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Home My WebLink AboutBuilding Permit #652 - 46 PRESCOTT STREET 4/9/2007Permit NO: Date Issued: ` d BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received . , DESCRIPTION OF WORK TO BE PREFORMED: Identification Please OWNER: Name: or Print Clearly) Phone:q'7 � 4,� 3 Q6?1+ 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: $ ad FEE: $ 20 Check No.: a 3 - "-Y Receipt No.: 6 NOTE: Persons contracting withz4ffregiLstered contractors do not have access to the ntv-fund 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;lnteriol' Work,. ❑ Engineering Affidavit' 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 o 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 ❑ 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 DATE REJECTED PLANNING & DEVELOPMENT ❑ COMMENTS DATE REJECTED CONSERVATION COMMENTS DATE APPROVED 11 DATE APPROVED 11 DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date D 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 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 M Locaflon�/to/ 1, No. Date TOWN OF NORTH ANDOVER AL +---4 L Certificate of Occupancy $ Building/Frame Permit Fee $ 2, C" Foundation Permit Fee $ Other Permit Fee $ TOTAL Check # c;9 -3 -�- 3 2 0 1 0 7 Building Inspector m m m x m v m _2 y d — d CO)CD o CD o CA CD C26� C d O CZ = y 0 � C2 CD CD O CL C7 "C d CD C CP y� �. y �• O C C2 CA O 'o Z CD St O � • CD 0 CD Lo cn cn O cn W r 'o I� C CD O 0 cc m 0 a m CO CIS c 0 I H C CL 0 H y a Fv C ? O< � c m �y o CL m H m .-► C 3 = a o C=L =r ��=� N CD 0 o m �C CA CL � CL o �� o o m CDa g 3 C, O1 y 06 y c W � a ,e N 7 m m oo: wo0: caa g: C:, m y C-3 m s m CAM _ m �q z O H 4 F - o m o m m e o n br2 b r7 x 0 z O H The Commonwealth of Massachusetts Department of Industrial Accidents = 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 Legibly Name (Business/Organ ization/Individual): Address: City/State/Zip: �c yqy Aga[bw _ Cll -ephone # i /P 4-� ?moi 3 __ Are y an employer? Check the appropriate box: 1.. I am a employer with a 4. ❑ I 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. I ship and have no employees working for me in any capacity. [No workers' comp. insurance required. ] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t These sub -contractors have workers' comp. insurance. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] 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 13. ❑ Other *Any applicant that checks box # I must also fill out the section below showing their workers' compensation policy information: f 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 an: an employer that isproviding workers' compensation insurance for my employees. Below is the.policy and job site information. A , , /7D Insurance Company Name Policy # or Self -ins. Lic. #: `�� Expiration Date: 16 Job Site Address:_Yj 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 6e violator Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for ins.uzance coverage verification. I do hereby certify un _ pains andpenalties of perjury that the information provided above is true and correct Si ature:'GX (2�E vE\ Date: 4— /6-1 swt Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/Liceuse # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Towu 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 -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 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 per-iit/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 