HomeMy WebLinkAboutBuilding Permit #665-2011 - 58 EDGELAWN AVENUE 4/5/2011TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO:�"����
Date Issued:
IMPORTANT:
Date Received
must complete all items on this
LOCATION 5V
Print
PROPERTY OWNER E k c t 4 `t
Print
MAP NO:��PARCEL: §r ZONING DISTRICT: Historic District yes d
Machine Shop Village yes
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
OTwo or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
A Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
®lSepticWell1.
� Floodp aui ®lWetlands
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D�
} Waterilied °stri�tA
. DESCRIPTION OF WORK TO BE PERFORMED:
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(Identification Please Type or Print Clearly)
OWNER: Name: li1+/Ad 6r I uy Phone: G,17 8'-(l ( Z111
Address: 5u V-96rl� tAUA/ 99 A) LvQove[(L meq Q1e2L,6_
CONTRACTOR Name: -/ RAW) Phone:
Address: 3 Lt k (Z v -/ rt" Y 6_T__ N. P -A_, Oo U �_ g M t4
Supervisor's Construction License: CS 5 5 Z v v Exp. Date: 31 51 Zu i Z
Home Improvement License: 1 I ty 09. Exp. Date: t 2 Z,0 l2„
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE. BOLDING PERMIT. $12.00 PER $6
9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ 7 2 FEE: $
Check No.: -?a 2l Receipt No.: �` J
NOTE: Persons contracting with unregistered contractors do not have access to the guuaraty, fund
Location_a /61 AoO
No. 6 �-- _.2 Date
TOWN OF NORTH ANDOVER
'i MiEW&K
TOW 0
Certificate of Occupancy $
04 4
Mu Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL . $
7, 2
Check #
2 4 0 %'J- 3
Building Inspector
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
TanningNassage/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
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
Reviewed on Signature
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:
FIRE DEPARTMENT - Temp Dempster on site
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Located 384 Osgood Street
yes no
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
NOTES and DATA — (For department use
Notified for pickup - Date
Doc:.Building Permit Revised 2008mi
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)
cable
❑ 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
IOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg .Permit
i all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
iat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
lust be submitted with the building application
Doc: Doc.Building Permit Revised 2008mi
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ACORD CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DD/YYYY)
04/04/2011
PRODUCER 978, 374.6352 FAX 978.521.5127
COSTELLO INSURANCE AGENCY
2 South Kimball St.
PO Box 5248
Bradford, MA 01835
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 #
INSURED Quinlan & Rand Contractors
34 Trinity Court
No Andover, MA 01945
INSURERA: National Grange Mutual Ins. Co
14788
INSURER B:
LIMITS
INSURER C:
Ton of North Andover
INSURER D:
MPS73609
INSURER E:
03/12/2012
vWvLA
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.
INSR
LTR
DD'
NSR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE MM/DD/YYYY
POLICY EXPIRATION
DATEIMMIDD/YYYY1
LIMITS
AUTHORIZED REPRESENTATIVE
Ton of North Andover
GENERAL LIABILITY
MPS73609
03/12/2011
03/12/2012
EACH OCCURRENCE $ 1'000'000
X COMMERCIAL GENERAL LIABILITY
DAMAGE TO RENTED
PREMISES Ea occurrence $ 500,000
CLAIMS
�
MED EXP (Any one person) $ 10,000
MADE OCCUR
A
PERSONAL & ADV INJURY $ 11000,000
GENERAL AGGREGATE $ 2,000,000
GENT AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG $ 2,000,000
POLICY PRO-
JECT 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 $
AUTO ONLY: AGG $
EXCESS / UMBRELLA LIABILITY
EACH OCCURRENCE $
AGGREGATE $
OCCUR CLAIMS MADE
DEDUCTIBLE
RETENTION $
$
WORKERS COMPENSATIONTATU-
OTH-
AND EMPLOYERS' LIABILITY Y / N
TOW RY LIMITS ER
E.L. EACH ACCIDENT $
ANY PROPRIETOR/PARTNER/EXECUTIVE❑
OFFICER/MEMBER EXCLUDED?
E.L. DISEASE - EA EMPLOYEE $
(Mandatory in NH)
If yes, describe under
E.L. DISEASE - POLICY LIMIT 1 $
SPECIAL PROVISIONS below
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
�rCrc I WAIM 1 G fIVLUCR CAN(_FI 1 ATInfj
^��•�� ����� •� v Tatsts-ZUUa ACUKU GUKPOKATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
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, ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
Ton of North Andover
Ben Costello
^��•�� ����� •� v Tatsts-ZUUa ACUKU GUKPOKATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
Quinlan & Rand Builders
34 Trinity Court
North Andover MA 01845
Tim Quinlan I Jeff Rand
978-457-0528 / 978-457-2698
Homeowner information
Dan Reilly
58 Edgelawn Rd.
North Andover MA 01845
617-842-1297
Lic. # CS 55288
HIC # 111089
Description of work
-Remove the and wallboard from tub area and walls outside tub area
-Remove file floor and sub floor
-Install Dura -rock on three tub walls
-Install wallboard on wall areas outside the tub area
-Tile walls around the tub to the ceiling and four feet up the rest of the walls
-Install sub floor and file floor
Total cost
$ 4200,00
Payment due upon completion. Job to start week of April 4th and will be compicte in 1
week.
Homeowner
Date
Date
The Commonwealth of Massachusetts
c ; F Department of Industrial Accidents
I� Office of Investigations
t rr;. , ,-�
1 ' 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): Q V t N L-A N -r 900v!9 3 Vi _ 0/*a3
Address: 3'-t -[V t/V l i y C;-111
City/State/Zip:/ +v Oyv•2 M4. Phone #: 111 q -+-(S-7 -c6-7-
Are
c52-
Are you an employer? Check the appropriate box:
1. ❑ I ama' employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. JW I air a sole proprietor or partner-
listed on the attached sheet. t
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.]
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.❑ 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 anew affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors acid their workers' comp. policy information.
lam 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
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.
I do hereby testify undeq' the,�ins qd pMalties of pejjury that the information provided above is true and cosec
- I/S-7 -0 S,
Official 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 aparhnents 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 cant' 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 confinnation 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 pennitllicense number which will be used as a reference number. In addition, an applicant
that must submit multiplapermit/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 pen -nits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or pennit 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-MA.SSAF.B
Revised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia