HomeMy WebLinkAboutBuilding Permit #719-14 - 410 GREAT POND ROAD 4/16/2014TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued:
P RTANT: Applicant must complete all items on this page
LOCATION 9Q�
PROPERTY OWNS DUN a'_V .
Prin 100 Year Old Structure
MAP NO: U PARCELIV 70NING DISTRICT: Historic District
Machine Shop Villaqe
yes no
yes no
TYPE OF IMPROVEMENT.
PROPOSED USE
Res'dential
Non- Residential
❑ l Iew 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 PERFORMED:
Identification Pleas y e Qr�Print Clearly)
OWNER: Name: A �C Phone: L0
Address: (o(�5p- U JI
4
CONTRACTOR Name: Al x'41 v,� �� Phone: D t c4 5 �5.
Address: D e 1 0 ) 9 6 L(
Supervisor's Construction License: aLI`�6r 621 Exp. Date: D 6
Home Improvement License: %ods 5-q,5-
Jq,5- _ Exp. Date: l Za 61
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BOLDING PER 12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: FEE: $
Check No.:�F L l9 Receipt No.: f
NOTE: Persons contracting with unregistered contractors do not have acc ss t tle guara and
Signaturq of Agent/Owner Signature of contract r 1
Plans Submitted Li Plans Waived ❑ /P ertified Plot Plan ❑ Stamped Plans ❑
05
Building Department
. The fol.Swing'is"a-list of the required -forms to be filled out for the appropriate permit to .be obtained.
Roofit,g, Siding, Interior Rehabilitation Permits
❑ B:ailding Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Gr G.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
a Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
a Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o 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
a Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
o Mass check Energy Compliance Report
Li 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 apw-�al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submAted with the building application
Doc: Doc.Buil,ding Permit Revised 2012
: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
KnTF-Q nnrl DATA _ (Fnr rlenartment use)
c�S o
® Notified for pickup - Date
Doc.Building Permit Revised 2010
Plans Submitted ❑
Plans Waived ElCertified Plot Plan ElStamped Plans ❑
TYPE _OF.;SEWERAGE DiSPOSAL-
Public Sewer V
Tanning/MassageBodyArt ❑...
Swimming Pools ❑
Well ❑
Tobacco.Sales ❑
ToodPackaging/Sales ❑
Private (septic tank, etc..- ❑ -
-Permanent D*pster on Site IT
THE. FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED - DATE APPROVED -
PLANNING'& DEVELOPMENT ❑
MMENTS 01tr3',;4 OF 6fnerCA) zone -
\
CONSERVATION Reviewed on Sic nature
COMMENTS : „5•:. '.'��, �
HEALTH Reviewed on Signature
CQQ�IIMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comm
Conservation Decision: Comments
Water & Sewer ConneCtionisignature & Date Driveway Permit
DPW Tow;; Engineer: Signature:
LOcatea 6M
FIRE DEPARTMI.E`N'T - Temp Dumpster on site yes no
Located'at 124 Mair Street
Fire "Departine►it signatu'r_e/date '
i
COMMENTS
a careet
Location
No. — Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $�
Building/Frame Permit Fee $/_
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # I�
Building Inspector
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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/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organizationgndividual):
Address:
City/State/Zip: % kfA JV1,61 p ' _Phone #: U
Are an employer? Check the appropriate box:
�1.I
Type of project (required):
1. am a employer with QL
4• ❑ I am a general contractor and I
6. ❑ New construction
employees (fffl and/o a-_&_jae)P
have hired the sub -contractors
�• ❑Remodeling
2. El am a sole proprietor or p er-
listed on the attached sheet.
ship and'have no employees
These sub -contractors have
8. ❑ Demolition
working for me in any capacity.
workers' comp. insurance.
9. Vuilding addition
[No workers' comp. insurance
5. ❑ We are a corporation and its
10.❑Electrical repairs or additions
required.]
3. ❑ I am a homeowner doing all work
officers have exercised their
right of exemption per MGL
11.❑ Plumbing. repairs or additions
myself. [No workers' comp.
c. 152, § 1(4), and we have no
12. ❑ Roof repairs
insurance required.] i
employees. [No workers'
131J Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information.
I 'Homeowners who submit this affidavit indicating they tie doing all work and then hire outside contractors must submit anew 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.
X am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. .� i _
Insurance Company N
Policy # or Self -ins. Lic. #: U 15 Expiration Date: L—
Job Site Address: �— NMI City/State/Zip: o ;4J1/0
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as requiredunder 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
Investigations p%e DIA for insurance coverage verification.
X do hereby tert� under the
ofperjury that the information provided,above is true and correct.
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. EIectrical Inspector 5. Plumbing Inspector
6. Other - - -
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 ofhire,-
express or implied, oral or. written."
