HomeMy WebLinkAboutBuilding Permit #727 - 64 SAUNDERS STREET 6/10/2008TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One family
Addition
Two or more family
Industrial
ation
No. of units:
Commercial
, replacement
Assessory Bldg
Others:
Demolition
Other
Septic Well
.Floodplain Wetlands .,
Watershed District'
WaterlSewer
DESCRIPTION OF WORK TO BE PREFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: a e 1,xs ,41mo v '- Phone: !a Z,9 -6 R.P ,Rw
Address:
ARCHITECT/ENGINEER
Phone:
Address: Reg. No.
FEE SCHEDULE. BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ A0 0 FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have i
to the guaranty fund
a
r
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:
Dimension
s
E
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
R
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
c� 51=
❑ 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 Ike
❑ Building Permit Application
.d'Workers Com vit
❑ hoto Copy f H.I.C. d r C.S. icenses
PY
o of Contrac
ork
ducts
9
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
LocatioKoe�r
No. Date 14
TOWN OF NORTH ANDOVER
s ,F
Certificate of Occupancy $
sCNUS t� Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
2 12 2 4 Building Inspector
Gerald A. Brown
Inspector of Buildings
Please ndut
TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
1600 Osgood Street Building 20, Suite 2-36
North Andover, Massachusetts 01845
Telephone (978) 688-9545
Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
DATE: �•/t•®�
JOB LOCATION: �i�-GG Sww.vers
Number Street Address MapJW
Mme Phone
PRESENT MAILING ADDRESS Sig pop
Town
State
Work Phone
Zip Code
The current exemption for "homeowners" was extended to include owner -occupied dwellings to two units or less
and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the
owner acts as supervisor). State Building (Code Section 108.3.5.1)
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended
to be, a one or two family structures. A person who constructs more that one home in a two-year period shall not
be considered a homeowner.
The undersigned homeowner" assumes responsibility for compliances with the State Building Code and other
Applicable codes, by-laws, rules and regulations.
The undersigned "homeowner" certifies that he(she understands the Town of North Andover Building Department
minimum inspection procedures and requirements and that he/she will comply with said pmcedures and
realrire�nts.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Revind 10.1005
Foam Ho=m mw EnmpWm
is
BOARD OF TPFALS 688-9541 CONSERV_MON 688-9530 HEALTH 688-9540 PL.LN'NING 688-9535
06/11/2008 14:16 6036423733 KINGSTON INSURANCE PAGE 01/01
04013873;' _. C E R T r F'„I.0 A T E O F r•,N S U R A N C z :IEeue date:: 6-11-08
Pruaucsr Thiz certificate is Istu.ed as a matter. -Of information, only and
CESI'•Agency Df New England confer✓; no right@ upon 'the certificate•helder..- This
•10 Chestnut Drive Unit E certificate does not.amend, extend or.alter.the coverage
Bedford. NH 03110 .,afforded by the Policies helew.
COMPANIES AffORDING COVERAGE
In9ulyd Cbmpanv letter A Nautilu6,InGiiranre
ROCRINGHAM,HOME Company letter S
rMPRDVEMENTS,• hLC
P.O. BOX'.64 domptany letter c
NBWT0N• JGT- -NR 03539
Company letter D
•,Compdny letter E
COVERAGES. -This -is to certify that•policies of insurance listed below have"-'bden -1ssned'to the
insdred•named above for the policy period 'indicated, notwithstanding any xequirement,
term or 'condition of any contraet•or other document With .'respect to which•...this•certi.ficate may
be .ieoue'd ,et may 06;t")at 6t,e inau'Sance afforded by the .pd11ci@G described herein is subject to
all the terms, exclusions and conditions of such policies'. Limits shown #ay tracebeen'reduced
by paid•claims:
Co
Lt
Type of Insurance
Policy'.number
Policy..
6ffsetive
Policy
Expire
ALL LIMITS IN -THOUSANDS
A
Gt%XRAL LIABILITY
X Commercial General Lieb.
N086410
5-14-08
.., 5-14-09
denerarl agcjregate•'...... 1,OOt
Products-coiopleted; '
Claims made
R. Occurance
ogorations'�aggrsgate..S1,00(
'
.;
Personal 4 • . .
Owner's S contractors
auvcLLloiuy 111 Wry:. ..4 50t
-,owner's
Each occuirence.......•.5 50t
"
Fire damaggo (any..
Ciref.
enc $ St
Medical expen3e )piny
one person) ......
AUTOMOBILE LIABILITY
CSL
S
An auto
- Al
owned'autos
- Scheduled autos(per
-
Bodily Injury
person).
$
Hired. autos,
Bodily:In77'uiy.
aper acaidenti)
$
-. Nu�r�wned autos
_. Garage• •liabil•i.ty
ProPa#V •damage
$
BXCEBS.LTABILITY
• Umiirel la -form
'.
Each'occurreneo;::Aggregate
•
-..Other than, UXrella fozm
g: ;
Statutory _
WORKERS! COMPENSATION
AND •
S ' aceideiit )
EMFLOYERS' LIABILITY
�each
S5 diseaae-polity limitl
(di eease-b'itch'empl.)
OTHER
Deacriptlon'ot opera tions/locstibns /vehicles /special•item's '
'CARPENTRY,. SIDING YNSTALLATION'•EXTERIOR MARbLL, MOSIAC OR TERRA ZZO.•WORE�INT ERiOR
PAINTING=NO SPRAY PAINTING, DR�WM'INSTALLA- CARPENTRY PAINTING 9:ROOFING-AI.,r..•,Rr9ID9NTIAL
TION; LANDSCAPE GARDENING 6 Tiu,.sTONC, NOT EXCEEbING 3 STORIES'IN'HEIGHT
certiricate holdeX -CANCELLATION Should any of the above described policies be
cancelled before the expiration data thereof.,
CARL'LANGLOIS the issuing company will. .endeavor to mail 1'0", days;.Written
noC-ice to the certificate holder named to' tie left . buttfailure
C4G6 SAt7NDLRs srxF>rT to trail 6u h notice 'shall impose no obligatioA- or.iiabslity of
NO, .ANDOVER. MA 01845 = any . Find a combari agents of : repreaehtat vcs .
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The Commonwealth of Massachusetts
1
A 14
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
f '. www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual)-ae .ee
Address: 7 y Mn,( v-
-City/State/Zip: �1��� -,VW 43KS3?� Phone #:
Are y an employer? Check the appropriate box:
I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partner-
ship and have no employees
working for the in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
have hired the sub -contractors
listed on the attached sheet. I
These sub -contractors have
workers' comp. insurance.
❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. F1 Electrical repairs or additions
11.Woof
PIbing repairs or additions
12. repairs
13.❑ Other
*Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information.
t Honieowners 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.
1 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.., 9: (—n uq Expiration Date: �01,=t
Job Site Address: _�+gT1918 Yl 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 $1,500A0 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.
1 do hereby certify under the pains andpenalties of perjury that the information provided above is true and correct.
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 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
Revised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia