HomeMy WebLinkAboutBuilding Permit #322 - 42 ROYAL CREST DRIVE 10/29/2007 SC)T-- O` r►ORT#f BUILDING PERMIT o��t,b° '616 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 2� Date Received f10 ,r,° 9SSACH�15�� Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION cit of nnt PROPERTY OVIINER ^ s Pnnt MAP N0: PARCEL: ZOJVING 1STCT 1 RIHist©ric Distfiet yes : } "Machine 5ho.p Village ares n 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 -0 11 Ftoodplaln 111etlands Watershed:t3 strict Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: Identification Please Type or Print Clearly) OWNER: Name: Gk- Phone: isa Address: ­-` its CQNTRACT R Narrae: -Phone: x7 C Supervisor's ConstructionLicense %.' 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 BAS D ON$125.00 PER S.F. V Total Project Cost: $ Vlr00.cac) FEE: $ Check No.: A Receipt No.: �O�3-2— NOTE: NOTE: Persons contracting Wzue red contractors do not have access to th uaranty fund Signature of Agent/Owner Slgraature of cont=actud i Plans Submitted Plans Waived Certified Plot Plan Stamped Plans i 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 DAT EJECTED DATE APPROVED CONSERVATION ' COMMENTS DATE REJECTED DAT APPR ED HEALTH COMMENTS e� 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 Located at 384 Osgood Street FIRE DEPARTMENT -Teriip'Dumpster on site dies no Located at 124Main Street Fire Department sigma"tureldate e, ,-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 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 - Date �...... _ _.__.._—._._._... ---._......_................ _......._.......... Doc.Building Permit Revised 2007 t 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 a 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 i 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 BuildingPlans 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 DEPARTMENT:BPFORM07 Revised 2.2007 1 %ORTH �q o 4Andover Town _ 3 A-61. dover, Mass., 11 COCMIC EWICK A'rEC '9S E BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THISCERTIFIES THAT............67M. .k(w.a...............................................il.L................................................................ Foundation has permission to erect........................................ buildings on ....�.l.....j. .... ./.4,04,017- ...... ....... Rough to be occupied as..)..Ot 'L.. ...� .� ............7.✓.. i. ......:.'f.... ..... ................. .... imn y . h' e provided that the person accepting is per shall in every respect conform to the terms o he application 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 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU STARTS Rough Service ............................... ............................................ ............ PECTOR 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 SIDEJ Smoke Det. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street W= Boston,MA 02111 F- aM www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): 2 co Address: i �� �e �►c�o.�q S� City/State/Zip: MA OisQ Phone#: 5Gxs .761-111 Are,you an employer?Check the appropriate box: Type of project(required):, 1.❑ I am a employer with L__ 4. ❑ I am a general contractor and I * have hired the sub-contractors employees(full and/or part-time). 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers9. ❑ Building addition [No workers' comp.insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised.their 11.[9-Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.[1 Other 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. lContractors 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-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. n Insurance Company Name: Policy#or Self-ins. Lic.#:, kJC. `� O3 Expiration Date: Job Site Address: 1:q1_2) 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 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties ofperjury that the information provided >above is true and correct. Signatuie: 'z _- Date: `L`/ � 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 61 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 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.ra 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(!)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 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 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 Fax# 617-727-7749 Revised 1122-06 www.mass.gov/dia ✓fu;�arremrnau�a.�a ts�..��JJtt.��.ts¢�8'; � _; � �` `� BOARD OF BUILD[NG RECyUi:ATIQtJS 1 .;�k ��' License: CONSTRUCTION SUPERVISOR , ., Number CS 077853 Birthdptes 11118/1957 Expires: 11/1812007 Tr.no: 9499.0 b Restricted 00 KENNETH E SALSMAN 2 ADAMS STREET WESTBORO, MA 01581_. Commissioner �'lee-Pamvrnamurea�a�✓�ae��ud�a Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR t Registration: 149914 Expiration: 2/21/2008 Type: Private Corporation TREELINE CONSTRUCTION,INC. KENNETH SALSMAN 130 WESTBOROUGH STREET ,, ✓ MILLBURY,MA 01527 Administrator TEc�+�o,YYYY, .aca1.. D CERTIFICATE OF LIABILITY' INSUPANCE GSR pA PRODUCER THIS CERTIFICATE IS ISSUW AS A MATTER OF INFORMATION f ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Kittredge Insurance Agency Inc HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 155E Otis St. , P.0, Sox 1129 ALTER THE COVERAGE AFFORDED BY THE POUCIESBELOW, Northboro NA 01532 Phone: 508-393-77441 Fax:508-393-6983 INSURERS AFFORDING COVERAGE NAIC0 INSURED INSURGRA: NAUTILUS INSURANCE COMPANY INSURER B: Hanover in$=ance Group . 22292 x'x6 eline Construction Tno, INSURER C: Aftaklosn Homs mmuranaa Co. 3.30 Westboro Street INSURERO: ~ blilibury HA 01527 -_ INSURER E: COVERAGES THE PO'ICIES OF INSURANCE LISTED BELOW HAVE BEEN iSSUEO TO THE INSURED NAMED ABOVE FOR THE POLICY F[R10D INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CON-RACT OR OTHER DOCUMENT WIYH RESPECTTO WHICH THIS CERTIF)GATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED SY THE POLICIES OESCRIOE0 HEREIN IS SUBJECT TO ALL THE TERM$,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.Ac.10keGATE LIMITS$HOVyN MAY HAVE SEEN REDUCED BY IAIO CLAIMS. LTR NSR YYFE FI RANCE POLICY NUMBER 007E µpUDOIYY� + LIMITS AENHRAL.UA81LITY EACH OCCURRENCE $1000000 A X OOMMERCIALGENERAL LIABL.ITY 14C659999 04/21/07 04/21/08 P REM ISES(Eeo ice) $100000 CLAIMS MACe u OCCUR MED EMP(Arty cr person) $5000 RSONAL&ADV INJURY $1000000 LGE NEPAL AG(3REGA-f5 s2000000 GEtr"L AaGR[GA'TE LIM17 APPLIES PER, i PRODUCTS•COMPIOPAC,G $2000000 11-71 POLICY ECT LOC AUTCMO�LE LIAUIUYy COMBINED SINGLE LIMIT ANY AUTO AFN838702401 07/27/07 i 07/27/08 1 (Es accltlem) $1000000 ALL OWNED AUTOS I I BODILYINJURV S X SCHEDULED AUTOS I (Parprrson) X HIRED AUTOS X NOT-OV/NED AUTOS BODILY INJURY I$ (Pef erctlent; 1 PROPERTY DAMAGE $ {Per accident; GARAGE LU1Bil.ITY AUTO ONLY-EA ACCIDENT $ - EA ACC $ L�I ANY AUTO i 01HTO ONHYN ACiG S I EXcE55NMBRELLALIABILITY [ACh OCCURRENCE $ OCCUR �± CLAIMS MADE ! I I .AGGREGATE $ OEDUCTI81-E ! Yj P.E?ENTION II S WORKERS COMPENSATION AND - EMPLOYERS'LIASIUTIY S TOR I&A RR ANY PROPRIEYOR/FARTNERIMCUTIVE WC8979703 12/24/06 12/24/07 E.L EACHACCIDENT yes,abBCfIDe rXrye! $1000000 IP Yea,OB OIMEMBEREXCLUDED? I E.L.DISEASE.-EA EMPLOYE $1000QO.0 SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $1 GOOD OO OTHER DESCR!PnON OF OPERA'MONS I LOCATIONS I VEHICLESI EXCLUSIONS ADDED BY ENDORSEMENT i 5PECIAL PROVISIONS ' CERTIFICATE HOLDER CANCELLAT*N NOANDDV SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BC CANCELLED BEFONX THE EXPIRATIQN OATS THEREOF,THE 1$810I0,10 INSURER WILL GNbeAVOR TD MAIL 20 DAYS WRITTEN N07IC.E TO THE CERTIFICATE HOLDER NAMED YO THII L$FT,BUT FAILURE TO DO SO SHALL Town of North Andover IMP05E NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,IT$AGENTS OR REPR TATIVES. North Andover. HAL AUTHDREPRES,EN TIVE �2/ ACORD 25(201)1f08j @ACORD CDRPORA*nON 1988 IMPORTANT If the certificate holder is an ADDITIONAL_ INSURED, the policy(les) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing Insurer(s),authorized representative or producer,and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25(20!11(08) Location No. �� , Date 1&ORTN TOWN OF NORTH ANDOVER ' Certificate of Occupancy $ Building/Frame Permit Fee $ J�cHus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 20762 Building Inspector