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Home My WebLink AboutBuilding Permit #527 - 67 MAIN STREET 2/1/2007TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Issued: IMPORTANT: A LOCATION M 0,L PROPERTY MAP NO. PARCEL: menu A lull TTCL nun n nirivr_ Date Received icant must complete all items on this 5�—Pk . i L�l Print ZONING DISTRICT:_- 141gTnUIC DIRTRICT VES I1 6 6,61V j XI -1 0 � TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ Addition 1�9Alteration ❑ One family ❑ Two or more family No. of units: ❑ Industrial ❑ Repair, replacement ❑ Demolition ❑ Assessory Bldg PCommercial ❑ Moving (relocation) ❑ Other ❑ Others: ❑ Foundation only DESCRIP�ION,� WnRK •I•��b>1✓ru�l �� 1 Identification Please Type or Print Clearly) ti :� Name: U �� f� Phone: Address:, q +Z)r � CS -t J�%l of N CONTRACTOR Name: -V�, C:L l 1 0-4 Phone: 0-- 60, —, �3 �0 Address: � (� 66 "L/67� N-1Pr� • aJ,--� Supervisor's Construction License: rF4 C� 9 9 Exp. Date: Home Improvement License: 153 g5�� Exp. Date: ZGdl� ARCHITECT/ENGINEER Name: Phone: Address: Reg. N FEE SCHEDULE: BULDINC PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost FEE:$ —TO Check No.: /Jl Receipt No.: /,q �J Page I of 4 TYPE OF SEWERAGE DISPOSAL Art ❑ Swimming Pools ❑ Public Sewer F1Tanning/MaTanning/Massage/Body Well Tobacco Sales ❑ Food Packaging/Sales [I❑ Private ❑ Permanent Dumpster on Site ❑ (septic tank, etc. Electric Meter 1 catt to proj ect 114 v I r.: rersons contractin a unregis red con racto o not have ac Signature of Agent/Owner G- Signature of Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan THE FOLLOWING SECTIONS FOR OFFICE USE —.,— INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT ❑ COMMENTS CONSERVATION COMMENTS DATE REJECTED DATE APPROVED DATE REJECTED 11 DATE REJECTED HEALTH ❑ COMMENTS FIRE DEPARTMENT - Temp Dumpster on site Fire Department signature/date COMMENTS Zoning Board of Appeals: Variance, Petition N Planning Board Decision: Conservation Decision: Comments Comments IN DATE APPROVED DATE APPROVED ❑ 2�` • e +sry t yes no Zoning Decision/receipt submitted yes Water & Sewer Connection/Signature & Date Driveway Permit Building Setback (ft.) Dimension Front Yard Side Yard Rear Yard Require Provided Required Provides Required Provided- rovided 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:BPFORM05 Created JMC. Jan.2006 J �� a 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 • an ❑ Workers Comp Affidavit Ey ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract? If ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) V k rydiance R- 1f Applicable) ass I'- %,gjlv 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 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:BPFORM05 Page 4 of 4 ylW W x 1'd 0 Q x x h ANG v w w w � a � a ;00 W o _ o tu o vi oo U) ylW W J= f. 1'd 0 Q Q0 ilk o��Q' h ANG b uj z CL s cm H U) 0 U a U 0 O v a 7Z, 10 v 5N j J 00 SIN r 0 7(5 Lo C,4 24 CL LU C-0 uj Co, coo `.z 7Z, 10 v 5N j J 00 cm $A r Timothy A. Giard P.O. Box 782 North Andover, MA 01845 Name / Address Lisa Mederios 67 Main Street North Andover ma 01845 Estimate Date Estimate # 2/3/2007 1121 ri lune tr 978-689-8336 nLl e0wvMowwea" Board of Building Regula ions and Standards One Ashburton Place -Room 1301 Boston. Massachusetts 02108 Home Improvement Cotractor Registration Registration: 153255 Type: Individual Tr# 253301 Expiration: 11 /13/2008 TIMOTHY A GIARD TIMOTHY GIARD P.O. BOX 782 N ANDOVER, MA 01845 Update Address and return card. mark r n.ior change. ost Card Address E] Renewal 0 Employmentfl CAI Co 50M-04/05-PC8698 TIMOTHY A GIARD TIMOTHY GIARD 60 SAUNDERS ST. N ANDOVER, MA 01845 Administrator License or registration valid for individul use only before the expiration date. If found return to: Board of Building Regulations and Standards :Not Place Rm 1301 Bosto08 lid without gnature .......�, eldAmC7. .uAa.,w Mxso w,. .5....e,,. •..._ .. ... .... ... . .,. ,.. .J/le OW11nLO I2l(JGCL(�/L. 0/•�//"""""!/.f./2CldP.G[O '\ Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR k J Registration: 153255 Expiration: 11/13/2008 Tr# 253301 Type: Individual TIMOTHY A GIARD TIMOTHY GIARD 60 SAUNDERS ST. N ANDOVER, MA 01845 Administrator License or registration valid for individul use only before the expiration date. If found return to: Board of Building Regulations and Standards :Not Place Rm 1301 Bosto08 lid without gnature .......�, eldAmC7. .uAa.,w Mxso w,. .5....e,,. •..._ .. ... .... ... . .,. ,.. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations R 600 Washington Street Boston, MA 02111 vet www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): r'k Address: ve _6 4 L City/State/Zip: Phone .#: 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. employees and have workers' [No workers' comp. insurance comp. insurance.t required.] 5. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t 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.❑ 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 a new affidavit indicating such. tContractors 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 isproviding workers' compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: 5 e ct 5' yt, Ici 2 :70 6- Expiration Date: Job Site Address: 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 t 0.00 and/or one- ear imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up t $250.00 day againsAp violator. ldadvised that a copy of this statement may be forwarded to the Office of I do I ereby certio under th a'._ s findWna)Ff1s of perjury that the information provided above is true and correct Phone #: use only. Do not write in this area, to City or Town: or town official 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. # 617-727-4900 ext 406 or 1-877-MASSAFE -- -- - F-ax-#-fY1-7--727=-7749--- Revised 11-22-06 www.mass.gov/dia b�,JL �Ov,- 1/7 , oor. r a FEB -01-2007 THU 10:12 AM Francis Provencher Insur FAX N0, 9784549343 P, 01/01 — — — — — DATEIMM(DPIYYYY) OP ID B Ac RD„ CERTIFICATE OF LIABILITY INSUIRANCE EpASAMAT RT12TER Or NFORMATION 07 TIS 'RODUGCR ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE ?ranci!3 Provencher Insurance HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR agency, Inc ALTER IN COVERAGE AFFORDED BY THE POLICIES BELOW 530 Rogers Street Lowell MA 01852 Phone;978-459-8681 Fax: 978-454-9343 INSURED Timothy Ciard Plumbing 6: Heating Inc- POSox 782 N. Andover MA 01845 INSURERS AFFORDING COVERAGE — NAIC # IN5URCRA; Merchants InSurance Groin_ 34'154 INSURER B' COmAl�rCe TnsuranCe Come--._ INSURER C Ammocle04d =plcyare ioous�aae— _ — - --- INSURER E: THE POLICICS OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMkv nouvc ANY REQUIREMENT, TERM OR CONDITION Of ANY CONTRACT 0R OTHER DOCUMENT WITH RESPECT TO WHICH yHIS CERTIFICATE MAY BE ISSUED OR ANY PERTAIN, THE , TERM OR AFFORDED BY THE POLICIES DESCR19E0 AIEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCHMAY ^-- POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. — FrfVCTI9r- Pb'0CPtXrTRA fi0 LIMITS �uao'm'nn•L1— —' _-- POLICY NUMBER DATE MMIODIYY DATE MMIDOIYY R ENCS $1000000 GENERAL LIADILITY A X COMMCRCIALGENERAI.LIABILITY CCP 1030489 _I CLAIMS MADE I ^ OCCUR GCN'L AGGREGATr: LIMIT APPLIES PER: POLICY JFPRCT O- LOC AUTOMOBILE LIABILITY B ANY AUTO QVZ742 ALL OWNED AUTOS X SCHCOUI•ED AUTOS }( HIRED AUTOS X NON -OWNED AUTOS GARAGE UABILITY 1 ANY AUTO CXCESsIUMBRELLA LIABILITY 7 OCCUR F. I CLAIMS MAGE LL)FIQUCTIOLE TION 5 tANY ORKERS COMPENSATION AND MPLOYERS' LIABILITYFFIGGRIMCRO MBER EXCLUOF�OXECUTIVF 11 y( -G. deecrlae under SPECIAL PROVISIONS below ['Al 300000 04/07/06 04/07/07 PREMISCS(F.yoccurencaL —.— MCD EXP (Any an0 PBr600 5 5000_ —.— PERSONAL & ADV INJURY 51000000 GENERAL AGGREGATE P 2000000__ PRODUCTS-COMPIOPAGG $ZOOOOOO —, COMBINED SINGLE LIMIT S 01/09/07 01/09/08 1(Ea accident) -�— BODILY INJURYI s 20000 (Per p6(6an) BODILY INJURYI $ 40000 trier accident) PROPERTY DAMAGE s 100000 (Per accldenil AUTOONLv.fAAGCIDENT S OTHER THAN EA ACC S _—,— AUTO ONLY; AGC 5 EACH OCCURRCNCE— AGGREGATE S — wCA9093654 06/19/06 06/19/01 C.L.FACHACCIDENT— 16100000 _ E.L. DISEASE - CA EMPLOYEE '5100000 E.L. DISEASE -POLICY LIMIT $500000 SCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY PLVIMBING TE HOLDER Town of North Andover 120 Main Street N. Andover MA 01845 Ar -ORD 25 (2001108) TION NANAOVE SHOULD ANY OF THE ABOVE. DESCRIBED POLICIES BC CANGt6"U Ot—l" I– DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED YD THE LEFT, BUT FAILURE TO DO SO 61-IALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON , ITS AGENTS OR REPRESENTATIVES, e.nI...,zEDAEPRESENTATIVE _ Colleen 90 ACORD CORPORATION 1