HomeMy WebLinkAboutBuilding Permit #767 - 550 TURNPIKE STREET 6/24/2008BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: 7�1
Date Issued: -
4 IMPORTANT:
Date Received
must complete all items on this
LOCATION5 �a -7_01Z4
Print
PROPERTY OWNER
MAP NO
to
I Print
_2-!j PARCEL:[_ ZONING DISTRICT: Historic District
Machine Shop
yes no
ves no
TYPE OF IMPROVEMENT
PROPOSED USE
/
/
d»S
Residential
Non- Residential
New Building
One family
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
air re lacement
Assessory Bldg
Others:
Demolition
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: , Il 4 f
L I ,R Aeen Phone:Q 7cl (o 6 °7Zo4
Address: E* / u2pi tl, k t
CONTRACTOR
Name:
/
/
d»S
l e
Zelae. / Phone) JaAj)
4, r-6(Zy
<<3-693o
.
c.e tI
Address(a IJ
A S �,,Jyqe
i
NW
Supervisor's Construction License: oSS 'Exp.:Date:
Home .Improvement License:
ARCHITECT/ENGINEER Phone:
Address:
Reg. No
FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST ASED ON $125.00 PER S.F.
Total Project Cost: $� `i�3, 00 FEE: $
Check No.: ��� Receipt No.: C�_ ) a ,–+�—
NOTE: Persons contracting with unregistered contractors do not have access to t czuaranty fund
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 Reviewed on Signature
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No:
Planning Board Decision:
Comments
Conservation Decision: Comments
Zoning Decision/receipt submitted yes
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Locatedat924 MainStreet
Fire Department signature/date
COMMENTS
Dimension
f
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
Doc.Building Permit Revised 2008
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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2008
Locationa�-vw,,,��/!�s'
No. Date
NORT1y
TOWN OF NORTH ANDOVER
0��•o r•.,tiC
� • OL
9
Certificate of Occupancy
$
y� a^CMUS <�
Building/Frame Permit Fee
$
Foundation Permit Fee
$
Other Permit Fee
$
TOTAL
$
Check # r 12
2 12 7 2 Building Inspector
z : yfnei.
\�
Drounna1 Page No. , of -3 Pages
—y'.
Aarplattre of f riaposal —The above prices, specifications
and conditions are satisfactory and are hereby accepted. You are authorized Signature
to do the work as specified. Pay ill be made as outlined ab
Date of Acceptance: (/ Signature
PRODUCT 1183 � Inc., Groton, W. 01471. Tu O,ft PHONE TOLL FREE] +800225- 3380
LEBEL CONSTRUCTION
General Contractors
(603) 635-2025
PROPOSAL SUBMITTED TO
PHONE
DATE
STREET
Al CI)
JOB NAME
CITY, STATE AND ZIP CODE jj
N —M, c/dcrJ/�
JOB LOCATION
ARCHITECT DATE or PLANS
JOB PHONE
We hereby submit specifications and estimates for:
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Or Fropnsr hereby to furnish material and labor — complete in accordance with above specifications,
for the sum of:
4�VaLc_ -A�` #iK�l .�. •� 1�.>-.cL+eN -ww �9 Y�h,'��/f�'� dollars
Payment to be made as follows.
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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 above specifica- Authorized
tions involving extra costs will be executed only upon written orders, and will become an Signature
extra charge over and above the estimate. All agreements contingent upon strikes, accidents
or delays beyond our control. Owner to carry fire, tornado and other necessary insurance. Note: Thisgo, may be
Our workers are fully covered by Workmen's Compensation Insurance. withdrawn by us if nn�lacrantari within
—y'.
Aarplattre of f riaposal —The above prices, specifications
and conditions are satisfactory and are hereby accepted. You are authorized Signature
to do the work as specified. Pay ill be made as outlined ab
Date of Acceptance: (/ Signature
PRODUCT 1183 � Inc., Groton, W. 01471. Tu O,ft PHONE TOLL FREE] +800225- 3380
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06/23/2008 09:59 FAX 603 497 2521 ELLIOT INS AGENCY
Z002
ACORD CERTIFICATE OF LIABILITY INSURANCEDAN00#00MYM
I„
1 SMUG-3860862-3-
"000CER
ELLIOT INSURANCE AGENCY
I I NORTH MAST STREET
P O. BOX 428
GOFFSTOWN,NH 03045
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
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE NAIC P
INauItw STEVEN & SYLVAIN LEBEL
LESEL CONSTRUCTION
36 NASHUA ROAD
PELHAM, NH 03076
IN UR A• NGM INSURANCE COMPANY
INSURERS: LIBERTY MUTUAL INS. CO.
INSURER C:
INSURER :
INSURER E:
nnvicewn_CC
v 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 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.
- -- -
POLICYNUMBER POLICY EFFECTIVE POLICY EXPIRATION LIIAIT$
A
861 TURNPIKE STREET
GENERAL LIABIJTV
X COMMERCIAL GENER L LWBp-ITY
/X
MPK86836
06MI2008
06129/2009
EA H C URRENGE 1I 000 GOO.
DAMAGE TD RFMEO
s 600,000.
MED EXP An ene eon 310,000.00
CLAIMS MADE OCCUR
R NAL 6 A0V INJURY $600,000.
GENERAL GG E 1 000 000•
GEN -L AGOREGAY'E LIMIT APPLIES PER:
PRO S - COMPIOP AGG111000, 000.
7X POLICY PRO• LOC
AUTOMOBILE
LIABILITY
ANY AUTO
COMBINED SINGLE LIMIT
(Ea aaaldan0 =
ALL OWNED AUTOS
SCHEDULED AUTOS
BODILY INJURY =
(Pel Porion)
HIREDAUTOS
NON -OWNED ALTOS
BODILY INJURY 6
(Per BOA"o
PROPERTY DAMAGE :
(PitecdoanU
GARAGE LIABUJTY
AUTO ONLY . EA ACC IOFNT
OTHER THAN EA ACC
ANY AUTO
AUTO ONLY: AGO 5
EXCESSMMBRELLA LIABILITY
OCCUR ❑ CLAIMS MADE
EACH OCCURRENCE f
AGGREGATE t
f
DEDUCTIBLE
:
RETENTION f
WC 8TATU-OTM-
WORKERS COMPENSATION ANO
E.L. EACH A CIDENT 8100,000.
B
EMPLOYERV LLAGUM
ANY PR OPRIETORIPARTNEArdXECUTNE
OFFICER/MEMBER EXCLUDEDT EXCL.
I Yw. QieW 0a under
5 CULL v
6ZZUB-3860862.3-07
11 M V2007
11/1512008
,4 DISEASE • EA EMPLOYE P.1001000.
E.L. DISEASE •POLICY LIMIT i I
OTHER
f PTLOR OF OPERATIONS I LOCATKINS I VEHICLE$ I gx%.M$ION8 AD= BY ENOORSOtENT I SPECIAL PROVISIONS
COVERING WORK TO BE DONE AT CROSSROADS
FAX: 878486-4314
f-CftTtL9PATC Yf%l t1C0 CANCFI_LATION
ACORD 25 (2001108) wsmiuKu w:uKrutwl IVIi TIl00
$HOMLO AMI OP THE ABOVE 0EICRI660 POLICIES BE CANCELLED BEFORE THE EXPIRATION
BILLY SHAHEEN AND JOHN PALLONE
DATE THEREOF, THE 168MIN0 INSURER WILL ENWAVOR TO GAUL 10 DAYS WRITTEN
861 TURNPIKE STREET
NOTICE TO THE CERTIFICATE HOLOER NAMED TO THE LEFT, WT FAILURE TO 00 $G $HALL
NORTH ANDOVER, MA 01845
EIIPOSE NO 08LIOATKM OR NABILITY Of AMY KIND UPON THE INSURER, ITS AOENTB OR
RfPRE05MTIVM
AUT p NT
ACORD 25 (2001108) wsmiuKu w:uKrutwl IVIi TIl00
The Commonwealth of Massachusetts
c Department of Industrial Accidents
k:,
° 'i Office of Investigations
600 Washington Street
UP
Boston, MA 02111
P4 www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/individual): // C --,o S -imus_
Address: ,;( YJA S UA R
City/State/Zip: � 2 ( � t) 30? L Phone �- (gp3)
Are you n employer? Check the appropriate box:
❑ I m a employer with
4. ❑ I am a general contractor and I
Zemployees (full and/or part-time).*
have hired the sub -contractors
tm 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.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We 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
1 I.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
*Any applicant that checks box # I 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 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: �� ' otSu0.4 ri ce�{C-evtc y
Policy # or Self -ins. Lic. #: ki�l Q /C 84, Expiration Date: Z
Job Site Address: :ik ?SSA ri C / k -C City/State/Zip:Al. g, do j-e�_ M R
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 andpenalties of perjury that the information provided abovQ is true and correct.
FIA
--bx 30
Oficial 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-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 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 permit/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 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 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. # 617-7274900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26-05. www.mass.gov/dia