HomeMy WebLinkAboutBuilding Permit #489-13 - 540 SHARPNERS POND ROAD 12/27/2012Date Issued:
BUILDING PERMIT
TOWN OF NORTH ANDOVER °
APPLICATION FOR PLAN EXAMINATI N -
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T Date Received
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IMPORTANT: ADnlicant must complete all items on this
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PROPERTY OWNER C ,,.��4��,�.,�—S' &
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MAP NO: _PARCEL: ZONING DISTRICT: Historic District yesFn
Machine ShOD Villaae ves
TYPE OF IMPROVEMENT
PROPOSED USE `
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
wl�epair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septic ❑ Well
❑ Floodplain - ❑ Wetlands
❑ Watershed District
❑ Water/Sewer
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
Address: ls'to
CONTRACTOR Name: �� �. �a fW i Phone:
Address:
3
Supervisor's Construction License: 'Exp: ate:
i0 Y361
Home Improvement License: _ _ Exp: Date: ,
ARCHITECT/ENGINEER 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: %CI
) fes, o'' FEE: $
Check No.: a C2, f Receipt No.: dt
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
signature
nature of contractor
9:.
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
PLANNING & DEVELOPMENT ❑
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE APPROVED
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
,13,
Comm
Conservation Decision: Comments
!'Water & Sewer Connection/Signature Dafie Driveway Permit
]DPW Towp. ]Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124,Matrj"Strdet .
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
DANCER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA — For department use
B Notified for pickup - Date
Doe.Building Permit Revised 2010
Building Department
The folowing 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
o Workers Comp Affidavit
o Photo Copy Of H.I.C. And/Or C.S.L. Licenses
o Copy of Contract
o Floor Plan Or Proposed Interior Work
Li 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
a Certified Surveyed Plot Plan
o Workers Comp Affidavit
o Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Mass check Energy Compliance Report (If Applicable)
o 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)
o Building Permit Application
o Certified Proposed Plot Plan
a Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
Li Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Copy of Contract
o Mass check Energy Compliance Report
o 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 submAted with the building application
Doc: Doc.Building Permit Revised 2012
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Location 1
No. 7!� �3 Date (/
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $�
Foundation Permit Fee $
Other Permit Fee $ '"
TOTAL $
26058 1; Building Inspector
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Action Siding
Invoice No. r
1028
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INVOICE
Customer
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Date
Address.,
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Order No.
City—
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Phone
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TOTAL
Subtotal
Deposit
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Comments
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3PINEWOOD ROAD
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PEABODY, MA;01960 ;
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ACORD. CERTIFICATE OF INSURANCE
PRODUCER
JOESPH PINTO INS AGCY IN.
142 PLEASANT ST.
MALDEN,MA 02148
27BSY
INSURED
ACTION SIDING
3 PINEWOOD ROAD
PEABODY, MA 01960
DATE
THIS CERTIFICATE IS ISSUE 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
POLICES BELOW.
COMPANIES AFFORDING COVERAGE
COMPANY
A HARTFORD GROUP
COMPANY
B
COMPANY
C
COMPANY
A
COVERAGE
THIS IS TO CERTFY THAT THE POLICIES OF 11SURANCE LISTED BELOW HAVE BEEN ISSUED TO THE 11SURED NAMED ABOVE FOR THE POLICY PERIOD
E4DICATED, NOTWITHSTANDING ANY REQUIREMENTS, TERM OR CONITIONS OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THB
CERTIFICATE MAY BE ISSUED OR MAY PERTARL THE INSURANCE AFFORDED BY THE POLICES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO
LTR TYPE OF INSURANCE
GENERAL LIABILITY
COMMERCIAL GENERAL LIABILITY
CLAIMS MADE OCCUR.
OWNER'S & CONTRACTORS PROT
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULE AUTOS
HIRED AUTOS
NON OWNED AUTOS
GARAGE LIABILITY
ANY AUTOS
POLICY EFF POLICY EXP
POLICY NUMBER DATE (MMODWY) DATE (MM0DWY`)
EXCESS LIABILITY
UMBRELLA FORM
OTHER THAN UMBRELLA FORM
WORKER'S COMPENSATION AND
A EMPLOYER'S LIABILITY 6S6OUB-0274NO4 03-20-12 03-20-13
THE PROPRIETOR/ -9-12
PARTNERS/EXECUTIVE INCL
OFFICERS ARE: X EXCL
LIMITS
GENERAL AGGREGATE
PRODIJCTS-COMP/Qp AGG
PERSONAL && ADV. INJURY
EACH OCCURRENCE
FIRE DAMAGE (Any one fire)
MED. EXPENSE (Any ONE person)
COMBINED SINGLE LIMIT
BODILY INJURY (Per Person)
BODILY INJURY (Per Accident)
PROPERTY DAMAGE
AUTO ONLY EA ACCIDENT
OTHER THAN AUTO ONLY:
EACH ACCIDENT
AGREGATE
EACH OCCURRENCE
AGGREGATE
STATUTORY LIMITS X
EACH ACCIDENT $100,000
DISEASE — POLICY LIMIT $500,000
DISEASE — EACH EMPLOYEE $100,000
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/RESTRICTIONS/SPECIAL ITEMS
THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE.
THE WORKERS COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR CARBONE ARTHUR R.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
ACORD 25-5 (3193) THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR
TO MAIL 10 DAYS WRATEN 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 COMPANY, ITS AGENTS
OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
Ramani Ayer
The Commonwealth of Massachusetts = T Print Form
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): cc �C„`' J l CJS 8 CAm6\6 i
Address:
City/State/Zip:
Phone #:( C,`4 -
Are you an employer? Check tke 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. ❑ I am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub -contractors have
working for me in any capacity. employees and have workers'
[No workers' comn. insurance comp. insurance.I
required.]
3. [:11 am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
❑ 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'
coma. insurance reauired.l
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
*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 and state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #: Expiration Date:
Job Site Address: 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.
Ido hereby certify under theins and penalties of perjury that the information provided above is true and correct:
Phone #: (a Ci 1_ 01,35 __Vo C
Official use only. Do not write in this area, to be completed by city or town offw&L
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 #: