HomeMy WebLinkAboutBuilding Permit #902-14 - 410 BLUE RIDGE ROAD 6/11/2014TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
.
Permit N0. Date Received 6hzl�
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION
Print
PROPERTY OWNER -
,/� Print 100 Year Old Structure
MAP NO: V (9� PARCEL: ZONING DISTRICT: Historic District
Machine Shop Villa
yes no
yes( n
no
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 ❑ Well
❑ Floodplain ❑ Wetlands
❑ Watershed District
El Water/Sewer
DESGKIP IIUN OF VVUMM I U ut rtmrUmmr-u.
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
A _I _I
CONTRACTOR Named V % Phone �_ �Z,�
Address:
Supervisor's Construction Licenser LS �� �D ��, Exp. Date:
Home Improvement License:
Exp. Date:
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: $ FEE: $ V, 4 `60
Check No.: I l L�-] Receipt No.: 2-] �eGlb
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner Signature of contractor
Plans Submitted LJ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
Location
No. -�142-lq
Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee
Other Permit Fee
TOTAL
Check #-�14l
r k
66ilding Inspector
Plans Submitted ❑ Plans -Waived ❑.- - Certified Plot Plan ❑ Stamped Plans ❑
-TYPE OPSEWERAGEDISRO .
Public Sewer
Tanning/MassageBody Art ❑ ..
.Swimming Pools ❑
Well ❑
Tobacco Sales ❑
Food Packaging/Sales ❑
Private:(septic tank, etc_ ❑ -.::.
permanent Dfiinpster on -Site El
THE -..FOLLOWING ISECTI.ONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED - DATEAPPR-OVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
CONSERVATION Reviewed on_ Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
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 'Tu`v Engineer: Signature:
FIRE DEPARTME--`NT -Temp Dumpster on site yes
Located:at 124 Mair Street
- Fire Departinerit signature/date`''
COMMENTS .
Located 384 Osgood 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.l.ocatior, mast -or service drop requires approval of
Electrical Inspector
Yee No
No
DANGER Z®NEt on 2E�A and RE m.$1oo � o0o fine
MGL -.Chapter 166.Se
Doc.Building Permit Revised 2010
�,ernned Plot Plan [T Stamped Plans 0
Building Department
The fol'owing is'a=list of the required.foims to be_filled outtfor.the appropriate. permit to be obtained.
Roofii g, Siding, Interior Rehabilitation Permits
o Building Permit Application
❑ Workers Comp Affidavit
o 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 cans .if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the apur?al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be subm.tted with the building application
Doc: Doc.Bui?ding Permit Revised 2012
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The Commonwealth of Massaehusetts
Departmentoflndusfrigl,4ccidle is
Office of Investigatzons
640 Washington Street
Boston, .MA 02111
www.mass.gov/clia
Workers' Compensation Insurance Affidavit: Buffders/Cont°actors)FIectriclansMIiimber�
Mplitcant �nforznaiion Please Print Le�itbXy
Name (Busin¢ss/Organizationftd%vidual):
.A.ddress:, � � s �� � VF
City/State/Zip: al' eA Phone #•
Are you an employer? Check the appropriate box:
Type of project (required):
am a employer with
4. ❑ I wn a general contractor and 1
6• [] New cOnsiraction
employees (full and/or part-time).*
have B redthe sub-contractors/tk
.L
7• [Remodeling � %
2. [] I am a sole proprietor or partner
listed on the attached sheet.
eeV
ship and`haveno.employees
working forme in any capacity,
These sub -contractors have
workers' comp. insurance.
S. El Demolition
g, ❑ Building addition
[No workers' comp. insurance
5. ❑ We are a corporation and its
officers have exercised.their
I0.)] Electrical repairs or additions
required.]
3. [] I am a homeowner doing allwork
-right of exemption per MGL
I1.[] Plumbing repairs or additions
myself: [No workers' comp.
c.152, §1(4), and wehave no
UPRoofrepairs
insurancere ed. i
]
employees. [No workers'
13.[] Other
comp. insurance required.]
,!Any applicant that checks box#I must also fill outthe section below showing their workers' compensation policy information.
i Homeowners who submitfhis affidavit indicatingthey Air doing all workand then hire outside contractors must submit a new affidavit indicating such.
TContractors that checkthis box must attached an additional sheet showingthe name of the sub -contractors and theirworkers' comp. policy information.
am an employer that isproviding MvkeYs' cornpelasation insurance fot' my employees B&W is the policy antijolt site
information. n 1
Insurance Company
Policy # or SOJf ins. Lic. #: Expiration Data:
lob Site Address: ��� �City/State/Zip:
Attach, a copy of'the workers' comp ensation$oUcy declaration page (showing the policy number and expiration date).
Failure to secure coverage as xequiredunder Section 25A of`MGL o.152 can lead to the, imposition of criminal penalties of a
flue up to $1,500.00 and/or one-year imprisonment, as well .as cKpenalties in the form of a STOP WORK, ORDER and a fins
ofup to $250.00 a day against the violator. Be advised that a copy of this statement may be foxwaxded to the Office of
fnvestigations of the DIA. for insurance coverage verification.
X do Hereby ger " u dei t nd penalties of verjury that the information provided above is true and correct.
DOB -
Official use only. Do not write in this area, to he completed by city or tort 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 Pers on• Phone M.
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 orimpH4 oral orwxztien."
An employdis defined as "an individual, partnership, association, corporation or other legal entity, or anytwo or mole
of the foregoing engaged in a joint enterprise, and including the legal representatives of w deceased em to r or the
receiver ox trustee cf an individual, partnership, association or other legal entity, employing employees VT ver the
owner of a dwelling house having notmore than three apartments and who xesides 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 outhe grounds or building appurtenant thereto shall not because of such employment be deemedto bean, employes."
MGL chapter 152, §25C(6) also states that "every state or local iieensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth .fox 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 ofpublic work until acceptable evidence of compliance with the insurance
requirements of this chapterhave beenpresented to the contracting authority."
Applicants
Please fill out the Workers' compensation affidavit completely, by checking ,fie boxes that apply to your situation and, if
necessary, supply sub -contractors) name(s), address(es) andphoue numbers) along with their certificates) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with, no employees other that, the
members or partners, are notrequired to cant' workers' compensation. insurance. Iran LLC or LLP does have
employees, a policy is required. Be advised thatthis affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance caverage. Also be sure to sign and date the affidavit. The affidavit should
be xetumed-to the city or town thatthe application for the, permit or license is being requested, not the Deprartment of
industrial Accidents. Should you have any questions regarding the law or if you are required to obtain, a workers'
compensationpolicy, 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 andprinted 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 Whichwiil 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 iudicaiiug current
Policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
towau):':& copy of'the affidavit that has been officially stamped or marked by the city or town may be provided to fire
applicant as proofthat a valid aff davitis on file for future permits or licenses. Anew affidavit mtist 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 Offzce 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:
Tho CQxMoil
oatZ ol'XV1as �a..e?zv._.Ptf� -
DepaztmeAt QfWwWal Acoldeliia
600WasWVon Sjjeet
L'090111 U.. A 02111
TO, 0 617-7.27-4..00 W406 or 1-877- MSAF
Revised 5-26-05 FM # 617-727-7749
' v�W�xta��,gQvfdia
Paychex, Inc. RF 5/29/2014 3:13:21 PM PAGE 2/002 Fax Server
CERTIFICATE OF LIABILITY INSURANCE
05/29/2014 DY'
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 NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WANED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsement(s).
PRODUCER
Paychex Insurance Agency, Inc.
CONTACT .
Pnoroe------- FAX
150 Sawgrass Drive
IA/CEMAIL Ext • AfC Na:
Rochester, NY 14620
ADDRESS;
X i COMMERCIAL GENERAL LIABILITY !
INSURERS AFFORDING COVERAGE-- A
877-266-6850
-----------
INSURERA: At''GUARD INSURANCE COMPANY
INSURED
INSURER B; NORGUARD INSURANCE COMPANY
David M Morin
INSURER C:
DBA DAVID M MORIN REMODELING
INSURER D:
365 SUTTON STREET
INSURERS:
NORTH ANDOVER, MA 01845
i DABP507523
06113@013
INSURER F:
vTHIS IS TO CERTIFY THAT 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 VNTH 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR E XP
15 5U'). MMS YDlYYYY LIMITS
LTR TYPE OF INSURANCE POLICY NUMBER MMIDIOA'YYY
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DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required)
NORTH ANDOVER BUILDING DEPARTMENT
OSGOOD STREET
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE
POLICY PROVISIONS, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO
OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS, OR
REPRESENTATIVES.
0 ACORD CORPORA", Alt rights reserved.
ACORD 25 {2.010105) Tho ACORD name anrl:rogo are registered marks of ACORD
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Commercial Dev �� Environmental Affairs/MassGIS. The information depicted on this ma is
: �'� P P
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Development Dist r definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER
Development Dist �" MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING
Zoning Overlay
Industri
it1 District THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY
BAdult Entertainment
:- Industri
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Proposal Submitted To
Phone �: r,
Date
Address
Job Name
Job Location
Architect
Date of Plans
Job Phone
we nereoy suomit specincations ano estimates tor:
WE PROPOSE hereby to furnish material and labor — complete in accordance with specifications below, for the sum of:
t 1 * dollars
Payment to be made as follows: '
All material is guaranteed to be as specified. All work to be completed in a workmanlike
manner according to standard practices. Any alteration or deviation from above specifications
involving extra costs will be executed only upon written orders, and will become an extra
charge over and above the estimate. All agreements contingent upon strikes, accidents or
delays beyond our control. Owner to carry fire, tornado and other necessary insurance. Our
workers are fully covered by Workman's Compensation Insurance.
Acceptance of Proposal:
The above prices, specifications and conditions are satisfactory and are hereby accepted.
You are authorized to do the work as specified. Payment will be made as outlined above.
Date of Acceptance `'
Authorized t //
Signature
Note: This proposal may be withdrawn
by us if not accepted within
Signature _L�z!�— V,
Signature-�
days.
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