Attach a copy of the workers'cOmpemtion policy declaration page(shoving the policy cumber 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 impriromnent,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against:the violator. Be advised that a copy of this statement maybe forwarded to the Office a Investigations of the DIA for insurance coverage verification. I do hereby cerf6 aatder lar pain(ss and penaida ofperjury that the igJorma[ron provided above is&xu and correct Signature: Phone#: -i$'fo to 4- a© p of}law use only. Do not write in tkis area,to be conrpkW by city or mown official City or Town: PermWLicense# Issuing Authority(circle one): 1.Board of Health 2.Buflding Department 3.City/Tovvn Clerk 4.Electrical Inspector 5 Plumbing Inspector 6.Other Contact Parma: Phone#: 17 9�All aENcN s w 5x5 Sx � SUPPLY LAV. L x2. N k x x sITT � NG RM h ,a a oA x r � f Q' G I JAI 711 1 , Ll I I , i j I i 11 ! I I � i r • i Brd Arming �gu&tio4is a`1nd~tan U, :; Construction SypernisorL'icense l LiC60-se: -CS 18440 �:.. Ex ptrafian -�i 111/20'09 Tr# 91`93 i �. ��,� ,IRes nation flQz� ANGEL O PETRQSf10j• .: 29 WESTWARID SIR r N READING,MA 0166`4" Commissioner . ,per fie �omvaw�wrrcr,�/./ oo�✓�aaeae`ivael�a -\ Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registratio`d:, 131504 Expiration ,$1312010 Tr#' 271672 4 Type 1116lV4dual Angelo Petrosino Angelo Petrosino ~" 29 Westward Circle'.. X North Reading,ma 01864 Administrator Residential Property Record Card PARCEL—ID-.210/064.0-0102-0000.0 MAP:064.0 BLOCK:0102 LOT:0000.0 PARCEL ADDRESSA10 BEAR HILL ROAD FY:2008 PARCEL INFORMATION Use-Code: 101 Sale Price: 1,346,050 Book: 07288 Road Type: T Inspect Date: 09/05/2003 Tax Class: T Sale Date: 11/21/02 Page: 0171 Rd Condition: P Meas Date: 09/05/2003 Owner: Tot Fin Area: 6505 Sale Type: P Cert/Doc: Traffic: M Entrance: X BROOKS, SAMUEL&GAYLE Tot Land Area: 1.03 Sale Valid: Y Water: Collect Id: RB Address: Grantor: CAFUA, MARK P Sewer: Inspect Reas: S 410 BEAR HILL ROAD NORTH ANDOVER MA 01845 Exempt-B/L% / Resid-B/L% 100/100 Comm-B/LP/o Indust-B/L% / Open Sp-B/L% / RESIDENCE INFORMATION LAND INFORMATION Style: CL Tot Rooms: 12 Main Fn Area: 3943 Attic: Y NBHD CODE: 8 NBHD CLASS: 8 ZONE: R1 Story Height: 2.35 Bedrooms: 4 Up Fn Area: 2562 Bsmt Area: 2562 Seg Type Code Method Sq-Ft Acres Influ-Y/N Value Class Roof: H Full Baths: 2 Add Fn Area: Fn Bsmt Area: 1 P 101 S 43560 1.000 226,947 Ext Wall: FB Half Baths: 2 Unfin Area: 896 Bsmt Grade: 2 R 101 A 0 0.030 228 Masonry Trim: Ext Bath Fix: 1 Tot Fin Area: 6505 VALUATION INFORMATION Foundation: CN Bath Qual: L RCNLD: 1078381 Current Total: 1,305,600 Bldg: 1,078,400 Land: 227,200 MktLnd: 227,200 Kitch Qual: L Eff Yr Built: 1987 Mkt Adj: Prior Total: 1,359,000 Bldg: 1,120,100 Land: 238,900 MktLnd: 238,900 Heat Type: HW Ext Kitch: Year Built: 1987 Sound Value: Fuel Type: G Grade: VE Cost Bldg: 1,078,40 Fireplace: 3 Bsmt Gar Cap: Condition: G Att Str Val1: Central AC: Y Bsmt Gar SF: Pct Complete: Att Str Va12: Att Gar SF: 1073/oGood P/F/E/R: ///92 Porch Type Porch Area Porch Grade Factor M 195 P 286 SKETCH PHOTO P 13 286 Sq. 3 14 14 u 8 8 2 ci 1F0.35 3943 Sq.R Ft 1073 Sq. 2562 S q• i 33 37 a i 2 29 M • 13195 6[ a.: 410 BEAR HILL ROAD Parcel ID:210/064.0-0102-0000.0 as of 10/2/08 Page 1 of 1 Massachusetts Department of Environmental Protection Bureau of Resource Protection -Wetlands WPA Form 8B — Certificate of Compliance DEP File Number: Massachusetts Wetlands Protection Act.M.G.L. c. 131, §40 242-158 Provided by DEP A. Project Information Important: When filling out 1. This Certificate of Compliance is issued to: forms on the Mark Cafua computer, use Name only the tab key to move 410 Bear Hill Road your cursor- Mailing Address do not use the North Andover MA return key. c;ty�o,,,,r, 01845 State Zip Code 2. This Certificate of Compliance is issued for work regulated by a final Order of Conditions issued to: Zachary Realty Corporation and Mitchell Johnson Name seam 9/08/82 242-158 Dated DEP File Number 3. The project site is located at: 410 Bear Hill Road North Andover Street Address City/Town 64 Parcel 102 Assessors Map/Plat Number Parcel/Lot Number the final Order of Condition was recorded at the Registry of Deeds for: Property Owner(if different) North Essex 1606 264 County Book Page Certificate 4. A site inspection was made in the presence of the applicant, or the applicant's agent, on: 11/19/02 Date B. Certification Check all that apply: ❑ Complete Certification: It is hereby certified that the work regulated by the above-referenced Order of Conditions has been satisfactorily completed. ® Partial Certification: It is hereby certified that only the following portions of work regulated by the above-referenced Order of Conditions have been satisfactorily completed.The project areas or work subject to this partial certification that have been completed and are released from this Order are: 410 Bear Hill Road only(Lot#could not be determined) -No wetlands exist on the property or within 100 feet of the property wpaform 8b.doc•rev.12/15/00 Page 1 of 3 Massachusetts Department of Environmental Protection - Bureau of Resource Protection -Wetlands DEP File Number: WPA Form 8B — Certificate of Compliance 2-158 Massachusetts Wetlands Protection Act M.G.L. c. 131, 40 24 Provided by DEP B. Certification (cont.) ❑ Invalid Order of Conditions: It is hereby certified that the work regulated by the above- referenced Order of Conditions never commenced. The Order of Conditions has lapsed and is therefore no longer valid. No future work subject to regulation under the Wetlands Protection Act may commence without filing a new Notice of Intent and receiving a new Order of Conditions. ❑ Ongoing Conditions: The following conditions of the Order shall continue: (Include any conditions contained in the Final Order, such as maintenance or monitoring, that should continue for a longer period). Condition Numbers: C. Authorization Issued by: North Andover Conservation j Conservation Commission D e of Is uance This Certifica mu be si by majority of the Conservation Commission and a copy sent to the applicant an app priat gional Office(See Appendix A). Signatures• Cti loll On Of Day Month ay1d Year before me personally appeared S- 6 l"/ to me known to be the person described in and who executed the foregoing instrument and acknowledged that he/she)executed the/same as his/her free act and deed. Notary Pubic My comm sio expires wpaforrn 8b.doc•rev.12/15/00 Page 2 of 3 Massachusetts Department of Environmental Protection Bureau of Resource Protection -Wetlands j DEP File Number: WPA Form 8B — Certificate of Compliance Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 242-158 Provided by DEP D. Recording Confirmation The applicant is responsible for ensuring that this Certificate of Compliance is recorded in the Registry of Deeds or the Land Court for the district in which the land is located. Detach on dotted line and submit to the Conservation Commission. To: Conservation Commission Please be advised that the Certificate of Compliance for the project at: Project Location DEP File Number Has been recorded at the Registry of Deeds of: County for: Property Owner and has been noted in the chain of title of the affected property on: Date Book Page If recorded land, the instrument number which identifies this transaction