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HomeMy WebLinkAboutBuilding Permit #479-14 - 68 MOLLY TOWNE ROAD 12/5/2013TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 4 el-% /k -- C Permit NO: � Date Received Date Issuedi!A- 'q IMPORTANT: Applicant must complete all items on this page LOCATION_ 68 (KOIrbl `r P int MO(-tk PROPERTY OWNER 64J --v Print 100 Year Old Structure MAP NO: PARCEL: OA'1rr,, ZONING DISTRICT: Historic District Machine ShOD Villa e yes yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ater/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Please Tune or Print OWNER: Name: AriclrPcq- Phone: 1!�Ilw V_ %% -o"49- CONTRACTOR Name:,_113Lret4.!' C it Phone: CET B q 71 '_ 97 7160 Address: 7 c �c'+�,n C on �c ��� d ��� F � . vt ULV_6 Supervisor's Construction License: Exp. Date: Home Improvement License:_ l �J 07L/5- Exp. Date: it Lf ARCHITECT/ENGINEER 2n Phone: �71R 5_(502 J� 2 Address: (93 zap 04t ,n 5-T- 6309ot'p + /L " Reg. No. 6-5' FEE SCHEDULE: BOLDING PE MIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: � 1{01 Cid FEE: $ �10 — Check No.: 1 S Receipt No.: NOTE: Person contracting with unregistered contractors do not have acc es t e guaranty fund Signature_of Agent/Owner Signature of contrac Plans Submitted Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ "3 16 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OR SEWERAGE.DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ .. Swimming Pools El Well ❑ Tobacco Sales ❑ Food Packaging/Sales El 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 Dumpster on site Located at 124 Mair Street Fire Department signature/date COMMENTS Located 384 yes no. ood Street 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 E3 Notified for pickup - Date Doc.Building Permit Revised 2010 Building Department The foh'nwing is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofir g, 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 ❑ 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 apw-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.?ted with the building application Doc: Doc.Bui?,fiing Permit Revised 2012 tion �� Loca,,0'I No. Date mal_ ('L3 Check # 2 711 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Building Inspector qP 1* Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supen-isor License: CS -063503 -f Jr JAMES V CARROtL i 21 JOHNSON CIRCLE- I CLE"North NorthAndover NfA 01845 J�.�,.....iJ expiration Commissioner 07/19/2015 Office f Con er airnes�Regujn HOME IMPROVEMENT CONTRACTOR. Registration: ,A71245 Type: } Expiration: 3%1J2014 Individual CA OLL V. CARROLL 21 JOHNSON CIRCLE;:;,. NO. ANDOVER, MA 01.845 �— r -w Undersecretary 12104/2013 11:24 5786833147 PAGE 01/01 �� V CERTIFICATE OF LIABILITY INSURANCE DATE (tUIM10DlYYYY) 12j4/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OF! PRODUCER, AND THE CERTIFICATE HOLDER, IMPORTANT: If the curtlficate holder iS an ADDITIONAL INSURED, the policy([") must be endorsed_ If SUBROGATION IS WAIVED, Subject to the terms and conditions ofthe policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in li4iu of such ondalSemenR(s)_ PRODUCER M P ROBERTS INS AGCY INC 1060 Osgood Street North Al1daV�r, r MA 01$45 NAME: 4()nlo.exc {978) 683-8073 Arc No,ts7e) 6e3-3147 al ADDRESS:sndi@m robertsinsurance.com INSURERlaI AFFORorNG COVERAOt NAICB INSURER A.: ASSOCIATED EMPLOYERS INS CO INSURED NORTH ANDOVER REALTY CORP. 66 SPRING HILL ROAD NORTH ANDOVER, MA 01845 INSURER 9: INSURER C: INSURER D: INSURER INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY 'THAT 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 CE TIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 1S SUBJECT TO ALL THE TERMS, EXPLUSIONS AND C014DITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. rLTR TYPE OF NSVRANCE rroao wvD POLICY NUMBER MMlDD1YYYY '?AMlDDIYYYY LIMITS COMMFIRGru. FFNIIRAL LIAPP.ITy CLAIMS -MADE D OCCUR EACH OCCURRENCE S PREMISES(ES occurrence S MED EXP (Any oneperson) $ PERSONAL & ADV INJURY S GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO• ,IFCT F—] LOC GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG S S OTHER; AUTOMOBILE LUIBILITYIT Ea accident $ BODILY INJURY (Per person) S ANYAUTO ALL OWNED qGHFDULF.:D AUTOS AUTOS AUTO$ NON -OWNED HIRED AUTOS AUTOS BOOILY INJURY (Par mccidar>t) $ TKt5PF9TY 15 (Para^cldent S 5 UMBREI,LA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-A4ADE' iAGGREGATE $ DED RETFiNTIQN $ $ WORKERS COMPENSATION A AND EMPLOYERS' LIAMI.ITY ANY PROPRIETORIPARTNI!RtEXECuTIvI: YIN OFFrCEPJMEM2ER EXCLLUED4 N/A WCC5010734012013 03/13/13 ©3/13/i4 �_ STATUTE ER j E.L. EACH ACCIDENT $ 500 000 E.I., DISEASE - EA EMPLO$ 500,000 YE tory In NH)daacrtbe Linder V M Yea Visa DESdRIPTION OF OPERATIONS below E.L DISEASE -POLICY LIMIT I s 500,000 DESCRIPTION OF OPERATIC NS I LOCATIONS 1 VEHICLES (ACORD 101, Additional R?mark$ SChedUIS, mSV be etlached iF foto spaoa is mqulrad) EIAX: 978-655-4760 c^Fs� 1 rrCTI= wnr r%am TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES $I.. CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL Bs DELIVFREO IN 1600 OSGOOD STREET ACCORDANCE WITH THE POLICY PROVISIONS. NORTH',ANDOVER, MA 01845 AUTHOR17ED REPRESEN TIVF I ®1988- 013 A ORD CORPORATION, All rights reserved. (2013/04) The ACORD name and logo are registered marks of ACORD Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost 40,000.00 m $ - $ 480.00 Plumbing Fee $ 60.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 60.00 Total fees collected $ 700.00 68 Molly Towne Road 479-14 on 12-5/2013 Finish Basement with one Bath do Q 2 LL O O m C tate+ o O LL E ?ocu N a d In 0 WW Vf Z z n m = �' co o LL m o W A r U = LL 0 to Z O Z i d = o W = LL 0 N1 ? a u u W W ago o W V_ N N m C LL 0 a Z CQ7 t z o d' m = LL H °c a G 5 LL d E 3 m U wO +`� {n +i p Y E N i O R O v ,Q L CL as (13 a • s c o E 3 N � 'a- 0 �! E C1 L = s Q h = C a o m N V L t y 0 * * Q, C U)CD J L i m d An C R N o =4)> c R U = rn C =ss O E•:- c v rCD z O CD s � N a c tm 0 CL CD Cl) v R p •N O 0 r c c 1 Q i L R C = as Q CD '0 N Ujco °' '`2 m W_ _ •a +�+ O O 1L C N C O cn R E•v = V O • W L 0 L V 'av C) > N =oO $ n O , J O 0 > i Z G cc Z W w IL W H w CL �2 w a rm-7 CD 00 L Q O Q C Q C � C JM -0 d Z v Q. i i ry The Commonwealth of Massachusetts Department of IndustriglAccidents Df ce of Investigations 600 Washington Street Boston, MA 02111 quo www.mass gov/dia Workers' Compensations Insurance Affidavit: Builders/Contractors/Electricians/.Plumbers Address: City/State/Zip:N •rl 4Y°Q AW, 6 Q8 VS Phone #: AreyAu an employer? Check the appropriate box: 1. I am a employer with 4. ❑ T 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.1 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 3111 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 S. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. F1 Plumbing repairs or additions 12.❑ Roofrepairs 13.❑ Other Any applicant that checks box#1 must also fill outthe section below showingtheir workers' compensation policy information. I Homeowners who submit this affidavit indicating they tie 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. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. ,, Insurance Company :S'ja��at�� Policy 4 or Self=ins. Lic. #: WC (, .So 0 7 3 `f C 9 13 Expiration Date: lob Site Address._ �C+� d�T�� '{C City/State/Zip:A1'1i 46yxf, N 01*46 Attach a. copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 fo_nvardedto the Office of Investigations of the DTA for insurance coverage verification. Ido hereby ffrti, fy under tie pains andpenardes ofperjury 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): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone 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 ofhire, • express or implied, oral or. written" An employeY 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 as 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 certificates) 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 maybe submitted to the Department of Industrial Accidents for confn atioa of insurance coverage, AIso 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 licens e 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 IegibIy: The-DeparEinerit�as provided a space at the bottom of the affidavit for you t6 fill out in the event the Office of Investigations has to contact you regarding the applicant. Pleasfill e be sure to . in the permit/license number whichwill be, used as a reference number. In addition, an applicant that must submitmultiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (ifnecessary) 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 bum 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: Tho Gommonwca tea o Tassat✓1iu:sPfts DP-Partwe,lit dladustdai .A ccxdeats Office ofltnyestig-ations. 6QQ Wa$biigtou Street Boston, MAI 021 if ` ol, # 617-72.7-4900 ad 406 ox 1-8,77, ASSk4F� Revised 5-26-05 Fay ,# 617-727-7749 0 LO I .9-,66 l 110-,96 1 119-,61 .Z -,V7 „9 ,6 „9-6 9 .0-,9 ,J�- t 1.9-18 98 -. 1 - - - _ °- I�- i I I I I Z I I– --–--L7: - ----r--- I I - - - - - - - -J--I I ( I , r1•,z (� o � I I - 0 .— I L I Lij N D LL 71 M T Jrc I I co n - - - - - - - - - - - - - - - - - - - - - - —.x. .Z -,V7