bur 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 Fax # 617-727-7749 Revised 5-26-05 www.mass.gov/dia BUILDER MICHAEL RODDEN CONTRACTOR 47 Prescott St. North Andover, Ma. 01845 Phone 978 6872934 fax 978 6870293 Mrs. Henry Libby 46 Prescott St. North Andover, Mass. 01845 9/18/06 Remove and replace roof shingles on sun room. New shingles will be three tab type and match the main roof color as nearly as possible. The existing roof will be stripped down to the roof sheathing .The existing sheathing will be re -nailed and covered with a rubber ice and water shield that will extend 6" up the sidewall. Apply a new aluminum drip edge and apply new asphalt roof shingles. All job debris will be removed from the job site. Labor and material for above 1600.00 Note: This agreement does not include any labor or materials to repair any dry rot or insect damage that may be present. Payment terms are 800.00 at job start and 800.00 at completion. SENT BY: NORTH ANDOVER & FOSTER INSURANCE;9786888410; APR -5-07 10;59AM; PAGE 1/1 -ACM. CERTIFICATE OF LIABILITY INSURANCEDATE x4/05/5/ 2007 PRODUCER NORTH ANDOVER INSURANCE AGENCY, INC 9. WAVERLY ROAD �1ORTH ANDOVER MA OIB45-2415 THIS CERTFICATE 16 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 NSURED 4xchael Rodden 0 Premoott Street both Andover MA 01845- IN6URERA. CITIZENS INSURANICS CO INSiJ121,R u: HANVOER INSURANCE ,.- IN URERc:AMERICAN INTERNATIONAL GROUP INSURER D. IN UR. RE: THE PCUCIES OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAN REQUIREMENT, TERM OR CONDI PION OF ANY CONTRACT OR OTHER bOCUMENT WITH F THE INSURANCE AFFORDED SY THE POLICIES DESCRIB[D HEAEJAI IS ALmArCT Tn LOVE FOR THE POLICY PERIOD INDICATED. NO' WITHSTANDING ANY CT TO WHICH THIS CERTIFICATE MAY BE ISSUE, -0 OR MAY PEKTAIN, TMf-- T•GGNIC CWe-J 110111"a ALrh rnuh,rv,uc• nt t. ,..0 n _Q&a.6IMIT.-,5NOWN MAY HAVE BEEN IJ ,Fn BY PAID CLAIMS. IBR .TitGATE TYPE OF INSURANCE POLICY NLMSER POLICY IiFFlCnVK MERF W/YV POLICY EXPf N MM ODM 02/01/2008 LIMITS A GENERAL LIABILITY X OOMMERCIIALGENERALLIABILiTY CLAIMSIJIADE L -K OCCUR ZaN 8603683 02/01/2007 cAcl+oCCURRFNCF t 1 , 000 , 0_00 FIREDAMAGE(Anyor*fire) 300,000 MM EXP (Arly one son)10,000 .......... .... ..... PERSONAL aADV INJURY t 1'.. 000,0000 GENERAL AGGREGATE A 2,000,000 GEHILAGGREGAI E LIMIT APPLIES PER. P LMr ;T LOC TCO PRODUCTS COMP7DP AGG t 2,000,000 S AUTOMOBiLEL'ASILITY AD14 8336670 07/16/2006 07/16/2007 COMB INE DSINGLELIMIT ANY AUTO ,Ee 9=911t ; ALL OWNED AU10$ / / I / X 6CHEOULEDAUT06 BODILY W.URY IPe/Penan) 8 100,000 HIREDALROS BODILY INJURY �NON-OWNED AUTO$ (Fsr WIP dent) 300,000 PROPERTY DAMAGE (Ferwid*10 100,000 GAR A*&LIABILITY AUTO ONLY- EA AC Cl DENT t ANY AUTO E / I I OTHER THAN 'EA ACC t AUTO ONLY:— A00 t BXOSISS LIABILITYLACK t AGGREGATE e OCCUR F7 CLAIMS MADE t DEDUCTIBLE - 9 RETENTION F� IN INt �' LIAM L17AYY1dN AND S.L. EACH ACCIDENT t 100,000 WCi760133 IO1/01/2007 01/01/2009 E.L.DISEASE - EA EMPLOYEE 8 100,000 E.L. DISEASE -POLICY LIMM 4 500, 001) OT�oeR BSCRIPTION OF OPERATION L+II,OCATONSN&HICt iWFX46USIONS ADbRD BY 6fIDDR66M ENTfiPEd1AL OROVl6iON0 TOWN OF NORTH ANDOVER CORD 25-5 (7197) .,M INS0238 (ssip a I IHOULD ANY OF THE ABOVE OESCRIBED POLICIES BE CANOELI.ELI BEFORE THE EXPIRATION WE THEREOF, TNF ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTTIRDATE HOLDER NAKED TO THE LEFT, BUT FAILURE TO DO 60 4iK^" IMPOBC NOOBLIOATION OR UAD16LTY OFBMW"RVWQN THE AUTHORMO REPRESENTATIVE 845- ELE07RON11a LAa6R rORfM, INC. • (900)327,0646 OACORD CORPORATION 1968 PCU* I Of 2