HomeMy WebLinkAboutBuilding Permit #637 - 53 ROCK ROAD 5/21/2009BUILDING PERMIT o`tt�•o ;6'q�
TOWN OF NORTH ANDOVER �� ,� ,.. .:.. c
APPLICATION FOR PLAN EXAMINATION ~
Permit NO: Date Received 4 "`
pDRATlD I'PP.�5
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Date Issued: -
IMPORTANT: Applicant must complete all items on this page
LOCATION
PROPERTY OWNER iy rin{�
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Print
MAP NO: PARCEL- -JONING DISTRICT: _ Historic District yes no AILIZ
Machine Shoo `Village ves 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 OF WORK TO BE PREFORMED:
;?i ke 9(c-ce
Identification Please Type or Print Clearly)
OWNER: Name: Phone:57cam
Address:
CONTRACTOR Name: Phone:
'S L
�J t
Address
Supervisor's Construction Ocense: ?((2 Exp. Date: d
Home Improvement License: Jb § Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMI
$12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
1
Total Project Cost: $ t, , mac, FEE: $
Check No.: SQ V Receipt No.: 01 0 S7 3
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
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
L3. . Certified Proposed Plot Plan
'o Photo of H.I.C. And C.S.L. Licenses
r
❑ 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
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
COMMENTS
Reviewed on Signature
HEALTH Reviewed on Signature
MMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comme
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
t_ocatea 464 us ooa street
FIRE DEPARTMENT Temp Dumpster on site yes ono
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 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
Locations--3-�' 0?0
No. �;Z3 -,L-- Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
CHU Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL
Check# 5� �4r
220b3
Building Inspector
The Comnnonwealth of Massachusetts
s 1 Department of Industrial Accidents
Office of Investigations
a. a 600 Washington Street
Boston, MA 02111
ko www_muss.gov/dia .
Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
Applicant Information
Please Print Legihl�
NaXne (Business/Orpoirafion/Individual):' LddL cc Hyl Lkrvi
Address: �` ��f S %
City/<State/Zip:_� / A73 (<tz, cj �'-
Phone #:
Are ou as employer? Check.the appropriate box:
1.I am a employer with �_
4. ❑ I am a general contractor and I
L(full and/or part-time).*
2. El I am .a:sole proprietor or
have lured the sub -contractors
listed
partner-
on the attached sheet. i
ship and have no employees
These sub -contractors have
working for me .m any capacity,
[No workers' comp. insurance
workers' comp. insurance.
5. ❑ We are a corporation and its
required.]
3. ❑ 1 am a homeowner doing
officers have exercised their
all work
right of exemption per MGL
myself. [No -workers' comp.
C. 152, § 1(4), and -we have no
insurance required.] t
.employees. [No workers'
comp. insurance required.]
Type of Project (required):
6. ❑ New construction .
1. ❑ Remodeling
8. Q Demolition
9. M Building addition
10,13 Electrical repairs or additions
I I.❑ Plumbing repairs or additions
12.[] Roof repairs
13.❑ Other
'Any applicant that checks ba # t must also fill out the section below showier their worker' oo L—
1 Homeowners who submit this affidavit indicating they are doing all work end then kite outside contncctors moult slicyubmit information. new affidavit indicating such
4Contraators that check this box mustattecbed an additional sheet showing Me name of the sub -contractor and their workers' cecnp. Policy infomuuian.
t am an employer that is.proviaring 0orkers $ compensation insure for my employs
information Below is the policy ar:dyob site .
Insurance Company
kc
Policy # or Self --ins Lie. ,#:
_ Expiration Date:t
Job Site Address:-----
Ciiy/State/Zip: l U • m��j�{(1 2. c (§g-
AtEach acopy of the workers' compensation policy declaration page (showing the policy dumber and expiration dat-4 .
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 cqf y under
L/
ofgerjury that the information provided above is true and correct
<r(�(Ic"
7D'FA
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):
L Board of Health 2 Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Piumbing Inspector
6.Other—
Contact Persoa: 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 truster 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 shaU 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 complentely, by checking the boxes that apply to your situation and, if
necessary, supply sub -contractors) name(s), address(es) aired 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 maybe submitted to the Department of Industrial
Accidents for confirmation of insurance coverage.. Also lb,e sure to sign and date the affidavit. The affidavit should
be returned to 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'
compensation policy, please call the Department at the nurnber. listed below. Self-insured companies should enter their
self -insurance -license number on dw'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 pennittlicense number which will be used as a reference number. In addition, an applicant
that must submit multiple permiMicense 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 fiDed 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 lnvestigations 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 Lnvestiations
600 Washington Street
Boston, MA 02111
TeL # 617-727-4900 ext 406 or 1-8.77-MASSAFE
Revised 5-26-05 Fax4 617-727-7749
www.mass.gov/dia
51121/2009 9:02 AM FROM: Foster ^0: 1-978-687-0293 PAGE: 002 OF 003
GORDr. CERTIFICATE OF LIABILITY INSURANCE
DATE
AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
05/21/2009
PRODUCER
NORTH ANDOVER INSURANCE AGENCY, INC
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
M,T FOSTER INSURANCE
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE
163 MAIN STREET
NORTH ANDOVER MA 01645-2415
INSURED
INSURERA.CITIZENS INSURANCE CO
Michael Rlodden
INSURER E': HANOVER INSURANCE
Rodden Carpentry
INSJRERc:AMERICAN INTERNATIONAL GROUP
47 Prescott Street
INSURER D:
INSURER E:
North Andover MA 01845-
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 OCNDITION 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
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE MM1ODNY
POLICY EXPIRATION
DATE MM10DNY
LIMITS
A
GENERAL LIABILITY
NORTH ANDOVER MA 01845-
EACH OCCURRENCE S 1,000,000
FIRE DAMAGE (Any cne fire) 5 50,000
X CO1VMERC(AL GENERAL LIABILITY
C-AIMSMADE FX -71
X- OCCUR
ZBN8605683
02/01/2009
02/01/2010
MED EXP iAny oneper5cn) S 10,000
PERSONAL &ADV'INJURY S 1,000,000
GENERAL AGGREGATE S 2,000,000
GEN'L AGGREGA-E LIMIT APPLIE5 PER:
RRCOLCTS- COMP/0P AGG 5 2 , 000, 000
POLICY JELOC
B
AUTOMOBILE
LIABILITY
ADN8336670
07/16/2008
07/16/2009
COMEINEDSINGLE LIMT
ANY AUTO
(Ea accdent) S
X
ALLOVM!EDAUTOS
SCHEDULED AUTOS
/ /
/ /
ECDILYINJURY
(Perperson) S 100,000
HIREDA.UTOS
/ /
/ /
ECDILY INJURY
NON-CVvNED AUTOS
(Peraccident) S 30C , 000
FRCFERTY DAMAGE
(Peracddem) 5 100,000
GARAGE LIABILITY
AUTO ONLY - EA. ACC!DEVT S
ANY AUTO
/ /
/ /
OTHER THAN EA HCC S
AUTO ONLY: AGG S
EXCESS LIABILITY
/ /
/ /
EACH OCCURRENCE S
AGGREGATE 5
OCCUR C:-AIMSMADE.
S
DEDUCTIBLE
S
RETENTION $
WORKERS S LIABILITY ION AND
/
X
E.L.EA�IACCIDENT S 100,000
E.L.DISEAEE-EA EMPLOYE S 100,000
C
G►C1760133
01/01/2009
01/01/2010
E.L.DISEASE-RCL!CYLIMIT S 500,000
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER I I ADDITIONAL INSURED: INSURER LETTER: CANCELLATION
ACORD 25-S (7197) �. ACORD CORPORATION 1988
*T1-INS025S (sslo).DI ELECTRONIC LASER FORMS, !NC. -(300)527-0545 Page 1 or 2
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
10 DAYS Yvm7rEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT
TOM OF NORTH ANDOVER
FAILURE TO DO SD SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
INSURER, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
NORTH ANDOVER MA 01845-
ACORD 25-S (7197) �. ACORD CORPORATION 1988
*T1-INS025S (sslo).DI ELECTRONIC LASER FORMS, !NC. -(300)527-0545 Page 1 or 2
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Page No. of Pages
MICHAEL RODDEN
BUILDER - CONTRACTOR
47 Prescott Street
NORTH ANDOVER, MASSACHUSETTS 01845
Phone (978) 687-2934 Lic. #028538
PROPOSAL TO
PHONEE�
DATE
,
C
STREET
JOB NAME
CITY,,ST1TE and ZIP CODE
JOB LOCATION
Y
DATE OF PLANS
JOB PHONE
\ARCHITECT
We PropoSP hereby to furnish material and labor— complete in accordance with specifications below, for.the sum of:
ff� I 'A
L
Payment to be rhehe as follows: �— , 7` dollars (p$
(U , C CrC1 : <_.C- \C.iv C a `C JC !' I - e C, V7
All material is guaranteed to be as specified. All work to be completed in a workmanlike
manner according to standard practices. Any alteration or deviation from specifications be Authorized
-low involving extra costs will be executed only upon written orders, and will become an Signature
I)OCESZe 11, 1 (1 � ��, —
extra charge over and above the estimate. All agreements contingent upon strikes, acci- --
dents or delays beyond our control. Owner to carry fire, tornado and other necessary Note: This proposal may be
insurance. Our workers are fully covered by Workman's Compensation Insurance. withdrawn by us if not accepted within days.
We hereby submit specifications and estimates for
.... ..... .....
,�.............._ _._ ........... ,..............._ ............._.........._..__..
A
s
Acceptance of proposal— The above prices, specifications
and conditions are satisfactory an are hereby accepted. You are authorized Signature \ 'L�
to do the work as specified. P y rV1
�ient ill be made as outlined above. rj
Date of Acceptance: \a, & Signature