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Home My WebLink AboutBuilding Permit #348 - 561 PLEASANT STREET 11/18/2008 tIORT11 BUILDING PERMIT o`tt��° ,b�tio TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION « Permit NO: 7 Date Received �9q�,..T;o'PP�,c� gSSACHUS Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER { Print MAP NO: _3 _PARCEL ZONING DISTRICT: Historic District yes no Machine,Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alte No. of units: Commercial epair, replacemer Assessory Bldg Others: Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFOR ED: (bO k_ I Ar Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: A&_S��_ 5 CONTRACTOR Name: J Phone:s"tF-467-614 F Address: , Supervisor's Construction License: b Exp:. Date: l /C Home Improvement License: Exp`. Date; �C 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: Q FEE: $ (00 Check No.: Receipt No.: -Q1 702- , NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund f gnature of Agent/Owner Signature of contractor - Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. j 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) J '1 ❑ Building Permit Application a ❑ 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:Building Permit Application 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 Reviewed on Signature COMMENTS HEALTH Reviewed on Signature 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 Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT r Temp Dumpster onsite yes no Located iat 124 Main Street Fire Department signature/dater�l COMMENTS Dimension i 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 Location 61 No. Date NQRTh TOWN OF NORTH ANDOVER r• a � , Certificate of Occupancy $ �sskMuytt�' Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ i Check # . 2 7 21762 Building Inspector The Commonwealth of Massachusetts I I Department of Industrial Accidents I � I '4 Office of Investi;ations 600 Washington Street Boston MA 02111 {' WwK'-mass. rov/dia Workers' Compensation Insurance.Mfidavit: Builders/Contractors/Electricians/Plumbers A2-PPlicant Information Please Print LeaibI Name (Business/Organization/Individual): Address: fid / City/State/Zip: /4,�-ue('k- U Phone Are you an employer?Check the appropriate box: l.❑ I am a employer with 4. F7. ype of project(required): ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors ❑New construction 2. I am a sole proprietor or partner- listed on the attached sheet ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its 9. Building addition required-] officers have exercised.their 10.0 Electrical repairs or additions 3.❑ I an a homeowner doing all work right of exemption per MGL 11.7 Plumbing repairs or additions myself [No workers' comp. c. 152, §1(4), and we have no insurance required.] t employees. [No workers' 12.❑Roof repairs comp. insurance required.] ]3.❑ Other *Any applicant that checks box 41.must also fill out the section below showing their workers'compensation policy information, t homeowners who submit this a—gidavit iudicatin;t,'tey are uuii- I.to:r;a,,d Cncn hire outside cordraciurs muss submii a new am `uavit indicating such. tContractors 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: �e,4 C, e`{ S(lrc, Policy#or Self-.ins. Lic.#: _L LJ Q Expiration Date: /� 0 Job Site Address:_ b k0S 19AJ4 S11 City/State/Zip: AU00VeK_ 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 herebJ cert• under the pad and pe es of perjurJ1 that the information provided above is true and correct Signature: Phone#: Official use only. Do not write in this area,to be completed by city or town o iicdal City or Town: PermiVLicense 4 Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical inspector S. 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 ee is defined.as ...eve person� Y m the service �' P of another under any contract of hire, implied,or ex ressoral or wri tten. P 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 includin.g 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 o r local licensing agency shall withhold the issuance or renewal of a license or permitto 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 compi-etely,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 canry workers'compensation insurance. If an.LLC or LLP does have . employees, a policy is required. Be advised that this affid-avit 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 reg-riling the law or if you are required to obtain a workers' compensation policy;please call the Department at the nmanbenlisted 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/iicense number which will be used as a reference number. In addition,an applicant that must submit multiple permit/iicense 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 VJasliington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-8:77-MASSAFE Revised 5-26=05 Fax# 617-727-7749 WWIX.mass.gov/dia 10:JU HUG db, dWOU IV: FKEL U. UHLJXI.H tHA NU- t0(b-404-1Wb0 #151790 NHGE: 2/3 CORD,. CERTIFICATE OF LIABILITY INSURANCE °612009'10:28 ' 08126/200810:28 PRODUCER (800)225-1865 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Fred C.Church.bc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 40KeDozaAvenue HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Haverhill,MA01830 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 800-225.1865 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A Patrols Mniml GrOW of CameWC1][ DawGcbeil Home br ovemetd. 