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HomeMy WebLinkAboutBuilding Permit #29 - 436 MASSACHUSETTS AVENUE 7/15/2007 i NORTFt BUILDING PERMIT 3r O6 A-'` q�0� TOWN OF NORTH ANDOVER F p APPLICATION FOR PLAN EXAMINATION * ,� b � j Permit NO: � Date Received Date Issued: ?`�J IMPORTANT:Applicant must complete all items on this page LOCATIONta �rSS Print PRO_ PERTY OWNER '`' eyV e— Prilat MAP NO: PARCEL:CA>'� I ZONING DISTRICT: Historic District yes no MachineShop Village 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 Septic W611 . - Floodplain Wetlands Watershed District Water/Sewer DESCRIPTI N OF WORK TO BE PREFORMED: Identification Please Type or Print Clearly) OWNER: Name: N-f-r "-b4wrr2 Phone: Address: lVa ss, Q`/ CONTRACTOR Name: wr ® �/i" Phone: 6 3 Address: I b s' `e ' Supervisor's Construction =License: 060 t 1 I Exp. Date: 0 Home Improvement License: /Z l _ ..: Exp. Date: 4 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: $ Check No.: .� Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund ignature of Agent/Owner - Signature of contractor 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 2.2007 Plans Submitted Plans Waived Certified Plot Plan Stamped Plans j TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Safies �e •`�,a Private(septic tank,etc. Permanent Dumpster on Site j i THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS DATE REJECTED DATE APPROVED CONSERVATION COMMENTS DATE REJECTED DATE APPROVED HEALTH COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes f- Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature&Date Driveway Permit Located at 384 Osgood Street,,! - FIRE DEPARTMENT - �emp Dumpster on site yes noti Located at 124(blain S"e't° •` Fire Department signature/date COMMENTS i 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 i i ❑ Notified for pickup - Date Doc.Building Permit Revised 2007 Location� � No. Date a: k Mao*!v,h TOWN OF NORTH ANDOVER Certificate of Occupancy $ k �' cNustBuilding/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ l Check # 7 �� 2 0 3 o 9 ------ Building Inspector Pegs of Free Estimates 105 Haverhill Street Fully Insured Methuen, MA 01844 THOMPSON'S ROOFING (978) 691-1355 Shingles - Slate - Rubber Roof Single Ply - Copper Work PROPOSAL SUBMITTED TO PHONE DATE Pete Stone 17-11-07 STREET JOB NAME 436 Mass Avenue Q - - �:� CITY.STATE AND ZIP CODE JOB LOCATION f North Andover MA 01845 ra - (��(,j,j ARCHITECT DATE OF PLANS ,tpg 1*104E We hereby submit specifications and estimates for. Strip off all roof shingles on house and garage Renail all loose boards Install .024 white drip edge around roof line Apply ice and water shield 6 ft. up all along edge and in valley Apply 15 lb felt paper on rest of roof area Reshingle with a GAF timberline 30 shingle Install new flanges around soil pipe Cut in ridge vent , Remove all work related debris 30 year warranty on material 5 year guarantee on labor construction lic. #060112 improvement #128612 P rD Ore hereby to fumish material and labor—complete in accordance with above specifications,for the sum of: " " dollars(s 6 3 U I; . 0 0 ). Payment to be made as follows: $ 2 ,300 down balance upon completion All material is guaranteed to be as specdled M work to be completed In a workrro m ffamm according to standard practices.Any alteration or deviation from above specftaticas hya*q Auftrined extra costs will be executed only upon written orders,and will become an extra charge over and above the estimate.M strikes accidents or our upon . delays bib control Owner to carry fire,tomado and other necessary insurance.our workers are fuly Note:This proposal may be covered by Workmen's Compensation Insurance. vAdxW&wn by us N net accepted within �ttPlltdilit Of �lgPrD}10gd[ -The above prices,specifications and conditions are satisfactory and are hereby accepted.You are authorized to do ft signature work as specified.Payment will be made as outlined above. - Date of Acceptance: signature Town of Andover 0 No. 2 V` 00 dover, Mass., 0 LAKE CO HICHEWIC:CK 7�S RATED .1 BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THISCERTIFIES THAT ............11....:;:. ....... ........................................................................................ Foundation has permission to erect........................................ buildings on ...000........ ......em�........................ Rough tobe occupied as..­­ .........;�e. ��rAaol .