HomeMy WebLinkAboutBuilding Permit #425 - 460 MAIN STREET 12/2/2009 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued: Z�
IMPORTANT:Applicant must complete all items on this page
LOCATION <Q
n#
PROPERTY OWNER ! „'k , -'�
Print
MAP NO: PARCEL: " ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
New Building Z7,0ne family
Addition Two or more family Industrial
Alteration No. of units: Commercial
Repair, replacement Assessory Bldg Others:
Demolition Other
Septic Well Floodplain Wetlands Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: M,7s'e Phone: 9
Address: j
CONTRACTOR Name: Phone:
Address: _ ft
Supervisor's Construction Licensers /o0>S-0Exp. Date:-f-aQ'c
Home Improvement License: Exp. Date:
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: $ y ` ' FEE: $
Check No.: �7 2���-Z--
Receipt No.:
NOTE: Persons contracting with unregis a contr ctors do not have access to the guaranty fund
rig natureof Agent/Ownergnature ofcontractor
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: Doc.Building Permit Revised 2008
LocationJw
No. Date
Zr
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NORT1y TOWN OF NORTH ANDOVER
a
a
• i ; ; Certificate of Occupancy $
CHU <�' Building/Frame Permit Fee $
t
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # �l �
Building Inspector
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: 5 Date Received
Date Issued: _ Z'
IMPORTANT:Applicant must complete all items on this page
LOCATION V60
PROPERTY OWNER_M j rf.,�r' Y►, w_,� �t;`
Print
MAP NO: PARCEL: ' ZONING DISTRICT. Historic District yes no
Machine Shop 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 Well Floodplain - Wetlands Watershed.District
Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: Jtii,I�e tr�„ ��/�d1. c f Phone:
Address: w j
CONTRACTOR Name:. ,�,,�, z
__ �,� Phone: ->8/-�°,.5
Address: q
Supervisor's Construction Licensees' ,c>0>STj Exp. Date:O-i-,D)d c
Home"I mprovement License: Exp. Date.,
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 unregis cont r ctors do not have access to the guaranty fund
ignature of Agent/Owner wgnature of contracto � 0111,
`
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: Doc.Building Permit Revised 2008
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 DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on
Signature
COMMENTS
I
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition Na
Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature&Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
,,FIRE:DEPARTMENT -Temp Dumpster on site yes no
Located at, 124 Main Street
Fire Department signatureldate
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 p j
No
DANGER ZONE LITERATURE: Yes
MGL Chapter 166 Section 21A—F and G min.s100-s1000 fine No
4
NOTES and DATA— For department use
E
i
❑ Notified for pickup - Date
Doc:.Building Permit Revised 2008
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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 n Please Print Legibly
Name(Business/Organization/Individual):
Address: "Ib 0 N-41ti
City/State/Zip: A DOg AA)06V6Z,& Phone#: 97F (Og3 /gam
Are you an employer?Check the appropriate box:
Type of project yp p o�ect(regmred):
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. 1 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.El Electrical repairs or additions
3-A I am a homeowner doing all work 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.❑ Other
comp.insurance required.]
Any applicant that checks box ul must also fall out the section below showing their worker'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 their workers'comp.policy information.
lam an 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. Lic.#: 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 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 a aloes of perjury that the information provided above is true and correct
Signature: Date.: 12
Phone#:
693 9.58
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-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 retuned 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 bum 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#617-72.7-7749
Revised 5-26-05
vvww.mass.gov/dia
F µORTH TOWN OF NORTH ANDOVER
32 °L OFFICE OF
-~ ~ BUILDING DEPARTMENT
*�o ^e»* 1600 Osgood Street Building 20, Suite 2-36
North Andover Massachusetts 01845
�SSAC14 SES
Gerald A.Brown Telephone(978)688-9545
Inspector of Buildings Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
BUIDING PERMIT APPLICATION
Please print
DATE: ��C C2 j
JOB LOCATION: q0 9" SZErr
Number Street Address Map/Lot
I30MEOWNER3-95-97
�' � 5
Name Home Phone Work Phone
PRESENT MAILING ADDRESS. ,s /W
/U0e?1 �QNT�bt/ �l/. -
City Town State Zip Code
The current exemption for"homeowners"was extended to include owner-occupied dwellings to two units or less and
to allow such homeowners to engage an individual 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 owns 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 he/she willmply with said procedures and
requirements.
HOMEOWNERS SIGNATURE r
APPROVAL OF BUILDING OFFICIAL
Revised 7.2009
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
XAORT#q
Town of over .
0
No.
dover, Mass.,
0 LA
COCHICH Vic
Ids RATED
BOARD OF HEALTH
Food/Kitchen
PERMIT T Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT...........4��...........If .. .......................................................................... Foundation
.... ..... . .. ..........
has permission to erect........................................ .buildings on ..4,p........xwo?.....�.&......................................... Rough
Chimney
tobe occupied as...4:574"4_411L.......5.—/.& ..........................................................................................
provided that the person accepting this permit shall in every respect 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
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTI TARTS Rough
........... ................. ...................................
77::7 Service
BUILDING INSPECTOR 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 Inspect.or. Burner
Street No.
SEE REVERSE SIDE Smoke Det.
The Commonwealth of Massachusetts
t; 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/Organization/individual);__
Address: fir'.
City/State/ZipJm �1��,uhl. 357 Phone#: 2d/
Are you an employer?Check the appropriate box: Type of project(required):
1.2,1 am a employer with / 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.t 7. E]Remodeling
ship and have no employees These sub-contractors have 8. Q Demolition
working for me in any capacity, workers' comp. insurance. 9, (1 Building addition
[No workers' comp, insurance 5. ❑ We are a corporation and its
required.]. officers have exercised their
10.❑Electrical repairs or additions
3.❑ 1 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 12.❑ Roof repairs
insurance required.]t .employees. [No workers' 13.[�Other S//��n,
comp. insurance required.]
*Any applicant that checks boz#1 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.
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 employer that is providing workers'compensation insurancefor my
ployees. Below is the policy and lob-site
information. n
Insurance Company Name: ra/cam S v AN
Policy#or Self-ins. Lie. #:(,c�SG�tj0C)si0/cPS op: Expiration Date: /0-Gi -00/0
Job Site Address: <y�a
City/State/Zip:44047 A„ 0Y,er MA . O x111
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.
Ido hereby certify u der the pains and penalties ofPer!ur1that the information provided above is true and correct
Signature: Date: //-36-o 5
Phone#: 713/ 8-34/
� y
Oficial use only. Do not write in this area,to be completed by chy 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#:
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Employers Insurance Company
Burlington, Massachusetts NCCI NO 40959
(800)876-2765
POLICY NO, WCC 5000299012009 � I
PRIOR NO. `WGC 5000299012008
ITEM
1. The Insured KB Flooring
Mailing Address: 46 Schanda Drive
New Market NH 03850
(No. Street
Town or City County State Zip Code
® Individual ❑ Partnership ❑ Corporation ❑ Other
FEIN 04-3231482
Other workplaces not shown above:
2. The policy period is from10/01/2009 to 10/01/2010 12:01 a.m.standard time at the insured's mailing address.
3. 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.
5 0 0,0 0 0 each accident
The limits of our liability under Part Two are: Bodily Injury by Accident $ 5 0 0,0 00 policy accident
Bodily Injury by Disease $ Po y
Bodily Injury by Disease $ 5 0 0,00 0 each employee
C. Other States Insurance: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06 A
D. This policy includes these endorsements and schedules: SEE SCHEDULE
4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating plans.
All information required below is subject to verification and change by audit.
Classifications Premium Basis Rates
Estimated Per V00 Estimated
Code Total Annual of Annual
No. Remuneration Remuneration Premium
INTRA 251321
SEE EXTENSION OF INFORI 4ATION PAGE
Minimum premium$ 500.00 Total Estimated Annual Premium $ 1,632.00
As indicated,interim adjustments of premium shall be made: Deposit Premium $ 1,721.00
® Annually ❑ Semi Annually ❑ Quarterly ❑ Monthly
MA Assessment Chg.
$1,239.75 x 7.2000% $89.00
oa
This policy,including all endorsements,is hereby countersigned by (— eea 09/04/2009
Authorized Signature Date
GOV GOV I KIND IPLACING CLAIM NAME SAFETY
STATE CLASS I AUDIT OFFICE OFFICE CHECK GROUP Malcolm&Parsons Insurance
MA 5437 17 1505 Agency Inc
WC 00 00 01 A(11-88) 6 Freeman Street-P O Box 527
Stoughton,MA 02072
Includes copyrighted material of the National Council on Compensation Insurance,
used with its permission.
Massachusetts- Department of Public Safeti
Board of Buildin-; Regulations and Standards
Construction Supervisor License
License: CS 102750
Restricted to: 00 'A
r
KENNETH BEAUDET
46 SCHANDA DRIVE
NEWMARKET, NH 03857
Expiration: 2/1/2013
(mm:,issioner Tr#: 102750
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