is: If registered land, the document number which identifies this transaction is: Document Number Signature of Applicant wpaform 8b.doc•rev.12/15/00 Page 3 of 3 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands WPA Appendix A - DEP Regional Addresses I, Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Mail transmittal forms and DEP payments,payable to: Commonwealth of Massachusetts Department of Environmental Protection Box 4062 Boston, MA 02211 DEP Western Region Adams Colrain Hampden Monroe Pittsfield Agawam WaTyrles am 436 Dwight Street 9awam Conway Hancock Montague Plainfield Wales Suite 402 Alford Cummington Hatfield Monterey Richmond Ware Amherst Dalton Hawley Montgomery Rowe Warwick Springfield, MA 01103 Ashfield Deerfield Heath Monson Russell Washington Phone:413-7841100 Becket Easthampton Hinsdale Mount Washington Sandisfield Wendell Belchertown East Longmeadow Holland New Ashford Savoy Westfield Fax:413-7841149 Bemardston Egremont Holyoke New Marlborough Sheffield Westham ton Blandford Erving Huntington New Salem Shelburne p Brimfield Florida West Springfield Lanesborough North Adams Shutesbury West Stockbridge Buckland Gill Lee Northampton Southampton Whately Chademont Goshen Lenox Northfield South Hadley Wilbraham Cheshire Granby Leverett Orange Southwick Williamsburg Chester Granville Leyden Olis Springfield Chesterfield Great Barrington Longmeadow Palmer Williamstown Chicopee Greenfield Ludlow Pelham Stockbridge Windsor Sunderland Worthington Clarksburg Hadley Middlefield Peru Tolland DEP Central Region Acton Charlton Hopkinton Millbury Rutland Uxbridge 627 Main Street Ashbumham Clinton Hubbardston Millville Shirley Warren Ashby Douglas Hudson New Braintree Shrewsbury Webster Worcester, MA 01605 Athol Dudley Holliston Northborough Southborough Westborough Phone:508-792-7650 Auburn Dunstable Lancater Northbridge Southbridge West Boylston Fax:508-792-7621 Ayer East Brooldield Leicester North Brookfield Spencer West Brookfield Barre Fitchburg Leominster Oakham Sterling Westford TDD:508-767-2788 Bellingham Gardner Littleton Oxford Stow Westminster Berlin Grafton Lunenburg Paxton Sturbridge Winchendon Blackstone Groton Marlborough Pepperell Sutton Worcester Bolton Harvard Maynard Petersham Templeton Boxborough Hardwick Medway Phillipston Townsend Boylston Holden Mendon Princeton Tyngsborough Brookfield Hopedale Milford Royalston Upton DEP Southeast Region Abington Dartmouth Freetown Mattapoisett Provincetown Tisbury 20 Riverside Drive Acushnet Dennis Gay Head Middleborough Raynham Truro Attleboro Dighton Gosnold Nantucket Wareham Lakeville, MA 02347 Rehoboth Avon Duxbury Halifax NewBedford Rochester Welfneet Phone:508-946-2700 Barnstable Eastham Hanover North Attleborough Rockland West Bridgewater Fax:508-947-6557 Berkley East Bridgewater Hanson Norton Sandwich Bourne Easton Harwich Norwell Westport TDD:508-946-2795 Scituate West Tisbury Brewster Edgartown Kingston Oak Bluffs Seekonk Whitman Bridgewater Fairhaven Lakeville Orleans Sharon Wrentham Brockton Fall River Mansfield Pembroke Somerset Yarmouth Carver Falmouth Marion Plainville Stoughton Chatham Foxborough Marshfield Plymouth Swansea Chilmark Franklin Mashpee Ptympton Taunton DEP Northeast Region Amesbury Chelmsford Hingham Merrimac Quincy Wakefield 205 Lowell Street Andover Chelsea Holbrook Methuen Randolph Wal ole Arlington Cohasset Hull Middleton p Wilmington,MA 01887 Ashland Concord Ipswich Millis Revereg Waltham Phone:978-661-7600 Bedford Danvers LawrenceMilton Watertown Belmont Rockport WaylandFax: 978-661-7615 Dedham Lexin ton Nahant Roesler Wellesley Beverly Dover Lincoln Natick Salem Wenham TDD:978-661-7679 Billerica Dracut Lowell Needham Boston Essex Salisbury West Newbury ynn Newbury Saugus Weston Boxford Everett Lynnfield Newburyport Sherbom Braintree Framingham Malden Westwood Newton Somerville Weymouth Brookline Georgetown Manchester-By-TheSea Norfolk Stoneham Burlington Gloucester Marblehead North Andover Sudbu Wilmington Cambridge Groveland Medfield ry Winchester North Reading Swampscott Winthrop Canton Hamilton Medford Norwood Tewksbury Woburn Carlisle Haverhill Melrose Peabody Topsfield wpaform8b.doc•Appendix A•rev.11/20/02 Page 1 of 1 To: Julie Parrino November,15,2002 From: Mark P. Cafua Julie I'm requesting a letter of compliance for my house located at 410 Bear Hill Road. The file number is DEP# 242-158. Thank Y ar P. a f Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands DEP File LNumber: )t} WPA Form 8A — Request for Certificate of Compliance ' ���iS� Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Provided by DEP A. Project Information Important: When filling out 1• This request is being made by: forms on the t4ty K_ computer, use Name l only the tab D Gay H4I key to move G your cursor- Mailing Address do not use the Al, 4r4bMJr-k 0/'F9S return key. Cify/Town State 5o Q ' �� .9 ( Zip Code VCU Phone Number 2. This request is in reference to work regulated by a final Order of Conditions issued to: Applicant 12- Dated/ DEP File Number Upon completion of the work 3. The project site is located at: authorized in an Order of 410 Ar—M Street Address tT� f�-l1 -7 �{`/7y,( f✓� Conditions, the City/Town property owner &'7` /� must request a Assessors Map/Plat Number ParciVLot Number Certificate of Compliance 4. The final Order of Conditions was recorded at the Registry of Deeds for: from the issuing authority stating Property Owner(if different) that the work or �1 -,,,,/ portion of the /(/�Z `���Y l 612 work has been C nom_- Book Page satisfactorily completed. Certificate(if registered land) 5. [D/the request is for certification that (check one): L(�' the work regulated by the above-referenced Order of Conditions has been satisfactorilycompleted. ❑ the following portions of the work regulated by the above-referenced Order of Conditions have been satisfactorily completed (use additional paper if necessary). ❑ the above-referenced Order of Conditions has lapsed and is therefore no longer valid, and the work regulated by it was never started. wpaform8a.doc•rev.12/15/00 Page 1 of 2 Massachusetts Department of Environmental Protection ti Bureau of Resource Protection - Wetlands DEP File"umber: WPA Form 8A — Request for Certificate of Compliance }' Provided by DEP Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 A. Project Information (cont.) 6. Did the Order of Conditions for this project, or the portion of the project subject to this request, contain an approval of any plans stamped by a registered professional engineer, architect, landscape architect, or land surveyor? ❑ Yes If yes, attach a written statement by such a professional certifying substantial compliance with the plans and describing what deviation, if any, exists from the plans approved in the Order. ❑ No B. Submittal Requirements Requests for Certificates of Compliance should be directed to the issuing authority that issued the final Order of Conditions (OOC). If the project received an OOC from the Conservation Commission, submit this request to that Commission. If the project was issued a Superseding Order of Conditions or was the subject of an Adjudicatory Hearing Final Decision, submit this request to the appropriate DEP Regional Office (see Appendix A). wpaform8a.doc•rev.12/15/00 Page 2 of 2 I CERTIFY THAT THE EXISTING DWELLING IS LOCATED AS SHOWN HEREON