Loading...
HomeMy WebLinkAboutBuilding Permit #662 - 487 WINTER STREET 6/2/2009BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: (0 'G L� Date Issued: (0 —2::J0 IMPORTANT: Applicant must LOCATI Date Received all items on this PROPERTY OWNER_W— / l + 1tiff( /`f, Print MAP NO: _ f PARCEL-?[ ZONING DISTRICT: �a v StLev 1 OL of `* V,.. °y #/ 9 q. :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 e airacement Assessory Bldg Others: Demol�on Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: Identification Ple a Type or Print Clearly) OWNER: Name: Phone: �d 3-4 0 Address: CONTRACTOR Name: �,� .`�.=5 Phone: 'may Address: -o -{ Supervisor's Construction License: C� S (l q to Exp. Date; Home Improvement License:�Exp. Date: ARCHITECT/ENGINEER I---' 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: $ /3.3(30 FEE: $ L�o Check No.: f a 3� Receipt No.: NOTE: Persons contracting y ithljinregfs!Ared-yontractors do not have access to the guaranty fund of Agent/Owne y U w-1 tgignatqre 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 COMMENTS Reviewed on Signature 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: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpsteron site, yes no Located at 124 Main Street Fire Department signature/date COMMENTS A 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 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 Li 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 Location No. Date &ORTol TOWN OF NORTH ANDOVER Certificate of Occupancy $ S CHU Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# Building Inspector T The Commonwealth of Massachusefts Department of Fire Services Office of the State Fire -Marshal P. 0. Box 1021 State Road, Stow, NfA 01775 PERMIT Norah Andover Permit No ( Cityof Town) (If Applicable ) In accordance with the provisions of A G11 4 8 .Chapter as provided in section R 34 This Permit is granted to: /0fW,15z� &f1j7,f - /tel f 4"A" n c,u6,Cwgrq Date: Dig Saaffe/Nvm er Stmt Date Full name of person, Firm or Corporation r Permissionto locate dumpster foconstruction/renovation/demolition of building. Comments: dumpster must be. 251 from structure if unable to place with required Restrictions: clearance dumpster must be covered with plywood or tarp end of work -day at L�� % 6ti �n % L/� �✓ ( Give location by street and no., or describe in such manner as to provied adequate identification of location ) FeePaid$ 50.00 �.<� � Fire Chief This Permit will expire �, —�� -d� (Signa i ,ant g permit) ffical granting permit ( Tide) (A m m 14m X CA v m a) F u C � CD 'v O n Z CO) r CL o n� C C d = CO) c v CD CDCL cr o rF d CD CD o 0 mw a C O co). CL v n O. � v CD CO) O 1 Z CD O CD O vY 44 O 0 a :` 5 9/I 1� cn cn n O z cn a r I, C O o Z CD_ CD S.O co O C CL co m co C 0 7 H a?�O. =r_ _N O Q yim aom y a mCn Cl) yoaCC2 O dd= y .. m 't7 m C=L,�CL o m CO) Ir C -DR CA c y 2 O� C2: CCD, O yn: C=D m O 2 I: C, AND c =r ..� �O C 3r - m H 1 O m d 1 m� m� dJ G d C CD co m N N m �o co � -'IF o� �� CD 3� -Cos a CD _ �: O m ' cn m 1 y ,o o CD m m H n 0CR0; o 1 R O � o �q O 41 cn 0- cn to 01) w w �n w Ci7 � w 70 oCa � cn 0- cn to w w �n w Ci7 � w 70 oCa � n ;zcn go z ^ O. O x FAORTN TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT 1600 Osgood Street &ifl&g 20, Suite 2-36 North Andover, Massachusetts 01845 Gerald A. Brown Telephone (978) 689-9545 Inspector of Buildings Fax (978) 688-9542 HOMEOWNER LICENSE EXEMPTION Please mint DATE: (4) JOB LOCATION: K7 Number Street Address H0ME0WNER_LjjjL Nam Home Phone IN PRESENT MAILING ADDRESS City Town mapfla --US' -Z2 Work Phone State Zip Code The carrexemption for "bomeawnerC was extended to include owner -occupied dwellings to two units or Im and to allow such homeowners to engage an individual for hire who does not PON= 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 winch he/she resides or mtm& 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 dian not be considered a homeowner. The undersigned "homeowner" assumes responsibility for compliances with the State Building Code and other Applicable mim by-laws, rules and replatim. The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will ONVIY with said procedures and requirements. HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revimw io2oos Form Homeowners EmmVfion ROARD OF \PPE..U.S6RM541 CONSERVXF10N 6 -SR -9530 HE.\L'm 689-9540 PL.VNI-NING 688-9535 The Commonwealth ofMassachusetts Department o. f'Industrhd Accidents Office of Investigations 600 Washington Street Boston, MA 02111 c I www nzass.gov/dia . liWorkers' Compeusition Insurance Affidavit: Builders/Contractors/Electricians/Plumbers plicant Inrrorntatian Name (Business/Orgetaiza6arL Individual): Z� J Address: P0y City/State/ZigJv . -� \ e ' d2t;_? hone 0. . Are_aa employer? Check the appropriate box: 1:0 1 am a employer with 3 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. F1 I am.a.sole proprietor, or have hired the sub -contractors listed partner_ ship and have no employees on the attached sheet. These suis -Contractors have working for me in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.) 3. ❑ I am a homeowner doing officers have exercised their all work right of exemption per MGL myseI£ [No -workers' comp, C. L52, § I(4), and -we have no insurance required.) t employees. [No workers' comp. insurance required.] 9 Type of project (required): 6. ❑ New construction 7. ❑ Remodeling S. [] Demolition 9. Q Building addition l0.❑.Electrical repairs or additions I I .Q Plumbing repairs or additions IRoof repairs I3. Other Iii f . ;Any. applicant that checks boil #I must also fill out the section below show.in their workers' ao hoeotiotL wner¢ who submit this affidavit indicating they are doing an work end then hire outside ccon�tractors msgnm ast submlicy it a new afitdavit indicafia� such xContractots that check this box musrartwhed an additional sheet showing Che namo of the sub-connaetors and their workersc cm, .r moi itttbrmation. 1 arc aR eWkyer that is{:rov:ding:workers' Compensation h2surancef infor"Madon. or my employees: Below is the palicp mldjob site . Insurance Company Name: �_h Policy # or Self -ins. Lie. #: toe 3-) Expiration Date: Job Site Address: City/StatelZip:_ / �c[cr `Ji��l)' Attach a copy of the workers' Failure to compensation policy declaration page (showing the policy number and expiration datze� secure cover . age 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 andlor 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. 1 do hereby cerfify under the pains and penalties of pedwy A*& the infnr»mtion provided above is true and coned Phone #: Ofj`icial use only. Do not write in this area, to be complerad by, cay or town offidd City or Town; Permit/License # Issuing Authority (circle one): I. Board of Healtb 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information a nd Instructions Massachusetts General Laws chapter 152 requires all emp 3 overs 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 orm ore of the'foregoing engaged in a joint enterprise, and includir-kg the legal representatives of a deceased employer, or the receiver ortcustee 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 wont on such dwelling house or on the gmunds or building appurtenant thereto shall not because of such employment be deerned 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 evidencevt compliance with the insurance coverage required." Additionally, MOL chapter 152, §25C(7) states "Neither tiie 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 complertely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), addresses) arnd 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 drat the .application forr-tfre 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' oompensation policy, please can the Department at the nurmberlisted 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 Departmient 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 investigpations 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 Depart rent's address, telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investistions 600 Washington Street Boston, MA 02111 TeL # 617-727-4900 ezct 406 or 1-8.77-MASSAFE Fax # 617-727-7749 Revised 5-26-45 wwwmem.gov/dia Ldel Page: 002-003 QCORQM CERTIFICATE OF LIABILITY INSURANCE 06/0 /2 9 PRODUCER (603)898-6500 FAX (603)870-9444 C & G - Cross Insurance 288 North Broadway y Salem, NH 03079 Susan Gause 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 Collins, Michael DBA: The Collins Company P.O. Box 281 North Salem, NH 03073-0281 INSURER A: Western World Insurance Co INSURER B: LIBERTY MUTUAL INSURANCE CO INSURER C INSURER INSURER E. 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 ADDTPOLICY NSR TYPE OF INSURANCE POLICY NUMBER EFFECTIVE OATS MM1DD POLICY EXPIRATION DATE(MMIDDfffl LIMITS GENERAL LIABILITY NPP1167813 06/19/2008 06/19/2009 EACH OCCURRENCE $ 300,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 50,000 CLAIMS MADE a OCCUR MED EXP (Any one person) $ 5,000 A PERSONAL & ADV INJURY $ 300,000 GENERAL AGGREGATE $ 600,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/OP AGG $ 600,000 POLICY PRO- JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANYAUTO (Ea accident) ALL OWNED AUTOS BODILYINJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ N09OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY- EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR ❑ CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WC5-31S-227489-037 06/13/2008 06/13/2009 1 OT EMPLOYERS' LIABILITY ORYLIMITS E.L EACH ACCIDENT $ 100,000 B ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ 100,000 It yes, describe under SPECIAL below E.L. DISEASE - POLICY LIMIT $ 500,000 -PROVISIONS OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS 1'9:0TICIf'AT1T unl nro William Hadad 487 Winter Street N. Andover, MA 01845 ACORD 25 (2001108) FAX: (603)898-6338 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 William Corcoran ©ACORD CORPORATION 1988