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Home My WebLink AboutBuilding Permit #423 - 555 FOREST STREET 12/29/2006 TOWN OF NORTH ANDOVER NORTih APPLICATION FOR PLAN EXAMINATION °t��`" ;•.'�o O 9 * - Date Received Permit NO: '� °A4no , 1ss�cKust� Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION ^ print PROPERTY OWNER I d print MAP NO.: In PARCEL: ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ ri PROVEMENT PROPOSED USE Residential Non-Residential ilding ,ane family ❑Two or more'family ❑ Industrial n No.of units:❑Assesso Bld ❑Commercial eplacement t7' gion ❑ Others: relocation ❑Other ❑ Foundation onl DESCRIPTION OF WORK TO BE PREFORMED Identification Please Type or Print Clearly) J OWNER: Name: t Q / Q i1,(j,q SS o Phone• Address: Phone: ID�-n CONTRACTOR Name: d Address: 10 Supervisor's Construction License: 0 / 2 Exp. Date: 2 Exp. Date: Home Improvement License: / 2 - ARCHITECT/ENGINEER Name: Phone: Address: Reg.No. FEE SCHEDULE.BOLDING PERMIT:512.00 PER$1000.00 OF THE TOTAL EST/MATED COQ SED ON$125.00 PER S.F. ova Total Project Cost :$ FEE:$ _ Check No.: 9 Receipt No.:—L4 Page I of 4 Location �-c f-5 0L40 T x-r— No. _ V A Date NORT1y TOWN OF NORTH ANDOVER F 9 t Certificate of Occupancy $ b ^�•'<� Building/Frame Permit Fee ,sJACHUSE Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 1 9941 Building Inspector TYPE OVetc. E] Public SeTann Massage/Body Art Sw' ing Pools ❑ WellTobacco Sales ❑ Food "ng S s ❑ Permane umpster on i ❑ Private(sElec eter locatio roject NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund Signature of Agent/Owner Signature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF-U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION DATE REJECTED DATE APPROVED ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH -------------- ❑ ❑ c' a COMMENTS FIRE DEPARTMENT - Temp Dumpster on site yes no Fire Department signature/date COMMENTS Zoning Board of Appeals:Variance,Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveeyay permit Buildin Setback ft.) Front Yard Side Yard Re uired Provided Re uired Provides Rear Yard Re uired Provided Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: NOTES and DATA— For department use Page 3 of 4 Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORMOS Crated JMC.Jan.2006 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 Addition Or Decks ❑ Building Permit Application ❑ Surveyed Plot Plan ❑ Workers Comp Affidavit o 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) o Mass check Energy Compliance Report (If Applicable) 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 o 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 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 DEPARTMENTMFORMOS Page 4 of 4 V40 R TIi . 4 Town _ r�. ver 1k No. '- ,WAA&& = A E dover, Mass.,/D� COCMIC KE WICK ' H BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUIL THIS CERTIFIES THAT......Za4&-4-L...... ..i...A..c-'r.I1�.e� BUILDING INSPECTOR ....................................................... Fou has permission to erect...................................... build' gs on ..S. �........1%"W ... ............... Rough to be occupied as...S� A• Chimney ....... ...... .......... .................................................................................. provided that the person accep ing this permit shall in v respect conform to the terms of thea Iication on file in this office, and to the provisions of the Codes and By- relating to the Inspection, Alteration and Construction of Final Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough q� PERMIT EXPIRES IN 6 MONTHS Final ELECTRICAL INSPECTOR UNLESS CONSTRU S TS Rough ..., ... ....... Service .. ... .... ... . .. .. .............. BUILDING TOR Final Occupancy Permit Required to Ocmpy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE j Smoke Det. i Board of M lkHog Re{.hHaar..d WIN dr �. ' HOME IMPROVEMENT CONTOXTOIt ~ 3 Replsttitlbrt�x92861Z' THOMPSON'S - THOMAS DOYLE 8 WEST ST ' SALEM,NH 03019 92e gl.n ancueallJl BOARD OF BUILDING REGULATIONS } License: CONSTRUCTION SUPrz9VISORIL ' Number,.,'--.CS, 060112 ' Birthdate'08104!1956 Ex .-6W,64/20108 Tr.no 28784 6 i Restrictdd;3 00 w r THOMAS T DOYLE 8 WEST ST SALEM, NH 03079 "' ? y C �"^` Commissioner t o Haverhiij Street,page rU;R i ruliy insured 9 R00FINU I „ Shingles-p Slate�-Rubber Roo Single Ply — COPPer Work OATS �1 f� PHONE�, ��"� 3�1 _/ 4FROPosAL sueMrrTEo TO 77 j� /0 E 1 Judith Giarrusso JOB NAME j STREET ji 555 Forest Street JOB LOCATION Ci i Y:STATE AND ZIP CODE JOB PHONE North Andover Ma 01845 DATE OF PLANS ARCHrrECT l ii yye hereby submit specifics-tions and estimates for { strip ii ( ip ff all rOOf shingles on house and garage ! l � loose plywood and if any needs to be replaced it f will cost $50 .00 a sheets � n$ta,, aluminum drip edge around" roof line E, water shield 6 ft. Apply ice and up all along edges and in valleys Apply 15 lb. fetl paper on rest of roof area .gaf .com) timberline 30 architect Reshingle with a (www g Install new flanges around soil pipe l I Install new ridge vent Clean gutters of all debris ) Ain � � Remove all work related debris 1 ' P�.0 6v 30 year warranty on material I 5 year guarantee on labor construction tic. #060112 improvement #128612 If you decide to have a Velux skylight approx. 4x4 with and electric button it will be an additional $1 , 200 . (One thousand two hundred dollars)** . You might need to hire an electrician. • accordance with above specifications,for the sum of: PrOp05e hereby to furnish material and labor—complete In dollars($ Se en hi Payment to be made as follows: All work to be completed in a worlar�M Mannar helorized All material is guaranteed to be afNratbn or deviation from strove�invalvf� according to standard pr orcfers and will become an 0*2&AW over and extra costs Nell be executed only tion Note:This proposalmpy days. above tt*estimate.All agreemerds ter► strikes.aa�dents a delays beyond our be control. owner to carry fire,tornado and other necessary}nsurae• tux wort ma the fully withdrawn by us it not accepted within covered by Workmen's Comper wim 6mirerce• 0� r —The above prices,specifica6ona and ccetanCe �P conditions are satisfactory and are hereby accepted.You are authorized to do the signature w:AwJ On wM...It 4w,..wJw w.�.Jt:��J��•.� ACORD� CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DOlYYYY+ 10/27/2006 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Pelham Insurance Services, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P.O. Box 960 4 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 122 Bridge Street Pelham NH 03076 INSURERS AFFORDING COVERAGE MAIC# INSURED INSURER A:Nautilus Thomas Doyle INSURER B:Associated Industries dba Thompson Construction & INSURER C: 6 West St. INSURER D: Salem NH 03079 INSURER E: 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 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-tIMITS SHOV'T:MAY-HAVE BEEN RE-DUCED BY-PAID CLA MS. INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRO TYPE OF INSURANCE POLICY NUMBER DATE(MM/DD/YY) DATE(MM/DDIYY) LIMITS A GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIALGENERAL LIABILITY NC 532152 04/15/2006 04/15/2007 pREMSES(EaE TO oxurence $ 50,000 CLAIMS MADE � OCCUR MED EXP An one person) $ 1,000 PERSONAL 6 ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 - POLICY PROJECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $E AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ B WORKERS COMPENSATION AND AWC7012214012006 04/21/2006 04/21/2007TAT g WCS - U0TH- EMPLOYERS'LIABILITY TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE$ 100,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Residential Roofing CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT Ron Qrecco FAILURE TO DO$O SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE The Commonwealth of Massachusetts Department of Industrial Accidents W Office of Investigations w ' d 600 Washington Street ,W Boston,MA 02111 wM ,� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): 2 S d rt- 'S Address: COS �� ,� ��ff S _ City/State/Zip: (17 Le-4,7 a Phone.#: 6 �� Are you an employer?Check the appropriate box: Type of project(required):. 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp.insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.[2'Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp.insurance required.] *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.#:_ QCy C ZG I Z ( 4 0 1 ZdU G Expiration Date: 4 Job Site Address: City/State/Zip: /t/ �d rJ L%4 f 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 uder the pains and penalties of perjury that the information provided above is true and correct. Signature: b Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: PermitlLicense# 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 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. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 11-22-06 Fax#617-727-7749 www.mass.gov/dia