AND THAT THE EXISTING DWELLING MEETS THE APPLICABLE SETBACKS REQUIREMENTS AND THE ZONING BY-LAW OF THE TOWN OF NORTH ANDOVER AND THAT IT DOES NOT LIE WITHIN THE HUD FLOODco��� HAZARD ZONE A AS DEFINED ON THE LATEST FLOODYINSURANCE ATEMAP. �N OFJAMESW.NIEVA MES W. NIEVA P.L.S. #39399 39399 qQFESs10NP� PREPARED FOR AND OWNED BY: u v SAMUEL & GAYLE BROOKS 1-b 410 410 BEAR HILL ROAD NORTH ANDOVER, MASSACHUSETTS 01845 0 TELEPHONE: (978) 258-7006 PLAN REFERENCE: PLAN #11095, RECORDED AT NORTHERN Ni 81141.40 i DISTRICT ESSEX COUNTY 110.00 DEED REFERENCE: BOOK 7288, PAGE 171 - - ZONING REFERENCE: W 64 BLOCK 102 RESIDENTIAL (R-1) r 45,224 80. FT. 1.04 ACES ► N/F SAS JEL+GAAYLE ff=S I ASSESSORS MAP 64, BLOCK 102 BUILDING SETBACKS: rr FRONT 25' 0' I SIDE 10' iJ PROPOSED PATIO REAR 10' i I 3TAIBS PROPOSED292 1 THIS SITE LIES WITHIN A 1 POOL i WATERSHED DISTRICT. 1 DECK 1 PROPOSED ® PATIO i I 1 I r i ( j I 3 r EXISTING I tt Jr 2 -WOOD FRAMED CONCFIETE RE o N 1 No.410 DRIVEWAY � 0 N STEPS i 1 , i CONCRETE WALK i rSTEPS , r , 1 1 I 1 i pA i 1 Z i I J r (A 1 i 0) ! ( W N r r rn -- __ __ __ _BUILDING SETBACK�_1YPICALL WON ROD L=144.13' 54.11' R=606.20' S11'50'56"E BEAR HILI. ROAD MIM-WWDE) Dunn McKenzie, Inc. PROPOSED POOL PLAN LAND SURVEYING AND CIVIL ENGINEERING 410 BEAR HILL ROAD 206 DEDHAM STREET, Rt.1A at Rt.115 NORTH ANDOVER, MASSACHUSETTS 01845 NORFOLK, MASSACHUSETTS 02056 (508) 384-3990 — FAX (508) 384-3905 staff@dunnmckenzie.com SCALE: 1"=30' MAY 19, 2008 PROJECT #4658 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 permittlicense 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 bum 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 Revised 5-26=05 Fax#617-727-7749 www.mass.gov/dia ZN The Commonwealth of Massachusetts _ � r 1 De S t.J� ; '� � : Department of Industrial Accidents' ; ... Office of Investigations QA • 600 Washington Street \ b M M Boston , MA 02111 www-Mass-gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Piumbers Applicant Information Please Print Legiiily Name (Business/Organization/Individual): Ly_u Address: X`N, tee.. � C<rc_e City/State/Zip: N R-e��:^�.,r, ,�1 \$b`( Phone#: -Are you an employer?Check the appropriate box: Type of project(required): l.❑ I an a employer with 4. ❑ 1 am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6 New construction 2.® 1 am a sole proprietor or partner- listed on the attached sheet. $ 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. 7 Demolition working for me in any capacity. workers' comp. insurance. o workers' comp. insurance 5. 9. Building addition [N p. ❑ We are a corporation and its required.] officers have exercised.their 10:❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I 1-❑ Plumbing repairs or additions myself [No workers' comp. c. 152, §1(4),and we have no 12•❑ Roof repairs insurance required.] t employees. [No workers' comp. insurance required.] 13.0 Other *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information, Homeownerswho submit rids affidavit indicatifIg they are duitio eil ivur::and[hen'r-,ire outside cuntractors must submit anew 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 information. policy and job site Insurance Company Name: Policy#or Self-ins. Lic.#:—Nd C a ---:s S - 3rojy — a� '7 Expiration Date: Job Site Address:_ Ll )b City/State/Zip: Al 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of rr Investigations of the DIA for insurance coverage verification. I do hereby certify underlhe pains and penalties of perjury that the information provided above is true and correct (' V,, Sianature: ®� V Date: I 0 —� - UFS Phone#: g-7$'(o G Lt— p 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#: