HomeMy WebLinkAboutBuilding Permit #816 - 455 MASSACHUSETTS AVENUE 6/7/2007BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: l Date Received 1v .1
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
0 Assessory Bldg
0 Others:
0 Demolition
❑ Other
n (2oo
DESCRIPTION OF WORK TO BE PREFORMED:
14
Identification Please Type of Print Clearly)
OWNER: Name: Phone:
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: $ ���% U FEE: $_ Y-2- = 13 -z—
Check No.:
NOTE: Persons contracq*nA wj�# unregistered contractors
A'7\ / - I/
Receipt No.:
do not have access to the guarantyfund
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
o Workers Comp Affidavit
o Photo Copy Of H.I.C. And/Or C.S.L. Licenses
a Copy of Contract
cj 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 -Plermit
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/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
a Mass check Energy Compliance Report (if Applicable)
o 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)
o Building Permit Application
a Certified Proposed Plot Plan
o Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Copy of Contract
o 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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2007
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
COMMENTS
x
DATE REJECTED DATE APPROVED
❑ ❑
El
■❑
DATE REJECTED
DATE REJECTED
DATE APPROVED
El
DATE APPROVED
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
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
Location
No. Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
av
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ -3�
Check #
202b3--
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IN
ACIP
ISSUING OFFICE 354
INFORMATION PAGE
Workers Compensation and
Emnlovers Liability Policv
ACCOUNT NO.
SUB ACCT NO.
Liberty Mutual Insurance Group/Boston
1-348469
0000
LIBERTY MUTUAL FIRE INSURANCE CO.
POLICY NO.
TD/CD
SALES OFFICE
CODE
SALES
CODE
N/R
IST
WC2-31S-348469-016
XX X
WESTON
102
REPRESENTATIVE
3000
2
YEAR
ASSIGNED
2003
Item 1. Name of DAVID SCHAUFUS
Insured DBA J R C BUILDERS
Address 4 HAZELWOOD AVE
TEWKSBURY, MA 01876
Status 01 INDIVIDUAL
FEIN 02-9587618
RISK ID 000260726
Other workplaces not shown above: SEE ITEM 4
Mo. Day Year Mo. Day Year
Item 2. Policy Period: From 10-22-06 to 10-22-07
12:01 AM standard time at the address of the insured as stated herein.
Item 3. Coverage
A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states
listed here:
MA
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of.
our liability under Part Two are:
Bodily Injury by Accident 100,000 each accident
Bodily Injury by Disease 500,000 policy limit
Bodily Injury by Disease 100,000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
SEE END WC 20 03 06A
D. This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE
Item 4. Premium - The premium for this policy will be determined by our Manuals of Rules Classifications Rates and Rating
Plans. All information reauired below is subiect to verification and change by audit.
Mimmum Premium $ 500 ( MA ) Total Estimated Annual Premium $ 500
Interim adjustment of premium shall be made: ANNUAL
This policy, including all endorsements issued therewith, is hereby countersigned by
Authorized Representative Date 10-25-06
Loc. Code Term. Opel. Audit Basis I Periodic Payment Rating Basis Pol. H.G. I Home State Dividend RENEWAL OF:
1.0-25-06 1 NR MA 1WC2-31S-348469-015
GPO 4030 R1 Coovright 1987 National Council on Comoensation insurance WC 00 00 01 A
Premium
Basis
Rates
LINE 110
Estimated
Per $100
Estimated
Code
Total Annual
of RE-
Annual
Classifications
No.
Premiums
muneration
Premiums
SEE EXTENSION OF INFORMATION PAGE
Mimmum Premium $ 500 ( MA ) Total Estimated Annual Premium $ 500
Interim adjustment of premium shall be made: ANNUAL
This policy, including all endorsements issued therewith, is hereby countersigned by
Authorized Representative Date 10-25-06
Loc. Code Term. Opel. Audit Basis I Periodic Payment Rating Basis Pol. H.G. I Home State Dividend RENEWAL OF:
1.0-25-06 1 NR MA 1WC2-31S-348469-015
GPO 4030 R1 Coovright 1987 National Council on Comoensation insurance WC 00 00 01 A
✓lze-Varrvnzonuseall,� o�✓�%aaaac�ucaeka
Board of Building Regulations and Standards
Construotion Supervisor License
se
Licen.SCS 70432
DAVID E SCHAUFUS'
4 HAZELWOOD AVE
TEWKSBURY, MA 01876
Tr# 10921
Commissioner
—...........
_..__.-.
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration 127660
Expiration 12/3/2008 Tr# 130970
TY
DAVID SCHAUFUS
DAVID SCHAUFUSo
4 HAZELWOOD AVE
TEWKSBURY, MA 01876
if w1VIUU.11 J
�x� 1
Administrator'
- C.\ The Commonwealth of Massachusetts
14 Department of Industrial Accidents
Office of Investigations
600 Washington Street
u4p Boston, MA 02w
`Workers' Compensation Insurance Affidavit: Bu des/Contracto
rs/Electricilicant Information ans/Plumbers
Name (Business/Organization/individual): � V I
Address:
City/State/Zip %p� S �u
U-3 vc�i C/
Phone #: 5 2q 3 1<-
Are
1 --Are y u an employer? Check the an ro t ri
P P a e ox:
1 • I am a employer with 4. ❑ I am a general contractor
2. ❑employees (full and/orpar�em .*
I am a sole proprietor or
and I
have hired the sub -contractors
listed
partner-
ship and have no employees
on the attached sheet. t
These sub -contractors have
working for me in any capacity.
[No workers' comp, insurance
workers' comp. insurance.
5. ❑ We are a corporation
required.]
3. ❑ I am a homeowner doing all
and its
officers have exercised their
work
myself. [No workers' comp,
right of exemptibn per MGL
c. 152 1 4 and we have
),
insurance required.] t
no
m loy
employees.,
ees.
P Y [No workers'
coin
Type of project (required):
6. ❑ New construction
7• ❑ Remodeling
8. ❑ Demolition
9• ❑ Building addition
10.❑ Electrical repairs or additions
11 •❑ Plumbing repairs or additions
12.❑ Roof repairs
p. insurance required.] I 13 0 Other
*Any applicant that checks box #I must also 611 out the section below showing their workers'
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating s
compensation policy *_formation.
Contractors that check this box must attached an additional sheet showing the name of the sub-eontmet— .-A .L_:_ ___ _ .
g uch.
I am an - — • 1. 1115 comp. policy information.
employer that is providing workers' compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lie. #:
Expiration Date:
Job 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 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 S
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office TOP WORK ORDER and a fine
Investigations of the DIA for insurance coverage verificationof
- xr Nnwrr r par an/d�nalfties of perjury that the information provided above is true and correct
OJjicial use only. Do not write in this area, to be completed by city or town bra
City or Town:
Permit/License #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone #: