HomeMy WebLinkAboutBuilding Permit #721-11 - 52 HEWITT AVENUE 4/27/2011Permit NO•—/
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
Date Issued:— r
EWORTANT: Applicant must complete all items on this -Daae
_LOCATION f' AUS _
Print
PROPERTY OWNER
Print
MAP NO: D 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
epair, replacement
❑ Assessory Bldg
11 Others:
❑ Demolition
❑ Other
'❑Septic ®�Well�= �,Y4*� s� k
'�aFloodpla3 DOWelands y
E ;®�y,atersledDistxict;. ,,
-
t
DWater/Sewer 4
4 a J
i4 at�s t
_
DESCRIPTION
OF WORK TO BE PERFORMED-
kcexi2 )CtS>nN & /Ox(Z DC iC
Identification Please Type or Print CIearly)
OWNER: Name: Kwtm Foto.:T 37
Address: G Z 14W i tr ' ;2-73 ' 7d 44
CONTRACTOR Name: AJ A/SC- Phone: -t 80
Address: PO g� 13-L 1U �w,ec- iCi 0(8�'T-
Supervisor's Construction License: ft I(D Exp. Date:
Home Improvement License: (3-)5-52- Exp. Date:
ARCHITECT/ENGINEER 1,J ]A Phon
Address: Reg. N
FEE SCHED ULE: B ULDING PERMIT: $92.00 PER $1000.00 OF THE TOTAL EST/MATED COST B D ON $125.00 PER S F.
C.t.)
Total Project Cost: $ 0700 FEE: $
Check No.: Receipt No.: �d
NOTE: Persons contracting with unregistered contractors do not ha&e access to the guaranty fund
NMI
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/MassageBody Art ❑ Swmmung 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
DATE REJECTED
A
DATE APPROVED
Reviewed on Signature
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 Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
COA4MENTS
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions._______
Total land area, sq. t.:,
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
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
o 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
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
AL the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
ist be submitted with the building application
Doc: Doc -Building Permit Revised 2008mi
Locations
No. ��' Date
TOWN OF NORTH ANDOVER
A
Certificate of Occupancy P Y $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
24094
wilding Inspector
O
z_
I
•
�z
w
u
u�
U
A
PQ
a
L
O
G
U
V
,�
�
C.
O
0
w
t•
w
a
U)
-o
w
�'
O
ao'
m
w
w
w
w
�.
W
z
cn
,;
Q
o
cn
I
.a
2
6
O
0
x�
L
O
�
O
V
�m c
�
C.
O
h
I
cm
� C
c is
O O
�E
m m
o
c NC2
O
: c
coo
0
o
eov
Q�
CL
cma
CO2
C
4-0 c
C cc
CL C
�O.
O +O+
C
MM
CL
c
C C
C
c
CLCO2
O �
CD
Ea
L
CD ci
:.�.�
pd o
CD
M 5
o n
C
:.,.. m
:cam
o 0
C.0
u C
m c
�
CL=
L
®m
a
H
cm
CD
a
•"o
•s
=c
C
A
p
E N9
m.
aC �
m
OLD m '
=z
oCM
c
Go
dcL
•7
m
O
VH
0Z
o
C
�
t;
C C
�'o o-
CD
c
c
QE
:2mc
•o
=
m
:a
CD+�
ca
W
CD
•oma C=„
t
O
•yc
.�
P
.L.
y=... C
m .y
Z
O
C.3
o
o ®:C C
y
d
O :0
N
_
�
•�
v
cm
C m�
I
.a
2
6
O
0
Y/
LLI
W
19
W
LLI
19
uiW
N
0
x�
L
O
�
O
V
�
C.
O
h
I
cm
� C
A
O O
�E
m m
O
G j
0
o
eov
a
CL
cma
CO2
C
4-0 c
C cc
�O.
O +O+
C
CL
c
C
C
c
CLCO2
0
Y/
LLI
W
19
W
LLI
19
uiW
N
ssacbus
e lft14ovememt• R
Ie Contract
This Form satisfies all basic requirements of the state's home improvemeuit'Contractor Law (MOL chapter 142A), but does not 'include standard
language to protect homeowners. Seek Legal advice ifnecessary. An
y Person 1vTassachusetts consumer guide to home improvement" before agreeing to any work on youing r residence.oYou mayvements sobtain hould first
mfree copy b callin the
Office of Consumer Affairs and Business Regulatinn's ConsumerInfatmtrtion Hotline at 617-973-871;7 or u may28 obtain
a , PY in ria
PY Y g
H'omeowne'r Information
Contractor` Information
vt ti) `=0
ompany Name
Street Address (do not use a Post fiice Box address)
. N4o3
Contractor/ Salesperson/ OwnerName
Cl�Ov ° State Zip Cotte
N s r t(e�
Usines Address (must include a street address)
Daytithe Phone Evening Phone
lone 9''7 i i 3d,
I 1ty/Town
'
StaGte� Zip Code,
Mailing Address (11different from above)
Aj�_ (
nsiaess Phone ederal Employer ID or S.S. Numb
Lzw;;LdresHut most haue!M-$ome
'
The Contractor agrees io do the-foilowing work for the Homeo
MV=!nt contractors have a pro vementCaahacforae�.Numler axpi
Ud E's�trop Mont a
cn e m a r• 1:7 comp e e speer
' r2, J
Mer
Ria n s o e e an
�
ttsquired.Pertnits - The following%uilding permits are required
and �{{ill he secured by the contmctnr as the homeowner's agent,
(0 ners who secure their own permits will be
exclilded from, the Guarant}� Fund provisions' of
MGL chapter 142A.) '
Proposed Start and CompletionSchedule - The following schedule will
be adhered to unless circumstances beyotid the contractoes control arise
ALLDate when contractor will begin contracted work,
5 Date when contracted work will be -substantially completed.
Total Contract Pi•Ice and Payment Schedule
The Contractor agreer to perform the wort;, furnish the material and labor specified above for the total sum 6f
-
ma will be ``Lade abcording to the following schedule:
upon signing'contract (riot to exceed 113 of the'total contract price per the cost of'specia] order items, whichever is greater)
by ___ _I�1� or upon completion of
S by _f_/_ -or upon completion of
�Ud upon completion of the contract. (Law forbids demanding full payment until contract is cora leted to both a
P p rty's satisfaction)
The following inaterial/equipment must be special $ to be paid for
ordered before the contracted warl'begins in order
to meet the completion schedule.(**) to be paid for
NOTE, S: (*) Including all finance charges (**) Law requires that andeposit or down- a crit required by the contractor before work begins may
not exceed the greater a f (a) one-third of the total contract rice or (b) the uCd�iaj cost of any special
which must be special ordered in advance to meet the completi°n schedule. Y P equipment or custom made material
buDCbntractors - The contractor a _- -" 1e Yes all terms of the warran must be attached o the contract
grew to be solely responsible for completion of the
paily(subcontractor utilize' work described regardless of the actions of any third
ed by the contractor, The contractor further agrees to be solely'resp
Materials and laborunderthis aeement bnsible for all payments to all subcontractors for
Contract Acceptance - Upon• signing, this document becomes a binding contract under law. Unless otherwise noted within this document, the
contract shall not imply that any lien or other security into
carefully before signing this contract resthas 'been placed on the residence. Review the following cautions and notices
• Don't be pressured into signink the contract Take time to read and fully understand it. Ask questions if something is unclear.
• ' Make sure the contractor has a lid Home t.,,
subcontractors to be registered with the Director f Houle Ira` provem nt Contractor Registrati12mvenicurControgtor egi2tration The law on.` Vou may inquirec� most improvement contractor tors and
I by,writing to the Director at One Ashburton Place, Ra -m 1301, Boston, MA 02108 or by calling 617727-3200 oracthr
1:8001223-0933.
• Does the contractor have insurance? Check to see that your contractor is properly insured,
• Know your rights and responsibilities. Read tate Important lnfornlatiola on the reverse side Laof this form and get a copy of the Consumer
Guide to the Rome- Improvement Contractor w.
You may cancel this agreement if it has been signed at a platie o'firer than the contractor's normal place of business, provided you notify the
contractor in writing at his/her main office or branch office by ordinary mailposted, by telegram sent orb delide
third business day following,the signing of this agreement See the athrcllecL notice of cancellation form for an explanation of flus right
Y ry, not Inter than midnight of the
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES`!!
Two ide tical wpie i tmust completed and signed. one co bild g o to, thb ho
pYsumeowner. The other co
• py should he kept by the contractor.
ome ner's igna
Contra tors Sign e
Date (p
Date
MAR.15.2011 8:20AM ASSOCIATED INSURANCE
CERTIFICATE OF LIABILITY INSURANCE
NO. 0758 P 1
DATE (A9allDD/YY
03/15/2011
TBI: CERTIFICATE IS ISSUED AS A MATTER OF INSORMATION ONLY AND COMRO NO RIGHTS UPON THE CERTIFICATS HOLDER. THIS CERTIFICATE
DOER NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER TRE COVIRAU AFFORDED BY TRE POLICIES BELOW. THIS CERTIFICATE OF
INSURANCE =8 NOT CONSTITUTE A CONTRACT BETWEEN THE, ISSUING INOUHER(8), AUTHORIZED RE RESENTATIVE OR PRODUCER, AND TBE
CERTTP=TE HOLDER,
TbMRTANT: If the certificate holder is an ADDITIONAL INSURED, the Policy(ies) must be endorsed. If SUBROGATION TO WAVED, subject
to the terms and conditions of the policy, certain poliaiee aWy require an endorsement A Statement on this certificate does not
confer rights to the certificate holder in lieu of such endersamaell.f_
MSM Insurance Associates LLC
575 Chickering Road
North Andover, MA 01845
North Andover Building Corp
70 Pillon Road
Milton, MA 02186
COVERAGES CERTIFICATE NUNRER, PJMBZC I NtiM6ER:
THIS IS 20 CEATIFY THAT THE POLICIES OF INSURANCE LISTED BELON HAVE BEEN I88UED TO THE INSURRD NWO
5= FOR THE POLICY PERIOD INDICATED.
NOTWITHBTANDINC ANY REQUIREMENT, TERM OR CONDITION Or "T CONTRACT OR OTHER DOC&MENT HITH RESPECT TO
ICH THIS CERTIFICATE MAY BE I0OMD OR NAY
PERTAIN, THE INSURANCE AFFOROab BY THE POLICISR DESCRIBED HEREIN IB SUBJECT TO ALL THE TERM$, I)C=01
MAY HAVE BEEN REOUC:D By PAID CIAIMB.
tJ3 AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN
Z—POLICY
Ltb
TYPE OF ,INSURANCE
POLICY HUmm
RCS
m/mMrn
POLICY EXP
twWnnl
LIMITS
GENERAL LYASILln
r-10Dpaz:NCD.L ....'M UMiLITx
CI❑CIAIMI MRDEIR..vaa,srna.l
aOCCUR
ElN
EAON odawRMti 0
D&KRM To vim=
,
_
Ido nl IAWj ae. e.t..n) 0
umn 1 ADV IHOURY 1
09MUM
CLU' L AGG=Oat LINXT APOLI[S 9A:
POLICY pPAOJtat ❑LOO
MDD4cTe . oao/ev ADD 0
1
AUYg078ILE LIABILITY
QANY AWID
CONNIM IIMOLE LIMIT 0
lee aveLdentl
DODILx ENJUM IF- P.—I 0
ALL OWED Avtoe
M10NED=. ADT..
4DDIid iMAWTgee' +eeLie M •
�NIRED AVT09
❑DON-OdeED AV'tOS
❑
4PODiPTt Avg= 1
b.i L.DIIsQ
t
0
VM/RUTA LIAR ri OG.
oa ocLVRezQia 0
❑CCC[!e EIAs El C7A;x4 NRDt
A06gE0ATi 1
❑RUIXDEDUCTIBLE
TIOn 1
WORXRRB CONFENS&T1ONAND E!@LOYLLB LIABILITY
10a'^ eATHE
r!9
AEY.ECUTIVt
PROPRIETOR/PARTNERS/
Ott"2CER5 Alt
s.L. WN wcDtenns ,000
0Ytl1i U -'°uCC IST a 500, 000
incl ❑ excl
1023267012010X.L'
11/11/2010
1��11�2011
s.L, vZol"E - sA WKPloves / 100,000
CGNdNTe 7 NOCOITIOM W om"TIDBI DA LDCATIONeI
CERTIFICATE HOLDER CANCEMLTION
JOAN NCLAVGHLIN
SHOULD ANY OF THE ABOVE MCRiBrn POLICIES BE CAWCELLED BEFORE TBE
70 EILLON ROAD EXPIRATION DATE THEREOF, ICE HILL BE DELIVERED IM ACCORDANCE WITH THE
POLICT PROVISIONS.
MILTON, MA 02166 AVTYDAIt� uvRelrMTArm
2011-03-15 08:34 7800 876 2765 Pagel
Massachosetts - Department of Public Safe(A
Board of Building Regulations and Standards9 '
Construction Supervisor License
License: CS 82816
Restricted to: OD
JOHN R LEEMAN JIB
70 PILLON ROAD
MILTON, MA 02186
Expiration: V16W2
('ontill issioil cr Tr#: X393
u Office of Consumer Affairs and 11usiness Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement C ��tor Registration
NORTH ANDOVER BUILDING
JOHN LEEMAN
P.O. BOX 132
N. ANDOVER, MA 01845
DPS-CA1 0 50M -04/04•G101216
R efglstrat'ion: 137552
Tym: Private Cupombon
Expuabon: 11-126r2012 Tr# 205622
1e Address and return card. Mzrk reason for change.
ddress n Renewal F] Employment [I bust Card
The Commonwealth of Massachusetts
Department of Industrial Accidents
i d;, - �'� Office of Investigations
► ` 600 Washington Street
Boston, MA 02111
" www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electriclians/Plumbers
Applicant Information Please Print'Legibly
Name (Business/Organization/Individual): /vA13C
Address: P u &A (3 Z -
City/State/Zip: � dj oa r . MA Phone #: q �7 ) 9 G
Are yo an employer? Check theAppropriate box:
4• ❑ I am a contractor and I
1. I am a employer with _
general
employees (full and/or part-time).*
have hired the sub -contractors
listed the attached sheet. t
2. ❑ I am a sole proprietor or partner-
on
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
5. ❑ We are a corporation and its
[No workers' comp. insurance
required.]
officers have exercised their
3. ❑ I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.]
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. [ 1emodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.0 Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
*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 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 acid their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: A 4'A
L
Policy # or Self -ins. Lic. #: -761- 'L GDO) Z 01 Q Expiration Date:
Job Site Address: 157 I�ew ar City/State/Zip: N s 4/y9t- �1
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 and penalties of pef jury that the information provided above is true and correct.'
�_...__. bate: 4Isc"(u -
q (0G
Official use only. Do not write in this area, to be completed by city or town offtciaL
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 #'
Inforrmation 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 confinnation 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 pen -nit 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 Deparhnent 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 pen-nit/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 pen -nits 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 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
Revised 5-26-05
Fax # 617-727-7749
www.mass.gov/dia