80 Munroe Sl INSURER B: Haverhill,MA 01830 INSURER C: INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHE 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 MAYBE 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. INR POALICYEFFECTIVE POLICYEXPIRATION LIMITS LTR F INSURANCE POLICY NUMBER GENERAL LIABILITY EACH OCCURRENCE $1,000,000.00 MAWE TO RENT X COMMERCIAL GENERAL LIABILITY PREMISES EaocaLL'rence $50,[100.00 CLAIMS MADE OCCUR MED EXP(Any one person) $5,000.00 A CTR0004458 11/24/2007 11/24/2008 PERSONAL&ADV INJURY $1,000,000.00 GENERAL AGGREGATE $2,000,000.00 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-OOMPIOP AGG $ 2,000,000.00 POLICY 7 PRO LOC AUTOMOBILE LY181LITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea actdderd) ALL OANED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIREDAUTOS BODILYINJURY $ NON-OWNED AUTOS (Per accident) PROPERTYDAMAGE $ (Per accident) GARAGE LIABILITY r. AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EAACC $ AUTO ONLY: AGG $ EXCESSIUMBRELLALIABILIIY EACHOCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ RY YVORKERSCOMPENSATIONAND VJCSTATLIMU- OTH- FR EMPLOYERS'LIABUTY ANY PROPRIETORIPARTNERIE?ECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBFREXCLUDED? E.L.DISEASE-EA EMPLOYEE $ It yes,desate under . SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER OESCFIPTION OF OPERATIONS I LOCATIONS I VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENTI SPECIAL PROVISIONS Job Site:32 Wed Brad Street CERTIFICATE HOLDER CANCELLATION Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPRATION 1600 Osgood Street DATE THEREOF,THE ISSUING INSURER VVILL ENDEAVOR TO MAIL 10 DAYS WRITTEN North Andover,MA 01845 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,RS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2001108) Client# 30198 Mg# 07/08 Cert Ccrl# O ACORD CORPORATION 1988 wf DRIVER'S LICENSE __ I 02660 032 y DATE OFI)MTH CIASS REST HUGiff SEX n f 01-31-1966 D 06 M100 � Exa�nEe � 01-31-2009 _ `GOBEIL DANIEL ` DANIEL L i � � J 88 H1UNROE ST HAVERHILL,MA 01830.883 ' , B On ua Ing atu tit s am au a,S& Constrttotion Supervisor License License: CS 63220 Expira3�an j32070 To# 16704 Restr"oc3von, O0 DAPI➢ELL GCBbL J.ct' 80 MONROE ST HAVERHILL,MA 01830-�- •%� 'U'Dmmissioner 1 - ,-�/�c/`��ZayG� •, ISI Board of Bdrdding Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 132182 Expit�jlQn: -111314[2008 `Type: - DAN GOBEIL coNTRJ'_cTINC DANIEL,GOBEIL 3. 80 MONROE ST. HAVERHILL,MA 01830 Administrator • V%O H c TONM of No.j qg dover, Mass., �. GOC HIGHS WICK Y RATED PP� BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System S V �f r 64 BUILDING INSPECTOR THIS CERTIFIES THAT.......................�`n�..�......... ................. Foundation f has permission to erect........................................ buildings on .....�� E.�........1'a ............................. Rough Chimney to be occupied as ,f ��(�..... �.L7.� y ........................... provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT' EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION S TS Rough ......................... ................................................................................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove 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 Smoke Det. Dan Gobeil Home Improvement LLC 80 Munroe Street Haverhill, MA 01830 (508) 451-0493 C.S. 063220 CONTRACT REG. 132182 CUSTOMER : Suzan Ierada DATE: November 15,2008 561 Pleasant Street North Andover PLAN: Install Atrium style door THE JOB WILL INCLUDE THE FOLLOWING: PRICE • Remove existing mullion window unit and install new Threma-Tru Hinged Patio Door, with white hinges, screen and internal mini blinds, "Using Existing Window Width Opening". • Insulate and finish trim inside and blend in siding outside. $2,950.00 • Material excluding door: $50.00 • Debris removal: $50.00 • Permit fee: $50.00 • Anything above and beyond said work will be done on a time and material basis @ a rate of$45.00 an hour • Clean and remove all related debris. $3,100.00 TOTAL MATERIAL AND LABOR ACCEPTED & AGREED TO BY: uzan Ierada 'el Gobeil DATE: l (/a/0 ` DATE: D