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HomeMy WebLinkAboutBuilding Permit #711 - 47 KINGSTON STREET 6/19/2009BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION I Permit NO: Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION _ 11 / �Uf/' 7V Al Q tt�•!D �6*NO q 1 runt PROPERTY OWNER -�� -Z �% X/ Z / Print MAP NO: 1 PARCEL:_ ZONING DISTRICT; HistoricDistrictye no Machine Shop Villaae ve 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 9F WORK TO BE PREFORMED: 0.;2 Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: CONTRACTOR N C)4)19— Supervisor's Construction License: % Exp. Date: -s jsl© Home Improvement License: 1,2 7 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. 12 Total Project Cost: $ l 7 `L)e FEE: $ -50 �— Check No.: 31 O y Receipt No.: 9a X11 NOTE: Persons cont acting with unregistered contractors do not have access to the g ar ty fund T /i 7 le re of Agent/Owner Signature of co 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 HEALTH Reviewed on Signature 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 Driveway Permit DPW Town Engineer: Signature: t_ocatea 384 Usgooa Street FIRE DEPARTMENT Temp Dumpster on site yes no Located at 124 Main Street Fire Department signatureldate 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 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 I Doc.Building Permit Revised 2008 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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 ACORD TM. CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 0611012009 PRODUCER Phone: (978) 475-0400 Fax: (978) 475-2171 THE HOWE INSURANCE AGENCY 4 PUNCHARD AVE 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 ANDOVER MA 01810 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MM/DD INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: National Grange Mutual GENERAL LIABILITY KEITH J CORMIER INSURER B: Granite State Insurance Company 07131/09 DBA K J C CONSTRUCTION 35 MAPLEWOOD AVENUE INSURER C: INSURER D: X COMMERCIAL GENERAL LIABILITY CLAIMS MADE FX—] OCCUR METHUEN MA 01844 INSURER E: MED. EXP (Any one person) $ 5,000 COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR ADD' INSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MM/DD POLICY EXPIRATION DATE MMIDD LIMITS GENERAL LIABILITY MPK46220 07/31/08 07131/09 EACH OCCURRENCE $ 500,000 DAMAGE TO RENTED PREMISES (Ea occurence) $ 500,000 X COMMERCIAL GENERAL LIABILITY CLAIMS MADE FX—] OCCUR MED. EXP (Any one person) $ 5,000 A PERSONAL & ADV INJURY $ 500,000 GENERAL AGGREGATE $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRO - POLICY JECT 7 LOC PRODUCTS-COMPIOP AGG. $ 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ BODILY INJURY ALL OWNED AUTOS SCHEDULED AUTOS (Per person) $ HIRED AUTOS NON -OWNED AUTOS BODILY INJURY $ (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 FICLAIMSMADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY WC007422121 02/10109 02110/10 WC STATU- TORY UMITS OTHER E.L. EACH ACCIDENT $ 100,000 B ANY PROPRIETORIPARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? E.L. DISEASE -EA EMPLOYEE $ 100,000 If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE -POLICY LIMIT $ 500,000 OTHER: DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS RE: 74 KINGSTON STREET NORTH ANDOVER MA CERTIFICATE HOLDER CANCELLATION THE VILLAGE GREEN WEST CONDO ASSOCIATION CIO CROWINGSHIELD MANAGEMENT COMPANY SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE 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 DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. Attention: AUTHORIZED REPRESENTATIVE J_�ACh&ristine J. range ACORD 25 (2001/08) Certificate # 5539 © ACORD CORPORATION 1988 The Commonwealth of Massachuset& j1 Department of Industrial Accidents _' ! Dice of Investigations 600 Nr it N. asking ton Street �Ua A Boston, MA 02111 www_nzassgov/dia . Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Pinmbers Applicant Information. Please Print LeQibl Name (Business/Orpoiza6on/Individual): r co (Gw COIr/cj�'. Address: 3S�4ele waa� City/5tate/Zap: AIA-q_ 0(-0y Phone ------------ A Are you an employer? k.the appropriate box: 1. ❑ 11 am a employer with 4. ❑ I am a general contractor and IF7=n roject (required): 2.� employees (full and/or part-time).* have hired the sub -contractors construction I am..a.sole proprietor or partner. Iiste-d on the attached sheet. _ odeiing ! ship and have no employees' These suis -contractors have working for me in act workers' comp, insurance. olrtion Ty Idi[No workers' comp, insurance .. 5. ❑ We are a corporation and itsng addition required ] officers have exercised their trical repairs oradditions I am a homeowner doing all work right of excerption pax MCL bing repairs or additions myself [No•workers' comp. t: 152, § I (4), and we have no insurance required.] t 12.❑ Roof repairs q ] .employees. [No workers' comp. histrance required.] 13.0 other `Any applicant that cberks bort # l must also fin out the section behow abow.ing theirworkers' oompensation policy information t Fiomeownars who submit this affidavit uufjceting they art doing all work and Then hbe outside conuaetors must subunit a new affidavit indicating such 4Conttactors that check this box mnstattaciz~d an additio=) sheat showing. the rtartie of rile so b-connactors and,their work=, corr Fcri-i �rmatioc I Ma an etxtt� doper brat is pr4?Vi&gg workers' taompensatrori imsuramee for irry. emploj ees: Blow it Ilse itrformadom Polfay and job site . Insurance Company Name: Policy # or Self -ins. Lie. #: Expiration Date: Job Site Andress: . CitylStatelZip: Attach a copy of the workers','cootpeasatiou policy declaration page (showing the policy number and expiration date}, Failure to secure coverage as required under Section 25A of MCL 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 cerfd der P ad penalties ofPerju7 Mar the information Provided ab is and eonEd Si tune: Date: Phone #: EofHealth Only. Do not write in fids area to be completed by dV or town o ssa[ Lath ; Permit/License # rify (circle one): ealth 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspectorson• Phone #: Information a nd Instructions Massachusetts General Laws. chapter 152 requires all emp Ioyers 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." i An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two ormore of the'fbmgoing engaged in a joint enterprise, and includir-tg the legal representatives of a deceased employer, or the receiver ortrustee of an individual, partnership, association or other legal entity, employing employees. •lioweverthe 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 ma -into ee, construction or repair work an such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an ernpioyer." MGL chapter 152, §25C(6) also states that "every state or local ficensing agency shag withhold the issuance or renewal of a license or permit to operate a baseness or *o construct buildings in the commonwealth for any applicant who has not produced acceptable evidence.oik7 compliance with the insurance' coverage required." Additionally, MOL chapter 152, §25C(7) states `Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performsnee of public work- until acceptable evidence of complir nc c with the insurance requirements of this chapter have bean presented to the contracting authority," Applicants Please fill out the workers' compensation• affidavit completely, by ohecking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es). and phone number(s) along with their certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not roquiredito carry workers' ccvmpe�nsation insurance. Van LLC or LLP does have employees, a policy is required. Be advised that this affid 2L-,* 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 m 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' oompensatbn policy, please—call the Department at the nu m. bar listed below, Self-insured companies should enter imir self insurance'license number on dm*appropi late 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 tlu event the Office of Investigations has to contact you regarding the applicant. Please be sura 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 marred by the city or town may be provided to the applicant as proof that a band 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 0& a flog license or permit to bum leaves etc.) said parson is NOT.required to complete this affidavit The Office of Inves i.0ions would like to thank you in advance fior 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 Deparftnent of 13ndustrial Accidents Office of Envestiastions 600 Washington Street Basten, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MA.SSAFE Revised 5-26-45 Fax # 617-727-7744 www.mass.gov/iiia 0 fA WD 0 J x o A ca O w v cn o U a COD z ° � p w O w G U G w w p w G x x 0 w a w p w c� C u. x p cL C w z � A a c CO C/) v 0 U) O FM4 O z O� H : c c o o � c ` N O C rc O _0 V CL eo cv �z o H C at CD rc L V O. N E5 � Z y o -� 4- 11 OE C :ca CO �y a C42 � 3 co m N c r. •> > a z c y O O m W o CL Z = O CD cm C O Q 32 y •_ ' p,ct m CD o� 30 h o - e� •- Z 0 coo c a Q o cmc •o s o m= 0 N 0 ..•CDCOD CDZ at�° M c Z oc •E v v •v, O y_ CLS s CIO-0cc y •O H t s aZ., oO Zoo C/) z 0 z 0 U C/) 0 M T •uM, 01 1E, I a K). CORMIER CONSTRUCTION 978.852-9461 D.B.A. Keith J. Cormier PROPOSAL SUBMITTED TO: �R LICENSED CONSTRUCTION SUPERVISOR HOME IMPROVEMENT CONTRACTOR Page No. of Pages DESCRIPTION OF JOB ARCHITECT DATE OF PLANS JOB ADDRESS+ CITY STATE ZIP PHONE ,,,;_' WE HEREBY SUBMIT SPECIFICATIONS AND ESTIMATES FOR: < w i f, VIC 1 ,T Al r Make Checks Payable To: Keith Cormier 5 —Maplewood Meth, MA 01844 ,✓' We hereby propose to furnish material and labor complete in accordance with abovespecifications, for the T5 {. m ` / A//11 sum of <yt{t� ,,,;_' proposal may be wit dollars $ ) ` a `5_i g ��� �`�:�C with payment to be made as follows: k 9' y r. All material is guaranteed to be as specified. All work is to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from specifications Authorized .' involving extra costs will be executed upon written orders, and will become an extra Signature' charge over and above the estimate. All agreements contingent upon strikes, accidents Note: This or delays beyond our control. Owner to carry fire, tornado and other necessary proposal may be wit insurance. Our workers are fully covered by Worker's Compensation Insurance. within—L2— days. by us if not accepted Acceptance of Proposal - The above prices, specifications and condi- ( n tions are satisfactory and are hereby accepted. You are authorized to do t 1 r the work as specified. Payment will be made as outlined above. Signature Date of Acceptance: '% �,� Signature �3 CA Err . ami C7 — [� = D = m -o n o C -0 ? N O Z m n K o 3 m `� O D aFD.on > o F \� D n of A N s O .i1 m rn n (atA x m d 11 3 00 '�rL � ( ix 171 O � ire A �G �iil w •O� t— C o xl ID CL la to CO) O o0 D.; o moo I w 000 OCO coy O Co „�,. (i Co O cC)o 00 a Z N . 0. o' tD � o to y 0 y^ ee C W G ` C." n u Location i� �"` i"'�cxn No.,( Date Ale lx� TOWN OF NORTH ANDOVER Certificate of Occupancy $ ::'.„S <� Building/Frame Permit Fee $� �! Foundation Permit Fee $ ` Other Permit Fee $ TOTAL $ Check # V �v 22163 -- Building Inspector