An employeiis 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 numbers) 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 maybe 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 Coxa momealth of Massachusetts
Departmeaat ofladustrial .Accidents
Office ofInvestigations
600 Washington. Street
Boston., MA 02111
TO. #r117-727-4900 ext 406 or 1-877 MASSAFE
Revised 5-26-05 Fax # 617-727-7749
49
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�\ Office of Consumer Affairs & Business Regulation License or registration valid for individul use only
OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
egistration: 125545 Type: Office of Consumer Affairs and Business Regulation
Up xpiration:: 1%�6/2076s Individual 10 Park Plaza -Suite 5170
T - Boston, MA 02116
TAYLOR MADE 4� � = = "�-
.,
VICTOR TAYLOR � �OF,
`
101 RESERVOIR ST;
_i
CHERRY VALLEY, MA 01611' Undersecretary Not valid without gnature
Massachusetts - Department of Public Safety
Board of Building Regulations and'Standards
Construction Supervisor
License: CS -048019
ANDREW V TAYT-hR
10 FIELDSTONE V
N READING MA%018
Y�
Expiration ,
Commissioner 09/10/2015
J
wry 1AYL (_Hk' ^ K 20LINNUU/62JO 001864
STATE AUTO®
r
Insurance Companies p eS INSURED COPY BOP 2730624 01
BUSINESSOWNERS POLICY COMMON DECLARATIONS
NAMED INSURED AND MAILING ADDRESS:
AGENT NAME AND ADDRESS.
First Named Insured Is Specified To Be:
LINNANE INS AGENCY INC
ANDREW TAYLOR
280 MAIN ST STE 101
10 FIELDSTONE WAY
NORTH READING, MA 01864
N READING, MA 01864
BUSINESS DESCRIPTION: Carpentry - Residential
POLICY PERIOD.
AGENT TELEPHONE NUMBER:
AGT. NO.
From: 04/03/2014 To: 04/03/2015
(978) 664-2000
0078230
COVERAGE PROVIDED BY:
A STATE AUTO INSURED SINCE.
Patrons Mutual Insurance Company of Connecticut
2011
AUDITABLE POLICY.
POLICY STATUS:
AFTER-HOURS CLAIMS SERVICE.
Yes
Renewal - Standard
800-766-1853 or www.stateauto.com
I he coverage and these declarations are effective 12:01 AM Standard Time on 04/03/2014 at the above mailing
address.
BUSINESS ENTITY TYPE:
BILLING ACCOUNT NUMBER:
BILLING QUESTIONS?
Individual
CB00582169
Call 800-444-9950 X5118
Direct Bill Insured 4 -Pay
BUSINESS DESCRIPTION: Carpentry - Residential
Upon valid payment of premium when due, these renewal declarations continue your policy for the period indicated.
In return for the payment of the premium and subject to all the terms of this policy, we agree with you to provide the
insurance as stated in this policy.
PREMIUM SUMMARY BY COVERAGE PARTS AND POLICIES
This policy consists of the following coverage parts or policies for which a premium is indicated. This premium may be
subject to adjustment.
COVERAGE PARTS PREMIUMS
Businessowners Special Property Coverages $29.00
Commercial General Liability Coverage Part $605.00
Businessowners Extra Coverage $27.00
Commercial Inland Marine - See IM Declarations SM 50 00 $78.00
Terrorism (included in total below) $7.00
POLICY TOTAL AT INCEPTION $739.00
If terminated at your request, this policy is subject to a minimum retained premium of
These declarations together with the Common Policy Conditions and coverage form(s) and any
endorsement(s) identified on these declarations and attached to your policy complete the above
numbered policy.
Countersigned
(Date)
By
(Authorized Representative)
Issue Date 01/20/2014 10:41.03 AM BP 60 00 (01/08) Page 001 of 002
350.00
ice►
yrs TRAVELERS J
TYPE AR
WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (6HUB-5B31898-1 -1 4)
RENEWAL OF (6HUB-5831 898-1 -1 3 )
INSURER: THE TRAVELERS INDEMNITY COMPANY OF AMERICA
1
INSURED:
TAYLOR, ANDREW
10 FIELDSTONE WAY
NORTH READING MA 01864
Insured is AN INDIVIDUAL
NCCI CO CODE: 13439
PRODUCER:
LINNANE INSURANCE AGENCY
280 MAIN STREET
NORTH READING MA 01864
Other work places and Identification numbers are shown in the schedule(s) attached.
_ 2. The policy period is from 04-11 -14 to 04-11-15 12:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in
item 3.A. The limits of our liability under Part Two are:
o.
Bodily Injury by Accident: $ 500000 Each Accident
Bodily Injury by Disease: $ 500000 Policy Limit
Bodily Injury by Disease: $ 500000 Each Employee
�= C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 0GA
o=
D. This policy includes these endorsements and schedules:
o� SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
o�
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All required Information is subject to verification and change by audit to be made ANNUALLY.
DATE OF ISSUE: 03-31-14 UA
OFFICE: ORLANDO INDUS AFF 161
PRODUCER: LINNANE INSURANCE AGENCY
000558
77TGX
ST ASSIGN: MA