HomeMy WebLinkAboutBuilding Permit #549-2017 - 44 BREWSTER STREET 11/21/2006r�p . BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
A. N t# S Date Received
Perms o .
Date Issued:
IMPORTANT: Applicant must complete all items on this
LOCATION
Print
PROPERTY OWNER k%.\ 1(t �4 D
rift 100 Year Structure yesFnoMAP PARCEL: =ZONING DISTRICT: Historic District yesMachine Shop Village yes
TYPE OF IMPROVEMENT
❑ New Building
❑ Addition
❑ Alteration
f� Repair, replacement
❑ Demolition
OWNER: Name:
Address: q
PROPOSED USE
Residential
❑ One family
Two or more family
No. of units:
❑ Assessory Bldg _
❑ Other
Non- Residential
❑ Industrial
❑ Commercial
❑ Others:
DESCRIPTION OF WORK TO BE PERFORMED:
J\Q, ' f Q- U Gv G`fl,r
IdenTication - Please Type or Print Clearly
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Contractor Name -1 -ca 4rtarn�
Email d �Ji d � CaSI-t� C.cra- i'0 V
Address: M3 0-
10
d;
one: (PI1 -
Phone: qhs -_b r3 - L -0-D
Supervisor's Construction License: C SS ' p 3
Home Improvement License: (0 4 S U I
ARCHITECT/ENGINEER,
Exp. Date: 0- 1 b'11_7
14.
EXD. Date: I $
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.
IF
Total Project Cost: $ q 0 00 FEE: $ C
Check No.: Receipt No.: 22L
y fund
NOTE: Persons contracting with unregistered contractors do not have access to the guarant
Location '--J L ' Li � �t.-. 5 T
No. `l do 17 Date { t - � i "- C)o 1
Check #
bj € 2 5
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ 10
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
�;/ Building Inspector
- Plans Submitted❑
Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
-TYPE-OF'SEWER AGE 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-
COMMEN
DATE REJECTED DATE -APPROVED
❑ ❑
-CONSERVATION Reviewed on Signature
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comments
Conservation Decision: Commen
Nater & Sewer Connection/Signature & Date Driveway Permit
DPW Tow;-, Engineer: Signature:
Located 384 Osgood Street
FIREDEPARTi DEPARTMENT =Temp Dumpstee on site yes. no
Located at 124 Mair Street
Fire Departrnent 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 services drops requires approval of
Electrical Inspector Yes No
DANGER Z®N--'LIT 'RATURE: Yes
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
NOTES and DATA — (For department use
® Notified for pickup Call Email
I Date _ Time Contact Name
Doc.Building Permit Revised 2014
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
o Workers Comp Affidavit
o Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
a Floor Plan Or Proposed Interior Work
o 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
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o 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
o 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: Building Permit Revised 2014
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
k9i 600 Washington Street
Boston, MA 02111
www. mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Auplicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:—A. 3 1 R 5 0TTO
DAA 1 D N\ST l L b N(= Roo F 1016 " S tVN G,J_N C
N S1 fZ EET 1J N IT 3�
City/State/Zip: N o, A N ib p v t rc
MA 0 1 Phone #: 'A% (a
3 3q a 0
Are you an employer? Check the appropriate bog:
4. I I
Type of project (required):
1.OI am a employer with
❑ am a general contractor and
6. FJ New construction
employees (full and/or part-time).*
2. Q I am a sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet.
7. ❑ Remodeling
ship and have no employees
These sub -contractors have
g, ❑ Demolition
workingfor me in an capacity.
Y P h'•
employees and have workers'
comp. insurance.t
9. Q Building addition
[No workers' comp. insurance
required.]
5. ❑ We are a corporation and its
10.Q Electrical repairs or additions
3. ❑ I am a homeowner doing all work
officers have exercised their
1 L Plumbing repairs or additions
myself. [No workers' comp.
right of exemption per MGL
12.7 Roof repairs
insurance required.] t
c. 152, § 1(4), and we have no
13.❑ Other
employees. [No workers'
comp. insurance required.]
•Any applicant that checks box 91 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 -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. c
Insurance Company Name: 2 A N 1-1 ES I S I �. I W J -J MM CC
Policy # or Self -ins. Lic. #: V V 3 �'I �S GI 3 Expiration Date: 9 -c 3 -off L) `7
Job Site Address: q `C 44 &U l_AJ S k ST" 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 may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify u r the ains an penalties ofperjury that the information provided above is true and correct
Signature: Date: '
Phone #: qJ c b J3 C 3 3 ti o)y
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 #:
ACOROCERTIFICATE OF LIABILITY INSURANCE DATE(MMIDOIY
9i27i2o16
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 AD017IONAL INSURED, the POlicy(les) 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 endorsers lsl_
PRODUCER
Eastern Insurance group LLC
233 West Central St
Natick MA 01760
INSURED
David Castricone Roofing & Siding Inc, DBA
231 Rear Sutton Street, Unit 3A
NaaE Select Department
PHONE . (800);72-4538 FAX 761-586-8244
19A PoLAIC No
selectwork@easterninsurance.com
World Insurance Co
(INSURERC:Granite State Insurance Co. 1
754
(North Andover MA 01845 INSURERP
COVERAGES re0TIC1rA1rr au raeere.wA---- —1— 1
-- "" — "-' --- "-- -- ISCVIAIUIV NUIWbIz K:
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 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
LTR TYPE OF INSURANCE S POLICY NUMBERPOLLIIC YEYFFF MMIDD EXP LIMITS
GENERAL LIABILITY
A
X COMMERCA. GENERAL LIABILITY
CLAIMS -MADE a OCCUR
rBA GL 2016
/6/2016
9/6/2017
EACH OCCURRENCE $ 1,000,000
P�MISE Ea occurrence) $ 50,000
MED EXP (Any oneperson) $ 1,000
PERSONAL &ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER'.
X POLICY r I P C LOC
PRODUCTS - COMPIOP AGG $ 2,000,000
AUTOMOBILE LIABILITYG
LE LIKT-
Ea accident 11000,000
B
AN'Y AUTO
ALL OYMED X SCHEDULED
AUTOS AUTOS
HIRED AUTOS X NON-OVeNED
AUTOS
Ix
CNGCV
/1/2016/1/2017
BODILY INJURY (Per person) $
BODILY INJURY (Per accident) $
PROPERTY DAMAGE
Per accident $
UMBRELLA LIAB
EXCESS LIAB
HCLAIWS-MADE
OCCUR
EACH OCCURRENCE $
AGGREGATE $
C
DED RETENTION
WORKERS COMPENSATION
AND EMPLOYERS'OTH-
LIABILITY YIN
ANY PROPRIETOR PARTNEREXECUTIVE
OFFICERIMEMBER EXCLUDED? Q
(Mandatory In NH)
IF ,
DESsdescribe under CRIPTION OF OPERATIONS below
N/A
RC003989723
/23/2016
/23/2017
$
Vrt;STATU-
X IMI T
ER
E.L. EACH ACCIDENT $ 100,000
E1.DISEASE -EAEMPLOYE $ 100,000
E . DISEASE - POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES (Attach ACORD 101, Addltlonal Remarks Schedule, It more space Is required)
ROOFING & SIDING INSTALLATION
PFRtlolrarr unl r)ro
TOWN OF NORTH ANDOVER
BUILDING INSPECTOR
1600 OSGOOD STREET
NORTH ANDOVER, MA 01845
ACORn 95 17n4nrnF%
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
John Koegel/MET
Iaool-cvlvHwKL)ILlKATION. Ali rights reserved.
INS025 (2010051.01 ThA ACORII namA and Innn arA rAnistwrAH marks of ACORr1
Town of forth Andover
Building Department
27 Charles Street
North Andover, Massachusetts 01845
(978) 688-9545 Fax (978) 688-9542
DEBRIS DISPOSAL FORM
00RTI1
T 'P C�LLLL [rl1c111 WItA 7.
AOR'ITCP /-��`A-1
�S�NCVIU5
In accordance with the provisions of MGL c 40 s 54, and a condition of.
Building permit # the debris re .sItirng from the work studl be disposed
of in a properly licensed solid waste disposal faeilil.; as defined by MGL c11, sl 50a.
The debris will be disposed of in /at:
1
IV d
Facility
Signature of Applicant
Date
NOTE:.A demolition permit from the Town of North Andover must be obtained for this
project tluough the Office of the Building Inspector,
('C//f I ^ f ,rr.,rll'
_-= Office of Consumer Affairs & Business Regulation
HOME IMPROVEMENT CONTRACTOR
�f Registration: 104569 Type:
' Expiration: 711412018 Private Corporation
DAVID CASTRICONE ROOFING, SIDING &
David Castricone
231 R SUTTON ST SUITE 3A
NORTH ANDOVER, MA 01845 Undersecretary
License or registration valid for individual use only
before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston,,MA 02116
Not valid without signature
Massachusetts Department of Public Safety
'•�� Board of Building Regulations and Standards
License: CSSL-099358
Construction Supervisor Specialty
DAVID T CASTRICONE
31 COURT STREET
NORTH ANDOVER MA 01it4b
Expiration:
Commissioner 12/16/2017