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HomeMy WebLinkAboutBuilding Permit #258-13 - 412 SALEM STREET 10/2/2012 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: �3 Date Received Date Issued: IM ORTANT: Applicant must complete all items on this page y� L®CATIO,Ni - - _ Pr�'t PROPERTiYP 01NNERb / / �//��� ° - - Print 10.0 YearL0ld'Structure yes,.4 MAP`'N0= FARGEL,y �.ZQNING ©IS;TRICT _ Histonc,Qistrict yes;P i . . - _ v Mdchine�Shop Uillagea yens n TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family I ❑Addition El Two or more family ❑ Industria ❑Alteration No. of units: ❑ Commercial epair, replacement ElAssessory Bldg El Others: ❑ Demolition _❑ Other _ i ❑ Septic, ❑Welly - p`Flooa_', M,Wetl5h-9, ❑ WatershediDistr ct� E;Water/S;ewer, DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: /,��� ��ss/f Phone: J l Address: Y �� . ',G NITRACITOR' Name - -11�k r --one._.c — -- - - -= r Ph ���� Address: } Supervisozs�ConstructonLicense �� / Exp Date . Horne Improvement License: �`.. ' r; 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: $ -g®- Check No.: m Receipt No.: �✓'�� �� NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund FSignatureof AgenUOwner=' �}�Signature�ofEcontractor, Y _ _s��. Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Swimmin Pools El Art ❑ g 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 COMMENTS HEALTH Reviewed on Siqnature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Siqnature ®ate Driveway Permit r DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT _ Temp Dumpster on site yes no Located at:124,M._ ain Street - � .: Fire Department sigiiatu're/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 DANCER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use ® Notified for pickup - Date r Doc.Building Permit Revised 2010 i 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 o 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 a Photo Copy of H.I.C. And C.S.L. Licenses o 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: Doc.Building Permit Revised 2012 1 Location N. D»/tl/,�Zz. ^\ TOWN OF NORTH ANDOVER - , �4i��Ta . \ «. . ! Certificate of Occupancy $ «/ Building/Frame Permit Fee $ ° { \� Funa,loPermit Fee $ _ Other Permit Fee $ � . y box. : TOTAL $ > g Check* IZI- � 25773 BaU $19et ? 9 NORTH own of tAndover o :� - .:�.. . 0 No. - T sa LAH! h " ver, Mass, <e i���- A_ COCNICHlW1CM - 7S U BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System THIS CERTIFIES THAT (/"��ll���` °� / G % .F�. ........................................................... BUILDING INSPECTOR has permission to erect.......................... buildings on . .... ......S�.lel................;......ArlJ ,�............................... Foundation Rough tobe occupied as .............................. ........l.`. '.r.: '. :........................1................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in 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 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough �yL/� Service ........................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. Smoke Det. SEE REVERSE SIDE too qJ4Wa C04161U",On . / PROPOSAL Bill McLiesh 412 Salem Street North Andover, MA 01845 978-687-7014 October 2, 2012 Remove and replace siding along roof line as discussed. TOTAL LABOR AND MATERIAL $ 1,250.00 Terms: $00.00 upon signing of contract(not to exceed 1/3 of total contract price) a $ Work to begin on %v c? $1,250.00 when job complete Job to be completed on Submitted by: Chris Rivet MA Lic#CS072173 HIC#139962 207 Winter Street (C)508-265-3115 (H)978-704-1165 North Andover,MA 01845 All Home Improvement Contractors shall be registered.Inquiries about a contractor relating to a registration should be directed to; Registration Division,Program Coordinator One Ashburton Place Room 1301 Boston, MA 02108 Tel:617-727-3200 ext.25239 All building permits required will be the obtained by the contractor.Homeowners who obtain their own permits are excluded from access to the Guarantee Fund. ACCEPTANCE OF PROPOSAL The above prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified.Payments will be made as outlined above. DO NOT SIGN THIS CONTRACT IF TITER ARE ANY BLANK SPACES! C r )) Date Homeowner s Signature (5 Date/V / / ' Contractors Signature Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-072173 CHRISTOPHER PRIVET�- 207 WINTER ST. gz N ANDOVER MA 0114',,-,--f ; Expiration Commissioner 06/02/2014 ✓fze'to. vzowwe o ,/l�aa�aclivaeC�a Off cco.'ConsurncrAffairs&B sincssRegulatii HOME iPROVEMENT CONTRACTOR ` yy .Registrkion .,1.39962 Type kr — expiration: ,918/2013 Individual >f.R STOPHER-F..RIVcT,'::- CIAIISTOPHER RIVET`=_ 2C-7 WINTER ST. N ;-ANDOVER,MA 0184-5--- Undersecretary' '��V CERTIFICATE ®F LIABILITY INSURANCE OP ID NEMA °Ao2(MM/DD /12 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(ies)must be endorsed. If SUBROGATION IS WAIVED,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). 