The URL can be used to link to this page

Home My WebLink AboutBuilding Permit #859 - 55 PLEASANT STREET 6/28/2007BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Issued:4 01 `d Date Received / V �tLED �6 o *z re D DESCRIPTION OF WORK TO BE PREFORMED: G ddr/ c. GP/-- OWNER: Name: ADAM -4f.- Please Type or Print Clearly) WL -.s N ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PER $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST/BASED ON $125.00 PER S.F. �� Total Project Cost: $ 00• FEE: $ � Check No.: ,33r Receipt No.: 3 NOTE: Persons contracting with unregistered contractors do not have access to Ae 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 o 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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Swimming Pools 11❑ ❑ Public Sewer Tanning/Massage/Body Art Well_LL cco Sales ❑ Food Packaging/Sales El Private (septic tank, etc. anent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED CONSERVATION El ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH E COMMENTS r Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/Signature & Date Driveway Permit 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 Doc.Building Permit Revised 2007 Location -5-5 No. Cf Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 193k" 2 0 3,r 4 N1 Building Inspector m m m m CO) m mm r L I�n O� t oo 97R g Zr —' � C y O Q H = dO R O -0 y a ® C-3 m C7 o CA CDIa� B m CD a of � 0 y �m o = � � CDCD — d co CD c COn CO) Cl). CA CD C) CO) r M a Sim `. CD 0 �. cc o =r :C C. r C/) ,o m m y •� CD ►-� m o m D. = y c H _ m z C o C CD CL 3L C 0 .. g H CL. C� co CD cr =Tm d N CD E •��' tG —� �- CD O m o CO3 av ° ZCD �0 Wim` �Q CD Ip CD e� ..• CD 0 o W DJ 0CL"a' co o y =o c ;_ CD _ o r v d Z ° °'- arc °'- o�c Ci7 a= aGa E = :3 0 r Cn n \ O CS # 022680 HIC# 103358 =,Vropool � A. J. Walsh & Sons 55 Pleasant Street North Andover, MA 01845 # of 978-688-6737 or 1-866-AJWALSH Proposal Submitted Job Name Job # Address^ ` Job Location - Date / 07 Date of Plans Phone # fax(/#ate (� 61 1 Architect We hereby submit specifications and estimates We propose hereby to furnish material and labor — complete in accordance with the above specific Ions for th"m of: $ A4� with payments to be made as follows: Dollars Any alteration or deviation from above specifications involving extra costs will be Respectfully executed only upon written order, and will become an extra charge over and submitted above the estimate. All agreements contingent upon strikes, accidents, or delays beyond our control. Note — this proposal may be withdra n by us if not acce ted within days. acceptance of roposal The above prices, specifications and conditions are satisfactory and are ignature hereby accepted. You are authorized to do the work as specified. Payments will be made as outlined above. Date of Acceptance Signature l ne (.ommonweatin uj 1YluJSucnu-3G«a Depai sment of Industrial Accidents P Office of Investigations d 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ' Please Print Legibly Name (Business/organization/Individual): �J Address: �� Fli City/State/Zip: LIQ I`T/ 7�y U�� M -Phone Are you an employer? Check the appropriate box: 1..0 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. ElI am a sole proprietor or partner- listed on tLe attached sheet ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers'_comp. insurance 5• El are a corporation and its 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.] t 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.❑ Plu mg repairs or additions 12. Ffnoof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information: t Homeowners wbo 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 subcontractors and their workers' comp. policy information. I ant an employer that is providing workers' compensation insurance for my employees. Below is the.policy and job site i» fnrmntin�t Insurance Company Name:�J / Policy # or Self -ins. Lie. #: / ,U(> �► 7� 2 �� / Expiration Date. Job Site Address: ,_�'✓ I / ZeI4S1 %yl City/ State/7ip:— Attach a copy of the workers' compensation policy declaration page (sho)aing 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-verificadon . Cd helld MD ly'Alip4ele I do hereby eertii Under the paiinnss aannd penalt�i js oaf perjury that the information provided aboojve is true and correct D -h 7 ate:/�" 7 0 Official use only. Do not write in this area, to be completed by city o. torvrr `off cia'l:, City or Town: Pern.:LR icense Issuing Autbority ,(circle one): k 1_ Board of Healtht 2: Building Depart.meut 3. City/T,own Clerk 4. Elecirioal Inspector S. -Plumbing lusjsecltor 6. Other f i• Contact Person: :Phone :#: Information and Instruct -ions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Puisuant 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 legalentity, 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 w=ith 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.. B.e advised that this affidavit may be submitted to the Deparvmnt 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 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 pernvUlicense number which will be used as a reference number. In addition, an applicant that must sub r t multiple penrit/lirencP.,appliCatiOIlS 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 m (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 per -nut not related to any business or commercial venture (i.e. a dog license or pen -nit 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 Uvestigatioms 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-N ASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.gov/din � G7� Board of Buildin k�c6ulations and Standards HOME IMPTVEMENT CONT RACTOR Regi t 3 358 � ` • .q 1. M -�� Corporation _. A: J:.WALSliSO ,&' Artbur�VU9sh�lr .. t CERTIFICATE OF INSURANCE SSUE 1111081 TE(MM/°D;YY) 2006 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE, Samuel J Durso Insurance DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Agency Inc 198 Mass Ave Suite 10113 COMPANIES AFFORDING COVERAGE North Andover, MA 01845 INSURED Arthur Walsh dba A. J. Walsh & Sons COMPANY A.I.M. Mutual Insurance Co LETTER A 55 Pleasant Street North Andover, MA 01845 COVERAGES THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECTTO 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE(MM/DD/YY) POLICY EXPIRATIO DATE(MM/DD/YY) LIMITS GENERAL LIABILITY GENERAL AGGREGATE $ PRODUCTS-COMP/OP AGG. $ COMMERCIAL GENERAL LIABILITY ' LAIMS MADEE::]DCCUR PERSONAL & ADV. INJURY $ EACH OCCURRENCE S OWNER'S& CONTRACTOR'S PROT. FIRE DAMAGE (Any one fire) $ MED. EXPENSE (Any one person) $ AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT $ BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per accident) $ HIRED AUTOS NON-OWNED AUTOS PROPERTY DAMAGE $ GARAGE LIABILITY EXCESS LIABILITY EACH OCCURRENCE $ AGGREGATE $ MBRELLA FORM THER THAN UMBRELLA FORM A WORKER'S COMPENSATION AND EMPLOYERS' LIABILITY THE PROPRIETOR/ INCL PARTNERS(EXECUT4V E OFFICERS ARE: RX EXCL 7014648012006 11/14/2006 11/14/2007 WCSTATU- OTH- - X TORY LIMITS R EL EACH ACCIDENT $ EL DISEASE—POLICY LIMIT $ 500,000 EL DISEASE--EA EMPLOYEE $ 100,000 OTHER DESCRIPTION OF OPF,RATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE TOWII Of North Andover EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 15 DAYS WRITTEN 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. i AUTHORIZED REPRESENTATIVE N2 4846 Date TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ... 7'� ...... /!.� ......... has permission to perform,--.-�.4-.--7-' ............... plumbing in the buildings of ......... e�� J, ................. a t .......... North Andover, Mass. Fee/15. Lic. No. 4 . . . . . . . . . . PLUMBING JN5PECTOR Check # WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING ape or print) NORTH ANDOVER, N Building Location�5 SACHUSETTS Date 06-06-01 $f'• Permit # y z''I, Amount Alorfk Andover, M U, Owner's Name New 1:1 Renovation 1:1 Replacement 1 Arthur Wash Plans Submitted FIXT'JRES OMMOMMONNOWNWOMMMMMMMNIMM M®MMM MMM . 4 • MM MMM mmmm ..• �� i�i�i�i�iiii�iiiiiiiii (Print or type) Check one: Certificate Installing Company Name WHITE ROCK PLUMBING & HTG. Corp. /IDOq G Address NORTH ANDOVER, MA. 01845 Partner. Business Telephone q 79— Q 7 $ — ¢ 2 L Firm/Co. Name of Licensed Plumber: pOb a r-+ Q • ta1 an chef+ vP- Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ElBond Insurance Waiver: 1, the undersigned, have been mdde aware that the licensee of this application does not have any one of the above three insurance Signature Owner 11 Agent 11 I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issue or this application will be in compliance with all pertinent provisions of the Massachu s Sta Plumbing Code d Chapter General Laws. By: Signarure Of kens um er Type of Plumbing License Title 14 5 g'7 City/Town icen mer Master Journeyman El APPROVED (OFFICE USE ONLY