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HomeMy WebLinkAboutBuilding Permit #435-2011 - 52 WATER STREET 11/19/2011 i I TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION . Permit NO: _ Ofd Date Received Date Issued: l tf < <- IMPORTANT:Applicant must complete all items on this page LOCATION I Print PROPERTY OWNER �i4/ fir- �i %yr/ C�/ 7 i2uS r Print MAP NO: ""bPARCEL:0 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 El Alteration No. of units: �1" `` ❑'Commercial Y'Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Se trc ❑Well ®Floocl"'lairi� D _ p ,=$ p Wetlands yVatershe„d District Ll®ORd'er DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER:_Name: PwA q/e r-gm /y I'Iey S r Phone: 97MY'73 - Address: e0-6&Y, L215- �esf CONTRACTOR Name: (24eA j i' .6tt IcJe�, r ` --Phone: l:3lS �ttg.i��h y Address: /0 601- 1401 Yin . Au DU Supervisor's Construction License: GS 3 94,5-0 Exp. Date: ��L� 490IZ. Home Improvement License: /0 -13! Exp. Date: 'T f Z® y ARCHITECT/ENGINEER '` � Phone: s. Address: - Reg. No. FEE SCHEDULE:BULDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. r Total Project Cost: $ - FEE: $ Check No.: Receipt No.: Z3 72 i NOTE: Persons contractingwith unregistered contractors do not have access to the guaranty fun Si tu-rvne-r .: � ature ofcontacSgeAgen - Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody 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 j HEALTH Reviewed on Signature • y 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: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes -• no A., Located aMain ,.. �--Fire'Department signature/date 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 No DANGER ZONE LITERATURE: Yes No - = MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine c , NOTES and DATA— For department use ..r e I EI' ` I Ll Notified for pickup - Date i - I Doc:.Building Permit Revised 2008 _ ' Building Department The following is a list of the required forms to be filled out for theappropriate ermit to be obtained. qpermit Roofing, Siding, Interior Rehabilitation Permits d ❑ 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 a ❑ Photo Copy-of H.I.C. And C.S.L. Licenses j ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And ll Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report If Applicable)able _- ' ❑ 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 2008mi Location No. ���' /i Date �� a �ORTM TOWN OF NORTH ANDOVER 9 Certificate of Occupancy $ . Mus Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 23726 Building Inspector The Commonwealth of Massachusetts A, r Department of Industrial Accidents �=i r fn Office of Investigations :r, a 'L 600 Washington Street %,-.fBoston,MA 02111:- www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print'Legibly Name (Business/Organization/Individual): � p�ryJ�l� 2,j,,&, Address: ��T,��}L yzo/ City/State/Zip: X/ AV DO-V­P�62_ . Phone##: 5'7F�Z 3 6!52 D Are you an employer?Check the appropriate b : Type of project(required): 1.❑ I am a employer with 4. [5 I am a general contractor and 1 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. # ❑ 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.❑ Electrical repairs or additions 3.❑ 1 ain 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.E] Roof repairs insurance required.]T employees. [No workers' 13.❑Other comp. insurance required.] *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: //e,4 ��p SGS 12G3�iC C� Policy#or Self-ins.Lic.#: .fid Expiration Date: Job Site Address: 52Z Gt) e-fL S`f 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 and penalties of perjury that the information provided above is true and correct.' Signature: Date: -47/, /Y 2-0 Id Phone#: 9 7 rZ/L3 6,!2 3 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 g gJ � 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-contractor(s)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 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 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 pen-nit/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 pen-nit 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. #617-727-4.100 ext 406 or 1-877-MASSAFB Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia F ORTH Andover TONM Of - - , -o . dower, Mass., // COC NIC MEWICK �� �7 ADRATED PPS\ �C;� qS BOARD OF HEALTH Food/Kitchen r Septic System ERMI � r BUILDING INSPECTOR THISCERTIFIES THAT /..Ct.���/E..:......,C!'!1%lr�....1.. .L! ........................................................................... Foundation . ..-.. ..P ... . ... ... .-...5g has permission to erect...................................... buildings on ..v�ff f Rou h �/ .. �i`.../l\. G�.1................................................................................................. nal y C e to be occupied as.................................F.O... .... ... .. 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 Reguiations'Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION ST TS Rough Service ­46i: ILDING INSPECTOR Final Occupancy Permit Required t0 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 Inspector. Burner. Street No. E[ESEE REVERSE SIDE Smoke Det. I V is \M -ts + ✓ 11/18/2010 11.31 9786"8331�47 Aca vri ® CERTIFICATE OF LIABILITY INSURANCE L 11/18/100 THS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE D17ES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED [�REFPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. t to IMPORTANT; R the certificate holder is an ADDITIONAL.INS ,Ino polieyflos)mstbe andolsed. If SUB ,su ec the ternsand conditions ofthe pof{cy,certain policies nay require an endorsement A Matement on thiseertificabt does not confer rights to the certlflcate holder in lieu of such endorsemen s. RTACT— PRODUCER N M.P. Raberta Insurance Agency P 1060 Osgood Street AD96k North Andowir, MA 01845 yocER 1177 INBURERI9)AFFORDING COVERAGE NAIC .. ........ -....._._.._... _. — tN9URED IPBURERA:Travelers Insurance CO. Creative Builders, Inc. INSURERS: P, 0. Box 401 1N RERERC: North Andover, MA 01845 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOInvlTHSTANDNG ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONOITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, _ ILTR TYPE I)F INIiURANCEIUM Cy NUM BER IL00lyEFF MMD LIMITS GENERAL LIABILITY EACH OCCURRENCE ! COM (IAL GENE RAL UABILITY DA IdRENTED EMlcee. ee,nenDe) s CLAtNB+enDE 11 OCCUR MED EXP(Ary or*Penan) PERSONALBADVINJURY S GENERALAGGREGATE S - GEN'I.A00REGATIiLIMIT APPLIES PER PRODUCTS•COMPIOPAGG S Y mLOC POMC AUTOMOBILEUA94ITY COMB INEOSINGLELIMR 3 {Ee ecclden) ANY AUTO BODILY INJURY(Per person) S~ ALLOWNED AUTOS EIODIIY INJURY(Per eccld9M) S SCHEOULEO A.UTOS PROPE RTY DAMAGE NIREDAUTOS (Pereeeidontl s NON OwNCD'LVTOB S UMBRELLA LI) OCCVR EACHOCCURRENCE S EXCESS CLAIMB•MADE AGGREGATG, $ DROUCTieLE e RETFNTI N V I%KEM COMPEI•SATION WC ST MTU• DIN• A 6185X308 3/29/10 3/29/11 AND EJAPLOYER6'LIABILITY ANY PROPRIETORIPAWNERBXECUTNE YIN E.LEACHACGDENT IL500,000 Mandeery In NN)OFFIOEWMEMBERE%CLIDEDT NrA E.L.DISEASE-EA EMPLOYEE B 500'000 pA■I�M IfI�w de■ale0 under E6ttIPT'IONOFWERATIONBCelow EL,DIS EASE-POLICYLMIT 3 500,000 L7 ....._T RIPn OE 9C ON OF OP[RATON91 LOCATIONS/VEMpLES (Ameh ACORD 101,Add{IlonO Rarl■Ilke Schedule,If Tae eply AI nQurad) F-978-887-7961/976-688-9542 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE A60VE DESCRIBED POLICIES BE CANCELL20 BEFORE TOWN OF NORTH ANAOVER THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN AOCOROANCE WITH THE POLICY PROVISIONS. ATTN. : MARY 1600 OSGOOD STREET AUTHORIZED REPRESENTATIVE NORTH ANDOVER, M 01845 it, 0 1988,2009 ACORD CORPORATION. All rights reserved. ACORD 26(200 9109) The ACORD name and logo are registered marks of ACORD CREATIVE BUILDERS, INC. P.O. BOX 401 NORTHANDOVER, MA 01845 978-887-3703 November 15, 2010 Daigle Family Trust P.O. Box 225 West Boxford, MA 01845 Re: New roof at 52-58 Water Street, North Andover The cost to replace the roof with IKO Cambridge shingles is $ 4950.00 Thank you, Robert K Daigle :+—..—•--�r,wa.SST •a'r cr�ea..LB'*',rr'°.ara�.,�,e_'.., �,•.�iw.�,.++..+,Wrww wm:s.,r+.... W4�.�::ala+y Off;ceon2�sumer arrsness egu HOME-IMPROVEMENT CONTRACTOR Type. Registration :x.1,05739 r 012 Private Corporatio': Expiration , G� VC , E BUILfDE Robert Daigle ) 297 MAIN STREET , . BOXFO-RD,MA 019'1 z Undersecretary Massachu�c#ts Dcia:tt Iiucrit of Publtt Sat2 7 ' Boat(I of Building Rt ulatiotts'and St�1r�{ iatfq' G,onsffuction Supervisor `Licens* E { 1acense CS 38650 t ' b t i A � (.' 8 A I 9i �• i ROBERT K aDAIGLE '. PO BOX 225 4;`' ILL " W,BOXFOR`D, MA04 B85`' Expitatinn 1723/20,1` ('�nnnu��cii�tr, Tr#: 14248. t �b'