Loading...
HomeMy WebLinkAboutBuilding Permit #723 - 456 SALEM STREET 4/12/2012BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Z3 Date Received f Nvn � ry q\ Q��t LED h616�O � i r TYPE OF IMPROVEMENT PROPOSED USE Resi ential Non- Residential ❑ New Building One family ❑ Addition ❑ Two or more family. ❑ Industrial El teration No. of units: Q Commercial Repair, replacement. ❑ Assessory Bldg ❑ Others: ❑ Demolition -P. tEc111e1t� ❑ Other -c - �= �0 1odlj�laan�C1Vt%tfands i� , �..'7 " rr r- a' 'Tu hec y®e �' a N, � � s�:.� r :�x f.`�' �` ,�- -�:�ii��%.�eW(4���x?,,,.�.�s�� _��..'�e..�,•'"-�`:�� _ter, _ DESCRIPTION OF WnRK TO RF PREF ORME `r^ .4 ti cf 1�'4--/' /0C e- F-' ?h Jr V -C.-5, Identification Please Type or Print Clearly) OWNER: Name: 1 „� ► 1- I LF -o Phone ?c�� 6 - �i� ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $' 0 FEE: Check No.: 3 l Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty flu d 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 N DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED 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 Nu i is ana UA I A — o -or department use ❑ Notified for pickup - Date Doc.Building Permit Revised 2007 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 Doe: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 Location / k ���1�? •,- No.—f 1 Date Z-' Check # 1; 3 (1. 25175 TOWN OF NORTH ANDOVER Certificate of Occupancy $_ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Building Inspector Gerald A. Brown Inspector of Buildings Please pj DATE:=�� �-- JOB LOCATION: HOMEOWNER TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT ;1600 Osgood Street Building 20, Suite 2-36 North Andover, Massachusetts 01845 Telephone (978) 688-9545 •Fax (978) 688-9542 HOMEOWNER"LICENSE EXEMPTION BUIDING PERMIT APPLICATION Number Street Address Name PRESENT MAILING ADDRESS Home Phone Work Phone C`ihi To,�,r, State - - Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings to two units -or less and to allow such ho neoti=hers to engage an ;ndividual.for hire who does not possess a license, provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) - DEFINITION OF HOMEOWNER Person(s) who 9was a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned "homeowner" assumes responsibility for compliances with the State Building Code and other Applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that h requirements, e e will comply with said procedures and HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CO)\'SERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 The Commonwealth of Massachusetts - Department of lndustriq[Accidie is Office of Investigations 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leizibly Name (Business/Organization/Individual): 4Y��y�� Address: 9,;z, :�a7km, 54::` City/State/Zip: A PV'J&�rZ �t 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).* 2. El am a sole proprietor or partner- have lured the sub -contractors listed on the attached sheet. �• Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. y, ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] 3.jjt am a homeowner doing all work officers have exercised their right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13. [i 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 Sie doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors 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 em ployeY that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Policy # or Self -ins. Lic. #; Expiration 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 o. 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 DTA for insurance coverage verification. I do hereby cerfi(y under the ppr s and penalties ofperjury that the information provided above is true and correct. 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 gnstructfl®ns 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 j oint 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 -contractors) 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 legibIy. 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 (ifnecessary) 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 Gomu ox1wealthofMossachusotts Dc,partment of Industrial .A,ccide�_ .ts Office ofiuvestigatious 6.04 WasMWoa Street Boston, MA. 021 It `lel,, # 61.7-727-4900 ext 406 or 1-877 UASSAFB Revised 5-26-05 Fax # 617"727-7749 wvw.znass,Vv/dia . N r . O ® v w E cn P4 A4 z A w C w a: U Cd W. a 0 a po A4 a4 w ac w 1 a: cn w H d - O w' C w z a w a w, W z cn v Q -Sd co 'mC*c ' o 0 C N O C �cc o :.ca cD O FU C/) z O E � d N o �. C N C 0 = w u cmIE Cf) I' C/) � W C l O cm C �C N OD t _ O Z O O 11, co O co cr. L O O v Z O CL O CO) 0 C O CM I O 'O D _ w M m m L- I� co CL �+ = O � O O OL env o a CL CM< ca C 0 C O Cd V J '0-M 'FL C3 co ca C = ts � C.3 ca c C C _O C. 0 LU U) LLI Y/ W W 19 W CA C NQ 0 i CO) O C.2 — to 0 0. F .. = m :moo p.. * a � W N m C .� r=.+ Z ra MD O C MAA �E g:CD 5 CD y.+ v LU m cmN V2Cos m .= = eC O y_ �a0m O FU C/) z O E � d N o �. C N C 0 = w u cmIE Cf) I' C/) � W C l O cm C �C N OD t _ O Z O O 11, co O co cr. L O O v Z O CL O CO) 0 C O CM I O 'O D _ w M m m L- I� co CL �+ = O � O O OL env o a CL CM< ca C 0 C O Cd V J '0-M 'FL C3 co ca C = ts � C.3 ca c C C _O C. 0 LU U) LLI Y/ W W 19 W CA Office of Consumer Affairs & B siness Reguiafion HOME IMPROVEMENT CONTRACTOR - Registration: , ,::168921 Type: Expiration: -4/1.9/2013 DBA :-. = T FITZGERgLD REMODELING 4 THOMAS FITZGEVRALD, 7 MT PLEASANT ST _-9 WINCHESTER, MA 01890 ', Undersecretary CERTIFICATE OF LIABILITY INSURANCE 04/14/2011 PRODUCER (781) 396-4900 FAX (781) 391-7597 J. 1. Ruddy Insurance Agency 153 Main St . Medford, MA 02155 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED Thomas Fitzgerald 7 Mt. Vernon Street Winchester, MA 01890 INSURER A: Travelers INSURERB: INSURER C: INSURER D: INSURER E: nnv=o An_cc vTHE 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, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY 6808394X119 04/14/2011 04/14/2012 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 300,000 ISFS (Fa nrr ::7 CLAIMS MADE a OCCUR MED EXP (Any one person) $ 51000 PERSONAL & ADV INJURY $ 1,660,000 A I GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 POLICY PRO- JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) BODILY INJURY $ ALL OWNED AUTOS SCHEDULED AUTOS (Per person) BODILY INJURY $ HIRED AUTOS NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR ❑ CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ TH- WC ATURYST..T WORKERS COMPENSATION AND DER E.L. EACH ACCIDENT $ EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. DISEASE - EA EMPLOYE $ OFFICER/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Town of Bedford 10 Mudge Way Bedford, MA 01730 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 FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE John Hackett, Jr.; .r /%O / ACORD 25 (2001/08) ©ACORD CORPORATION 1988