HomeMy WebLinkAboutBuilding Permit #804-15 - 42 PARKER STREET 5/1/2018 NORTF(
BUILDING PERMIT
L� TOWN OF NORTH ANDOVER 32 h `'• �_'h.:s `
APPLICATION FOR PLAN EXAMINATION ~ _
�D � 1
Permit N ++ t� Date Received I �y"OR
O#:U rED
SSACHU
Date Issued:
IMPORTANT:Applicant must complete all items on this page
IP,R®PERTY 01NNE2�
p-rint 10D XY a Str�ce yes
( � PARC:EL= =Z®NING'±DIS�TRI;CT HistonCe,Distict yes no.
- Machine Shop�%ill`ag ,yes: 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
__. _ �,__ d._ _ ... — ----
D;Septic Well. ❑IFloodplan Wetlands 0 1Nate shed ®istncf
gYWate�/Sewer_n
DESCRIPTION OF WORK TO BE PERFORMED:
Identificati Please Type or Print Clearly' p
OWNER: Name: Jp�i �✓'�6_&S rpt-- _ Phone:
/ / /Yll� /j/ 0194j—
Address:
__.
f- f
.Contractor Marne. _ -
Address:.
b7 a
$ S`tper�utsor's C�onstuctCon License a�_ �_ _ - n
S '.��� �4 __�EXp. EDatiea '�.�.� _�....
7 1 ®ate
+Horne clrnprov meriffce
`LinseJ �=_ iExp.#
. _ L9
— - -
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COSTS SED ON$125.00 PER S.F.
Total Project Cost: �Ul�
FEE:
Check No.: Receipt No.:
--NOTE-:-----
o. �
NOTE:----Persons contracting-with;unre -ed contractors do-not-havewccess-to-the-guaranty f UP d__
atu_re 'of+corfractor
Signature�of Agefit/Own.er__
=` I
Plans Submitted ❑ Plans Waived Certified Plot Plan ❑ Stamped Plans ❑ '
TypE, F SEWERAGE DISPOSAL
p1�bIic Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑
Well ❑ Tobacco Sales ❑
Food Packaging/Sales ❑
Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑
i
. I
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
4
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
I
a Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
i
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature& Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPAR�ITMEN. Hemp r®urnpstePion.site ye-
-a _ no
FLgtetl,at 124;Maln_SteeY -- -_-
Frre iDepartwont,
signature/date;_
C.OMMENTtS
Dimension
Number of Stories: Total square feet of floor area, based on Exteria imensions.
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)
❑ Notified for pickup Call Email
t
Date Time Contact Name {
Doc.Building Pennit Revised 2014
k .
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 _
jWorkers Comp Affidavit �— fi� 6 ►n d�L - r�J%0 ' '
❑ Photo Copy Of H� I.0 end/Or C.S.L. Licenses / d ' a
o 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
o Building Permit Application
o Certified Surveyed Plot Plan
o Workers Comp Affidavit
o Photo Copy of H.I.C. And C.S.L. Licenses
o Copy
Of Contract
o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And.
Hydraulic Calculations (If Applicable)
Li 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
o Certified Proposed Plot Plan
o Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
u 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
a 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
i
Doc:Building Permit Revised 2014
1
NORTH
own of . t ndover
0 :
No. -
�` h ver, Mass ti . iir
cocHicnew�c� �1'
BOARD OF HEALTH
Food/Kitchen
PERMIT D Septic System
THIS CERTIFIES THAT '- .� , BUILDING INSPECTOR
..... . .. . . ......... ...
has permission to erect buildings on ... ..... .* Q Foundation
.......I.............�... ........ ............. .... ........
Rough
to be occupied as ............... ... ...... ......... .......... .. ..... �®�..................... Chimney
provided that the person accepting this ermit shall in every respect conform he 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 CONSTRUCTI S Rough
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.
r ROOFSMITCHELL SAAB SMOKESTACKS
INSULATION GENERAL CONTRACTOR TOWERS
PAINTING POINTING
REPAIRING 57 Bridge Street • Salem, N H 03079 WATERPROOFING
SIDING 603-893-6332 Tel/Fax: 603-893-3466
PROPOSAL AND CONTRACT
DATE:........ .......................................
//�� / -� f/
TO\j75 t:. ....✓�� . . .... :.��'� '� Type of work........ .........................................................
YP
................ PROPERTY....T . .....� ..... . ... ......ojj .....
LOCATION ..,.. :.. .. .... ._ ..........
We propose to furnish all necessary labor, material, and equipment (except as noted below) to perform the
following work in First Class workmanlike manner.
Roof maintenance is required annually. Not responsible for water back up caused by snow and ice.
Scope of work./.e ` ....
2. .;� . ...� .. -.. .....................
9-. , .... - ... ........
�. �..... . . ..... . .... . . .. ......... .. _Zee.....4?t7...
(- C ......... ..... .... ... .... ....( ��a►.... —
oz
� � y
...�............. ............................................................................................................................................
For t e Sum of . J? ....................................
i
Signed by.... . ..
a
The Commonwealth of Massachusetts
M Department of IndustrialAccidents
a � --- 1 Congress Street, Suite 100
_ Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legib
Name (Business/Organization/Individual):
9
Address:
City/State/Zip: Phone#: 9s' c�
Are you employer?Check the appropriate box: Type of project(required):
1.0 I am.a.employer with_employees(fulland/or part-time.* 7. [:]New construction
2.FJ I am a sole proprietor or partnership and have no employees working for me in 8. []Remodeling
any capacity.[No workers'comp.insurance required.]
9. F1 Demolition
3.FJ I am a homeowner doing all work myself[No workers'comp.insurance required.]t
10E]Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
• 12.(]Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs
These sub-contractors have employees and have workers'comp.insivance.1
6.❑We are a corporation and its officers have exercised their right of'exemption per MGL c. 14.❑Other.
152,§1(4),and we have no employees.[No workers'comp.insurance required.] ,
*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 state whether or not those entities have
employees. If the sub-cbfi racfors have employees,they must provide their workers'comp.policy number.
I air an employer that is pro vidhig workers'compensation insurance for my employees.'Below is the policy and job site
information.
Insurance Company Name:_1/1-,/,0,,rr,57
Policy#or Self-ins.Lie.#: ��� �/>l! �'���"� Expiration Date:
zJob Site Address: City/State/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 MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
Idohereby certify under th pa'ns an enalt' s of per' ry that the information provided above is true and correct.
Si nature: Date:
Phone#:
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#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
s .t
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract-o:f 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,foi•confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned tb 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 pennit/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 bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel.# 617-727-4900 ext.7406 or 1-877-NIASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
V�6 C!-691!.7114Jt(IP.CI.I.f�Cr����GCIJJfGC/LIGiG'CIJ
Office of Consumer Affairs&Business Regulation
a
ME IMPROVEMENT CONTRACTOR
Urelgistration: 171835 Type:
piration: .;::4/24/20:15 DBA
MITCHELL SAAB GENERAL CONTRACTOR
MITCHELL SAAB
57 BRIDGE ST
SALEM,NH 03079 Undersecretary
- -- _
f _ 4' ''..Its.
3. v_
X1+5
tisaMe 14yp a
-.-SAAR
Massachusetts-Department of Public Safety, c
Board of Building Regulations and Standards
Construction Supcnisor
License: CS-020864 ;
MITCfIELL L SA.0
57 BRIDGE ST
SALEM NH 03079
lIIII'"% Expiration
Commissioner 07/23/2015
KI_ee-eU14t14tU) Ie; -i lrtln!y(.'tf]l(if 13tl Y ULtIlUUI
�...•+ SAASM-1 OP to:,JY
DA CERTIFICATE OF LIABILITY INSURANCE i �01
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY ARID CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRNAATIIIFLY OR NEGATIi1ELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE.POLICIES
AE"LOW THIS CERTIFICATE OF INSURANCE WFES NOT CONSTITUTE A CONTRACT 9ETAgFEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER;AND TM CERTIFICATE HOLDER-
IMPORTANT.
OLDERIMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the polley(1es)must be endorsed, if SUBROGATION IS WAIVED,ouojoat to
the Lanus and condi Ions of the policy,certain pollees may rnqulm an endorsamertt A statsmsm on this eartiftem class not center rl"to the
certificate holder In Hsu of such ondereemo s
PRoOQM Phone:978 688 8829; _ .
Michaud,Rowe And Ruscak Ins. FAX -------
P.O.Box 488 Fax:978 SSI 2130��
North Andover,ESA 01145 i MORE= i
Mark S.Rowe.CIG - - - -
rN AW-O! mGCOVERAGE NA1Gs
b=MM A-Travelers Insurance ComPaN
insaneo Mitchell Saab rKsuREll s
578 Bridge St
Salem,NN 02679 =LtIsuRERc
Rfsurz=tt a: --- --..----- --- - -
tNsuaERE:
I Ri3URERF:
COVERAGES CERTIFICATE NUFABER: RE MION NUMBER:
TWIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED SELOW H.AJE BEEN ISSUED TO THE INSURED NAMED A1GVE ZOR THE 00UCY PERIOD
INDICATED. NOTVtMSTANDING ANY REQUIREMENT.TERM CIR CONDITION OF ANY CONTRACT OR OTRI R DOCUNIENT W" RESPECT TO I,NIUCH THIS I
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DE:SCRBED HEREIN IS SJBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES-LIMITS TS SHOWN MAYHAVE B'�N REDUCED BY PAID CLAW.
--- - -
'INSRT *YPc QF NSUMntI"E _ [ADDLI9U8F�— POLICYNUNHER �' EFF=' ■YLTR UtbS"
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CERTIFICATE HOLDER CANCELLATION
f $NO=ANY CF THE ABOHE DESCRIBfID POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL. BE DELIVERED iN
ACCORDANCE WITH THE POLICY PROVISIONS. I
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IAU HOR¢EeRSPResar■ATILq
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01988-2010 ACORD CORPOPATIi3N. All rights reserved.
ACORD 26(2010105) The AGORD name and loge are regisWred marks of ACMD
CERTIFICATE OF, LIABILITY INSUIRANCE DA
`MMIRWYYYYi
TE
0411012015
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 certiflests holder is an ADDITIONAL INSURED,the policy(Ie9)mt.Ist be endorsed. If SUBROGATION IS WAIVED, subject to
the terns and condIdorm of the policy,certain pollciea may require an endominent A statement on We certificate does not confer rights to the
certificate holder In Mau of such endomement(s).
PRODUCER 52MITr LaftyCowan
Cowan Insurance Agency;Inc. PHONE 4.978 372.1451 F -mi52 -as
359 Main Street la coMwlninsuranceusm
Haverhill MA 01830 1 -
ANaftk CawAft
INSURED URER a• _
Mtchell Lee Saab MkU G- -
S7B Bridge Strut
Salam NH 03079 e9SURP-R E-
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COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSVREO NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM CR CONDITION OF ANY CONTRAQT 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 POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAMS,
INSRTypE{ INSURANCE. Alm V POLICY EPP POLICY*Omn EXP __ LIMITS
MERAL LUUAUTY m.
I EACH CURRENGE 300 400
A X ERCIAL GeNCRAL LIABILITY DA=i T; tom, i $50,000
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CLAIMSAWI! �occt;R L11MR91 0410212015 10410112018 MED Exp rAmeneoe-ani I s5 000
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603493.6332
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CERTIFICATE HOLDER CANCELLATION
SHOULD ANYOF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS,
77Z6A�TPIE
_ -
Q)19882010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010105) The ACORD name and toga areistered marks ofACORD
Location 2
Date
N..
. '- TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $ �
TOTAL $
Check#
2 8 6 g 1 Building Inspector