&.................................................................................... Chimney provided that the person accept! g this permit shall le �ecj conform to the terms of the application on 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 PERMIT EXPIRES IN 6 MONTHS Final ELECTRICAL INSPECTOR. UNLESS CONSTRUILNXTS' Rough ..................................... Service BUILD 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 SIDE Smoke Det. ��ZE i907YI/l�Zd/2fUQ-fLLGfL d�✓�AJQCJ Board of Building Regulations and Standards Licenke'or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before;the expiration date. If found return to: . Registration: 128612 Board[of Building Regulations and Standards Ex0i One Ashburton Place Rm 1301 P � 4/28/2009 Tr# 129477 t Type DBA BOstoa,Ala.02108 4 _. THOMPSON'S Rb60,J4 THOMAS 8 WEST ST SALEM,NH 03079 Administralor Not valid without signat e NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section I 0A. The debris will be disposed of in: L, L 4 ,5 Lo,.u-ell k y �CIC Ie W VV (Location of Facility Signature of ermit Applicant Fire Department Sign off: Dumpster Permit -2 — Ale d Date ACORD_ CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DD/YYYY) 05/03/2007 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Pelham Insurance Services, Inc- ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P.O. Box 960 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 122 Bridge Street Pelham NH 03076 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A:Nautilus Thomas Doyle INSURER B:Associated Industries dba Thompson Construction & INSURER C: 8 West St. INSURER D: Salem NH 03079 INSURER E: COVERAGES 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 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 SUBJECT TO ALL THE TERMS, EXCLUSIONS_AND,CONDITIONS-OF SUCH POLICIES. AGGR GATE-LIMITS SHOWN MAY HAVE rstEN REDUCED-8--FAID CLAIMS. INSR ADVL POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE(MM/DD/YY) DATE(MM/DD/YY) LIMITS A GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY NC 532152 04/15/2 007 04/15/2008 DAMAGE TO RENTED 50,000 PREMISES Ea occurrence $ CLAIMS MADE F-1 OCCUR MED EXP(Any oneperson) $ 1,000 j PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 PRO- POLICY JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY j NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ I ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS Mnor_ AGGREGATE $ I $ i DEDUCTIBLE $ RETENTION $ $ B WORKERS COMPENSATION AND AWC7012214012006 04/21/2007 04/21/2008 x WC STATU- OTH- EMPLOYERS'LIABILITY TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE$ 100,000 L'yes,describe under I SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATION S/LOCATIONSNEHIC LES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS various Construction L CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT Mike Rodden Construction FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. 47 Prescott ORRESENTATIVE N. Andover MA 01845 ACORD 25(2001108) ©ACORD CORPORATION 198E I N S 0 2 5(01C%8).07 AMS VMP Mortgage Solutions,Inc.(800)327-0545 .Page 1 of: NThe Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 t�..I�t• 1. _ 600 Washington Street U 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: City/State/Zip: Vh Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in an capacity. workers' comp. insurance. Y P tY• 9. E] Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its officers have exercised their 101-1 Electrical repairs or additions required.] 3.❑ I am a homeowner doing all work right of exemption per MGL 1 1.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12Toof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.)P q ] *Any applicant that checks boz#I must also fill out the section below showing their workers'compensation policy information. P P Y 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: 0(x S c�Corrt—t /�iL-P�S Policy#or Self-ins. Lic.#: C;-' !A.,(_ O/ZZ( Y o I Iii a L Expiration Date: y Dom' Job Site Address: J'L' 5 5 6W City/State/Zip: /V 4 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 under the pains andpenalties of perjury that the information provided above is true and correct. Signature: k, 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. 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. # 617-72.74900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia