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HomeMy WebLinkAboutBuilding Permit #501 - 53 FERNWOOD STREET 2/2/2010TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: �U Date Received Date Issued. ' rl IMPORTANT:.Applicant must complete all items on this page LOCATION S��' ✓1� -- Print ti Z �itcl MAP NO:PARCEL: OS ZONING L CT: 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 1 Others: Repair, replacement Assessory Bldg Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer urOUMIr II1UN Ur WUKK I U b PERFORMED: t4Liytic►l r '7 " )0 1 x -7-Z7 17 /t1 cl— -7-4,6 Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: CONTRA Address: Supervisor's Construction License: tJ{''] Exp. Date: Y /U Home Improvement License: � //Z//// p Exp, Date: ARCHITECT/ENGINEER Address: Phone: 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: $__�}, I FEE: $ Check No.: j Receipt No.: NOTE: Persons contracting with unregistered contractors do not have acs to the guaranty fund Signature of Agent/Owner a, Signature of contracto Location N Wado No. 4,0 Date _, �,. TOWN OF NORTH ANDOVER Certificate of Occupancy $ r� s °•,�� Building/Frame Permit Fee $ �3 ^C MUS 1 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 22/-77 Building Inspector 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 PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS DATE REJECTED 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 Os000d Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date 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 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 No 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 01/28/2010 14:37 036036250303 7 61 Elan Street, unit #3 mancheater, W. •03•"1.01 603-625-0303 + ti-9Vew.Bi4-THT #'B- akhlnh REBATH PAGE 02/05 "IL ..U7_.)__- aom#: AAddree trite, ZI Horsey Tel..." Work T®.].: work .rebathn.h r.01 rl n h and ,peelfics rparatedas a sales 0"grrrerttr,' no specifications In this agreement Are exact wofk to-e.porl6nYled, ONO:X•?illE' i �rot't S•TII e: reM SPECIFIED SY CFIECK M•IkR14 O" CIRC'E. OR WF"'TT,'-'N OLSCRIpTiON )NTNIS AGREEMENT WILL BE PE#ZFORMF.C). ACCEPT NO VERSA1. mon . White role Granite ,SSt1RANCES FROM APJYREFREJENTA•TIVE OF OWR•C.OMPANY. Company .greys to famish all labor and rrrerEdsis rmlwq otherwise. speefied, ed, f rhe Installation F'at CotUpg. tT Kvducts and services in accortlanCe with -the follcwln9 sp ' J r^' 5urrgcc, Rn Man Fud1•:�engtt+ I. 7�1 arlersby Soap So_dp Ceti_ Comdr primary Account Number: Secondary payment Mmthod: Seconear;•Account Number: Mecst•BrCard• 0•Visp, Customer a¢rees 10 Indemnify. hold harrMess, rekoaso and.forever dlacharge Ro-betFr of New HximPghlre a''K aath. LLCIPSuling legal dtarleEl:af Impes, es) for , Custom es, aucce:saols ofiloers. and directors fiom end a7palnat any and all toga, damage. pgnattlos, and experts (Jncluding Legal fees and expcnsss) for any and all olaims demands. sults, judgements. and coat Incurred by reason of or resulting frvrn the bathtub liner befn¢ Manufactured -are t and irts dict bll Rhaut the standard BE.th,lard slip resistant bottom, or for any mold and mildew found or not found at Job drum or In the future. Bain. the aro to ire wild o full on problems If the job requires removal of the tub or shower completion of )ob. less the contrnl t Dost of any defective item. Customer understands that If the axiSting wells nre to remain, a comps responsible for w&tar 16aka under the -new Rub liner. Re -Bath •is net be Incurred responsible o t for any drdrainfloor. p bass, hBatstamarote ! res onsi le for aO vrrer age Lhat Yr gas rocelpt of a opy of this a�rEernefit• Oral repressenntatio s are not binding, Mewitness If whc c Will "Seo Reworso For Wall(�a)IDraln Sage:Ftepalrs the Owners) has hereunto signed hisltler/their namejs)- ptlLdopoeitg nye not ral'undablo.sfter. tFiethn�n,�a� eprneoflatlan�lsrlad. DUptlsiA-W1111 be•aW. j6yd4a.40 > ! ry?wC °d f°*•thla eor�tcRet. Sarrwt4binpt�llktttons:teglilt, teat.allM1flo, tmrYaHie. an.vkxc0ftIfftWAred.gPPrmtlrxa�aih%'°3'vliA d/tlFty8•Si1bWCl°ODAStltlnateddelivery. . weeks. JOB TOTAL $ , Job to start In APPraxlmateiy_ _to $ G7TAXo REBATFI C%' �• < Dato:k_&j CONSULTANT_ �j TOTAL Customer; Signature: r bEP061`F D/Jr 7b _A •✓ rinln/, J�e.r•� •rN tc r rbmw (13 7 x W4 d .4j o u° v a cn 0O w z A ad 'or. w° a°' U m w w ao' cn LT. a W P-4 W ° v cn a i% a HO a o w c w H w w c4 cn o cn c c m c c i—a o � C y _O C O _v C) cc d CM p� C :.�. R �[ O y � CD E a c s C.3 qc VJ C.2 CD cm m c E .tom y •• �- m o a O V� to m = l cw t::0 m .3 N CO C43 E � �v CD y m :E:s O cm N _ CD C m CD O � cj C3 N O p cc �Z Hc Q co y m C •C = m ia�o N F- * coal m ca u, �E CJ � .y o v m o ®E c S C9 d m - C.— h p N $ a= m ::Ib V O O v • ..a co O E L O s Z ac O y p c I C C � p C Oa O O �ECOC2 co m m CLCD ~ O �co co p p ca O a, c a cao vCc Cc J= d O.6-0ca Z 0 C-) y O r C cc CLCO3 D The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations UV 600 Washington Street Boston, AM 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): 4 I4 Address: t�, Y S City/State/Zip: 1kV J M(L '074- Doa/u—"one #: 7 Y! �YY X16 J Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. 1 am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t listed on the attached sheet. $ These sub -contractors have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. [� Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12. ❑ Roof repairs 13. ❑ Other t....� —1 tiu a ;xt : r: mutt also 1111 out the section below shoR,L-,- +.II_ WCrr:eS' COmpeIIsailoII pOl2C}' Z^..fC.^.^.atioII., 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. I am an employer that is providing workerscompensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: S Policy # or Self -ins. Lic. #: '3bC-ci3 (03 Expiration Date: / I/ — I Job Site Address: Z-1 ep S 4— City/State/Zip: 1'10g� "a -e -K 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 off perjury that the information provided above is true and correct n IM, 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 returned to the city or tovm 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 permittlicense 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 021.11 Tel. # 617-72.7-4900 ext 406 or 1-8 77-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia ACORD CERTIFICATE OF LIABILITY INSURANCE ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTWIGATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 0 SUBJECT TO ALL THE TERMS, EMCLUSKINS AND CONDITIONS OF SUCH POLICIES. AGGREGATE UNITS SHOWN MAY WAVE BEEN REDUCED BY PAID CLAIMS. w W O r021002)'2010 PImmm THIS CEi'11FICATE E ISSU-07-Ar A MATTER OF NOWATION ! MT IASIDRANCR A108NCT ONLY AND OONFERS NO RIGHTS UPON THE CERTFICATE aNINALWmIn' HOLDER. THIS CERTIFICATE DOES NOT AMEND, OnIB•D OR ALTER THE COVERAGE AFFORDED BY .THE POLICES BELOW. 28 CHURCH ST SUITB 08 X COMMBICALGENENALLIAMIM X CLAM 16" E OCCUR 3DC9363 WIM MSTER, wh 01890 INSURERS AFFORDINGCOVEIAGE NAIC* INSURED Erie bftrphy MESum A 6SSzx INSURAMCR COlwAMZ FrAFER It 164 Sheridan Ave MffiURER C IHBURER Q GMIEMAGGREGATE $600,000 >iullord, MIL 02155 1 MURERE COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOWOMTANDHNG ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTWIGATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 0 SUBJECT TO ALL THE TERMS, EMCLUSKINS AND CONDITIONS OF SUCH POLICIES. AGGREGATE UNITS SHOWN MAY WAVE BEEN REDUCED BY PAID CLAIMS. LTR W O YPE Tof RA POLIDY N man �Y oRm LM! AUINOIIolD TEO aNINALWmIn' EACH000URIRNCE $ 600,000 X X COMMBICALGENENALLIAMIM X CLAM 16" E OCCUR 3DC9363 01/04/2010 01/04/2011 PREMIsEISu4mlw$ M0EXP(ftyom* w11mtf $ PIA SON& AADY NWAY $ 300, 000 GMIEMAGGREGATE $600,000 "nAE:OREUTEUMITAPPUESPM PRODUCT$•OCMPAPAGO $600,000 POLCY ,� LOC Aur000111a LIABLITY COMBANYAUTO ((lamo INGIE LMi11T $ dam ALL OWNED AUTOS $CHEDU EDAUTOS BODILY LW,JUM $ pvwm) HIRED AUTOS NON-GYRaD AUTOS BODILYIN.LJM $ (%r snow PROPSIM OHMAGE $ OARAAELIABILM AUTO ONLY• GAACGDENT i ANY WTO . 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