'RODUCER Macdonald & Pangione Insurance PHONE P.O. Box 428 (A/C,No,Ext): I (A/C,No): 104 Main Street ADDRESS: North Andover MA 01845 FIRMUCER CUSTOMERID#: CHRIS-5 Phone:978-688-6921 Fax:978-688-5350 1NSURER(S)AFFORDING COVERAGE I NAIC# vsURED INSURERA: Preferred Mutual Ins Co '15024 Christopher Rivet INSURER B! 207 Winter St. North Andover MA 01845 INSURERC: INSURER D: l INSURER E: INSURER F: :OVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS 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 CONTRACTOR 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 POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ,TR TYPE OF INSURANCE B F INS L WVD', POLICY NUMBER ;(MM/DDIYYYY)�(MM/DDIYYYY)I LIMITS GENERAL LIABILITY { (EACH OCCURRENCE I S 1,OOO,OOO A I X i COMMERCIAL GENERAL LIABILITY 'CPP 0180 57 01 05 (09/26/11 !09/26/;3 i PREMISES(Eaoccurrence) S 100,000 j ( CLAIMS-MADE X OCCUR _ I MED EXP(Any one person) 5 5,000 E, I PERSONAL&ADV INJURY I S 1,000,000 GENERAL AGGREGATE S 2 r 000,000 If GEN L AGGREGATE LIMIT APPLIES PER: { PRODUCTS-COMP/OP AGG $2,000,000 j X (POLICY I 1 dE ;LOC liiij i S I AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT I ANY AUTO i (Ea accident) $ 1 ( ! BODILY INJURY(Per person) $ ALL OWNED AUTOS ► I BODILY INJURY(Per accident) S I SCHEDULED AUTOS i 1 PROPERTY DAMAGE ' I HIRED AUTOS ,(Per accident) $ F-I NON-OWNED AUTOS I ! S I I_J UMBRELLA LIAB OCCUR I I i I EACH OCCURRENCE S EXCESS LIAB i CLAIMS-MADE I I I AGGREGATE S I -- ' DEDUCTIBLE i I RETENTION S J WORKERS COMPENSATION II WC STATU- 1 OTH- AND EMPLOYERS'LIABILITY Y/N ? _ TORY LIMITS I I ER ANY PROPRIETOR/PARTNER/EXECUTIV OFFICER/MEMBER EXCLUDED? .NIA i E.L.EACH ACCIDENT $ (Mandatory in NH) ! I ! I I,yes,describe under I i E.L DISEASE-EA EMPLOYEEI S DESCRIPTION OF OPERATIONS below ! t i E.L.DISEASE-POLICY LIMIT,S ; } I E I � ESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) :ertificate holder as listed below ;ERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRA71ON DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of North Andover AUTHORIZED REPRESENTATIVE Osgood St No Andover MA 01845 ©1988-2009 ACORD CORPORATION. All rights reserved. .CORD 25(2009/09) The ACORD name and logo are registered marks of ACORD 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/Organization/Individual): Address: /1,42 !i/3'/ City/State/Zip:�o, Phone#: r Are you an employer?Check the appropriate box: _ 1.❑ I am a employer with 4. ❑ I am a general contractor and I Type of project(required): employees(full and/or part-time).* have hired the sub-contractors 6 EJ New construction 2.�am a sole proprietor or partner- listed on the attached shget. t 7• [✓Remodeling ship and have no employees These sub-contractors have 8. El Demolition working for me in any capacity. workers'comp.insurance. 9. [❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.,0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12. insurance required.]f 12.E]Roof repairs q ued.] employees. [No workers' comp.insurance required.] 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. #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 isthe policy and job site information. Insurance Company Name: 100fAX_ Policy#or Self-ins.Lie. 0 0/3FO 7 OY- Expiration Date: Job Site Address: ��d� �L�• — Ci /State ' ty /Zip: �. 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 ' p civil penalties in the r firm 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 of the DIA for insurance coverage verification. fP l ry Ido hereby certify der a pain n enalties o er u that the information providled abov is tr a and correct. Si nature: Phone#: E only. Do not write in this area,to be completed by city or town official. n: Permit/License# hority(circle one): Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspectorson: 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 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 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: I The Corr-nonweaZth of Massachusetts } Department of Industrial Accidents Offiee of Investigations 600 Washington Street Boston,M.A. 02111 Tel. 4 617.727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.wass.gov/dia