HomeMy WebLinkAboutBuilding Permit #612-11 - 65 MAPLE AVENUE 3/5/2011TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO:
Issued: 15�
IMPORTANT:
Date Received
must complete all items on this
CLU
Print
-- Print
MAP NO: PARCEL: 0 b -O ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
IXTwo or more family
❑ Industrial
Ig Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
j Floodplain I.® Wet_landst
'®'WatershedtIDistYrict
l Sep --.1
7 MOW
Water/Sewer
f� sz., _._..r
OWNER: N
DESCRIPTION OF WORK TO BE PERFORMED:
e zoo r
Identification Please Type or Print Clearly)
.i S + e. U-),,- n -4 -
Address: S-? 9P�-
e -�
CONTRACTOR Name: % � , _ � � Phone:�/ � / 3 — Is
Address:,? GUS S S�
1
Supervisor's Construction License: ® 6 0 L I. Z Exp. Date: C) t
Home Improvement License: (le Z Exp. Date: 2 C) 1 l
ARCHITECT/ENGINEER Phone:
Address:
Reg. No.
FEE SCHEDULE: BULDING PERMIT: $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F.
Total Project Coat: $ FEE: $
Check No.: 2n
4-/ Z Receipt No.: p Scl r�
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
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
o 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
o 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
Chat 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: Doc.Building Permit Revised 2008mi
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
Well ❑
Private (septic tank, etc. ❑
Tanning/Massage/Body Art ❑ Swimming Pools ❑
Tobacco Sales ❑ Food Packaging/Sales ❑
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:
Conservation Decision:
Comments
Comme
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
COMMENTS
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 2008
Location-� 'Ala 4 -
No. Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
#4
Foundation Permit Fee $
Other Permit Fee $ r
TOTAL $
Check # --),0
23957
Building Inspector
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Fully Insured Thomas Do le D.B.A. Salem, NH 03079
THOMPSON' S ROOFING (978) 691-1355
Shingles - Slate - Rubber Roof
Single Ply - Copper Work
PROPOSAL SUBMITTED TO
PHONE
pytRE
Jay Stewart
STREET
JOB NME
59 Bradstreet
CITY, STATE AND ZIP CODE
JOB LOCATION
North andover MA
65-67 Maple Ave. No. Andover PIA
ARCHffECT
DATE OF PLANS
,IOg "'ONE
we hereby submit spedlica ons and estimates for:
•
Strip off all -roof shingles on lower roof and garage
Renail all loose boards and if any needs to be replaced it will cost
$3.50 a lineal ft.
Install 024 wh ite aluminum drip edge
Apply ice and water shield 6 ft. up all along edge
Apply 1-51b. felt paper on rest of roof area
Reshingle with a GAF 30 year Architect shingle
Remove all work related debris
1
30 year warranty on material
5 year guarantee on labor
construction li_c. - 0601.12
improvement 4,128612
P CDpOgP hereby to famish material and labor — complete in accordance with above �, for ft sum of:
Three thousand four hundred dohm(S__3.40n-0f)
Payment to be mads as folows:
$17400.00 start of job balance upon completion
Ae meterief is prom eed to be n tpecMed Al work to be aornpWed Ina worisrrsao morns
accom ft to standard prat icn Any aNration or drAmm fr n abas apacMlee- taebtp AaAlaxlasd
ex" Coate wa be erwcuted o* upon w Ww orders, and wa baooms an lata dwpe ow and so
atw" the eatmsts. M aprasnsrts oontlnpent upon aer*W aoddwrte or ddep bwd our
corWol Owner to Cary fYa. tortndo and oths raxeessy Nwanoe Qr workers a� fay Noes: This proposal may be
n mmld rw w,.e,,,W, r...,.,..,..w,., r,.....r.. u...1; ,ki- &.....�_.............61 —_ .... ,... _ .. W
9aLt#ras=t Of 3PrlDp00111t — The above prices, apedficaliom and
conditions are sadstac" and are hereby axepfed You are autained to do the
work as specified. Payment w bemade
' as o`WYned above.
Date of Acceptance:
NORTH ANDOVER BUILDING DEPARTMENT
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
at: is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c11,S150A.
Also, note Permits are required under Fire Prevention laws Chapter 148 Section
l OA.
The debris will be disposed of in:
.tS �6 Lvecl j Sq IPS kt 4
(Location of Facility)
V'�e�
Signature of Permit Applicant
3 -CI'-( //
Date
"'
� his IIAS iSSe.
�Q2 lv
1
V --1Aej N42Y 4 ree-
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: CU e S S
City/State/Zip: S'� �� �-. /V,� % Phone ##: t' '' i 3 - S��
Are you an employer? Check the appropriate box:
The Commonwealth of Massachusetts
c ..
Department of IndustrialAccidents
-•� .i� 1 � •
1
�J f Invesg
Office o Investigations
���' i°
600 Washington Street
These sub -contractors have
Boston, MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: CU e S S
City/State/Zip: S'� �� �-. /V,� % Phone ##: t' '' i 3 - S��
Are you an employer? Check the appropriate box:
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
2. ❑ I am 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.] fi
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
11.0 Plumbing repairs or additions
12.L�Jt�oof 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 a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub -contractors acid 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:
Policy # or Self -ins. Lic. #:��1 Z Z % �(. d ) Z UO or Expiration Date: L/ Z
Job Site Address: � ///ctG� �t� i� City/State/Zip: yr oI dyA0�
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 and penalties of perjury that the information provided above is true and correct'
Phone #: to l / — / 3 �s
Official use only. Do not write in this area, to be completed by city or town offrcial.
City or Town:
Permit/License #
-!Y -- /,
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 pennit/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 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. ## 617-7274904 ext 406 or 1-877 MASSAFE
Revised 5-26-05 Fax ## 617-727-7749
www.mass.gov/dia
i
ACORD
CERTIFICATE OF
LIABILITY INSURANCE
0DATE 5/1MID)
05/12/20102010
PRODUCER
Pelham Insurance Services, Inc.
P.O. Box 960
122 Bridge Street
Pelham NH 03076
ADO'L
INSRD
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
Thomas Doyle
dba Thompson
8 West St.
Salem
Construction &
NH 03079
A
INSURER A: Nautilus
GENERAL LIABILITY
INSURER B: Associated Industries
INSURER C:
EACH OCCURRENCE $ 1,000,000
INSURER D:
INSURER E:
WS063814
10[411TA =[41!TV =1
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
ADO'L
INSRD
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE (MM/DD/YY)
POLICY EXPIRATION
DATE (MM/DD/YY)
LIMITS
A
GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,000
MERCIALGENERALLIABILITY
CLAIMS MADE F—]OCCUR
N:_C:O1M
WS063814
04/15/2010
04/15/2011
pREMSETOR(EaENToccurence$ 50,000
MED EXP (Any one person) $ 1,000
PERSONAL & ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GENT AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG $ 1,000,000
PRO -
POLICY JECT LOC
AUTOMOBILE
LIABILITY
ANY AUTO
COMBINED SINGLE LIMIT $
(Ea accident)
BODILY INJURY $
(Per person)
ALL OWNED AUTOS
SCHEDULED AUTOS
BODILY INJURY
(Per accident) a
HIRED AUTOS
NON -OWNED AUTOS
PROPERTY DAMAGE $
(Per accident)
LI
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT $
OTHER THAN EA ACC $
ANY AUTO
AUTO ONLY: AGG $
EXCESS/UMBRELLA LIABILITY
EACH OCCURRENCE $
OCCUR EICLAIMS MADE
AGGREGATE $
$
$
DEDUCTIBLE
$
RETENTION $
B
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
AWC7012214012009
04/21/2010
04/21/2011
x ITCSTAT- ER
E.L. EACH ACCIDENT $ 100,000
E.L. DISEASE - EA EMPLOYEE $ 100,000
OFFICER/MEMBER EXCLUDED?
If yes, describe under
SPECIAL PROVISIONS below
500 000
E.L. DISEASE -POLICY LIMIT Is ,
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLES/EXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS
Roofing -Residential
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
Ed Lapore FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
113 Autumn Rd INSURER E OR REPRESENTA SS- 1 /
Dracut,Ma 01826 AUT'VIE;Kpy