HomeMy WebLinkAboutBuilding Permit #742 - 435 ANDOVER STREET 6/16/2002�ivn ry
BUILDING PERMIT of
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TOWN o
TOWN OF NORTH ANDOVER F �
APPLICATION FOR PLAN EXAMINATION
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Permit N0: Date Received�0
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Date Issued: � 6
IMPORTANT: Applicant must complete all items on this pane
LOCATION Z� 3 ,5- 44 anr -0--
PROPERTY
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PROPERTY OWNER c`'tZ,,7yG / —G I / -z-z- }
Print
MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Villaqe yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One family
Addition
Two or more family
Industrial
Alt of
No. of units:
Commercia
Ot f i6rs:
Repair, replacement
Assessory Bldg
Demolition
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
�
^ DESCRIPTION OF WORK TO BE PREFORMED:
i r r", L✓wi/C;6 COOL, & 7-41' 0-F i /� 1`x(1 lf-lNus a t ityaLGLy
( -r, 124 rY w, J,-, , -t d d N *,- JI f ) ✓ I Jti OL �4 r't r! A /,/- +�• a 11 J
Identification Please Type or Print Clearly) /
OWNER: Name: t 1'v Cc Cara- Phone:
Address: o - V IJ pr , ivurun60.y h rt'lt,
CONTRACTOR Name: 'J (r(411T a }rrnt,J-es at Phone: 7h `30'7 —Ls'/,f/
Address: J6 F XCA J 4.
Supervisor's Construction License: C,S OU Ua 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: $ y -S, C? Q FEE: $
Check No.: � Receipt No.: C,
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner d.^Signature of contractor,
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U(A`7
Location
No. Date
TOWN OF NORTH ANDOVER
9
Certificate of Occupancy $ _
Building/Frame Permit Fee $ t) Y
s�CHus
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # 0? 6
2 r} n
L
+ 44 Building Inspector
I
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
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
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
e
DATE REJECTED DATE APPROVED
Reviewed on Signature
rri
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/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
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
Doe.Building Permit Revised 2008
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
❑ 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
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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2008
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{ ' www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Informationnn Please Print Legibly
Name (Business/Organization/Individual): All-er.11 kr
Address: /�� weft k-V-rr J /. J'y`Fi s, Pro✓ �t,(r ()-256Y
City/State/Zip: v; Phone #: 5`4f' Y r l
Are you an employer? Check the appropriate bo
The Commonwealth of Massachusetts
^,
Department of Industrial Accidents
have hired the sub -contractors
Office of Investigations
MIN,
600 Washington Street
11,
` e °
R,� .
Boston, AM 02111
{ ' www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Informationnn Please Print Legibly
Name (Business/Organization/Individual): All-er.11 kr
Address: /�� weft k-V-rr J /. J'y`Fi s, Pro✓ �t,(r ()-256Y
City/State/Zip: v; Phone #: 5`4f' Y r l
Are you an employer? Check the appropriate bo
1. ❑ I am a employer with
4. am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ 1 am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. El Ne nstruction
7. emodeling
8. ❑ Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
11.❑ Plumbing repairs or additions
12. F-1 Roof repairs
13.❑ Other
*Any applicant that checks box # t 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 is the policy and job site
information. / /
Insurance Company Name: / y4 % 6,� t v , L( r l'l'! v -f L"& f
Policy # or Self -ins. Lic. #: J_/ _ PR _a 6 `%1 3 6o 2 Expiration Date: 0/ b/— OSS
Job Site Address: 'al r ndd", fir. City/State/Zip: /V J ,1Jr,,tr J17,, Oi0'Vl
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 may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify u �r pair a{id penalties of perjury that the information provided above is true and correct.
Signature: Date: ;/! 416
.30' ft's/
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.
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:
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
Revised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia
10/09/2007 16:54 4013335467 DOLAN INSURANCE AGCY PAGE 02
Page l of 1
. rAtilunl Insun:nce. C.).
One Beacon Centre
Warwick, Rhode Island 02886-1378
(401)825-2667 Fax 825-2855
Certificate of Porkers' Compensation & Em to ers' Liability insurance
CERTIFICATE HOLDER INSURED
Amaral Revite Corp
- — -- - — --- -- -- — -- DBA: Amaral Associates
148 West River Street
Providence, RI 02904-2615
This certificate is issued as a mat :er of information only and confers no rights on the certificate holder.
This certifirmte CinP4 not amend t,xtnnri nr nitFr tha by tln� -M—, I—]—,
COVr.RACES
This is to certify that policy of it isurance listed below have been issued to the insured named above for
the policy period indicated. Noti vithstanding any requirement, term or condition of any contract or other
document with respect to which this certificate may be issued or may pertain, the insurance afforded by
the policies described herein is s object to all the terms, exclusions, and conditions of such policies.
TYPE OF POLICY POLICY POLICY LIMITS OF
INSURANCE NUMBER EFFECTIVE EXPIRATION LIABILITY
DATE DATE
Statutory benefits Required by the
Workers' Rhode Island Workers
Compensation 0000012412 10-01-2007 10-01.2008 Compensation Law (X)
and
Employers'
Liability $1,000,000 Each Accident
$1,000,000 Policy Limit by disease
$1,000,000 Each Employee by
disease
DESCRIPTION OF OPERATIC NS/I OCATIONS/VEHiCLrS/SPECIAL ITEMS
COSTRUCTION SERVICES
T CANCELLATION
Should the above policy be canes!led before expiration date thereof, Thu Beacon Mutual Insurance
Company will mail 10 days wv tt m notice to the certificate owner named herein by regular mail.
Authorized Representative
Date Issued:
6 D
10/09/2007
Broker of Record ��
Successfully Submitted
James M Dolan
660 Mendon Road
Cumberland, RI 02864-6215
https.//beacononline.beaco.nrnutu il.comfbcneert.nsf/Toda.vs+Certificates/SF58360675C6A,,, 10/9/2007
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GENERAL CONTRACTORS
June 12, 2008
Lew Holt
Bertuccis Corporation
155 Otis Street
Northboro, MA
Re: Bertuccis Italian Restaurante
435 Andover Street
North Andover, MA
Take out remodel
We are please to provide services to complete the remodel of the take area at the aboved mentioned location.
For the sum of Forty-five thousand and 00/100 dollars ($45,000.00). The scope of work is as reviewed.
ACCEPTANCE OF PROPOSAL
By signing proposal it is understood that you are in agreement with the above summary of services. Please
sign and return and copy to our office.
Signature: Date:
Print Name: '� L✓ l f
148 West River Street, Suite 5 — Providence, RI 02904
T:401.454.6867 — F: 401.454.5485—www.amarairevite.com
aosror.r<;s,22r CERT;FiCATE OF INSURANCE
The company indicated below certifies that the insurance afforded by the policy or policies numbered and
described below is in force as of the effective date of this certificate. This Certificate of Insurance
does not amend, extend, or otherwise alter the Terms and Conditions of Insurance coverage contained in any
policy numbered and described below.
CERTIFICATE HOLDER:
I TYPE OF INSURANCE
L.ABILTTY
j [Xl Liability and
( Medical Expense
[XI Personal and
j Advertising Injury
j [Xl Medical Expenses
j [X] Fire Legal
( Liability
I
j [ 7 Other Liability
I
i AUTOMOBILE LIABILITY
( IXl BUSINFSS AUTO
[Xl Owned
[XI Hired
[XI Non -Owned
INSURED:
AMARAL REVITE CORP & AMARAL
ASSOCIATES
148 W RIVER ST STE 5
PROVIDENCE, RI 02904-2615
( POLICY NUMBER I POLICY I POLICY
j & ISSUING CO. TEFF. DATE IEXP. DATE
( 51 -PR -260489-3002 101-01-08 j 01-01-09
NATIONWIDE
MUTUAL
INSURANCE CO. j
I I I
I I 1
I I I
I I �
j I
I � I
I
51-B.A-260489-3004
NATIONWIDE
PROPERTY &
CASUALTY CO.
01-01-08
01-01-09
LIMITS OF LIA.8IL17t
(*LIMITS AT INCEPTION)
Any One Occurrence........ S 1,000,000
Any One Person/Org ....... 5 1,C00,000
ANY ONE PERSON S 5,000
Any One Fire or Explosion s iou'000
1 General Aggregate* ....... S 2,000,000 j
I Prod/Como Ops Aggregate* S 1,000,000 j
i
Bodily Injury
(Each Person) .......... S
(Each Accident) ........ S
Property Damage
(Each Accident) ........ 5
Combined Single Limit .... S 1,000,000
�I
EXCESS LIABILITY 151 -CU -260489-3003 1 01-01-08 01-01-09 Each Occurrence S 3,000,000 I
Nationwide j i Prod/Comp Ops/Disease
i [Xl Umbrella Form j Insurance Co. j j Aggregate* ............. 5 3,000,000
I I I I I STATUTORY LIMITS 1
([ 7 Workers' j j I BODILY INJURY/ACCIDENT ... E
( Compensation Bodily Injury by Disease
and j j ! I EACH EMPLOYEE .......... 5
I[ l Employers' j j I j Bodily Injury by Disease
( Liability I I ! POLICY LIMIT ........... 8
I
Should any of the above described policies be cancelled before the DESCRIPTION OF OPERATICNS/LOCATIONS
expiration date, the insurance company will endeavor to mail VEHICLES/RESTRICTIONS/SPECIAL ITEMS
written notice to the above named certificate ho'der, but failure to CONSTRUCTION SERVICES
mail such notice shall impose no obligation or liability upon the
company, its agents, or representatives.
Effective Date of Certificate: 01-01-2008 Authorized Representative: JAMES M. DOLAN
Date Certificate Issued: CI -16-2008 Countersigned at: 560 Mendon Road
Cumberland, RI 02864
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