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Home My WebLink AboutBuilding Permit #602 - 69 SALEM STREET 4/15/2008 1 BUILDING PERMIT Ot NORTH TOWN OF NORTH ANDOVER c? o°, APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received o�RTEG cy �SSACHUS�� Date Issued: q// I PORTANT: Applicant must complete all items on this page LOCATION -71 f, /VcdA andWa, Print PROPERTY OWNER Print MAP NO'. PARCEL: ZONING DISTRICT: Historic District yes no" Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial Repa , replacement Assessory Bldg Others: Demo ition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OWORK TO BE PREFORMED: .n <)1,5 Cf as Identification Please Type or Print Clearly) s OWNER: Name: MR X&-4<n-A,-5 Phone: 97P 607 -3/7o9 Address:---3/- v P_ La, CONTRACTOR Name: ./tnr�� „ (rl)n ,ks Phone: Address: Q ?lZOLd 3t Pew Cid v' m Cil m -r—T— Su Supervisor's Construction License: P �.� ��a Exp. Date: - 14/9S/20/0 Home Improvement License: f Exp. Date: 10 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ '300, QCT FEE: $ f Check No.: 2 /7 Receipt No.: � NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of AgentlOwner m Signature of contactor F i 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 ❑ 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 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 I THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS A s 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: Located 3 Os ood Street FIRE DEPARTMENT - Temp Dumpster on site' yes no Located at 124 Main Street Fire Department signature/date COMMENTS I 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 No. L Date �oRTN TOWN OF NORTH ANDOVER F R � Certificate of Occupancy $ Building/Frame Permit Fee $ _ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 7 081 Buffdi'ng P Ins ector The Commonwealth of Massachusetts Department of Industrial Accidents a Office of Investigations d 600 Washington Street Boston, MA 02111 ,. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lejibly Name (Business/Organization/Individual): Address: City/State/Zip:. Pc�bo 1YV QIg' Phone.#: 97Y` Are you an employer?Check a appropriate box: Type of project(required):. Lk I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contTactors have 8. ❑ Demolition working for me in any capacity. employees and have workers' insurance. ' 9. ❑Building addition [No workers' comp. insurance comp. required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.[1 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12 ,'Roof repairs insurance required.]t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'comp policy compensation olic 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. 1 Contractors 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 is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: �lj,J �,(��JG2 r0� c 5Z�C, S Policy#or Self-ins. Lic. L Ic V ml,> / Expiration Date: 6- Job Site Address: 6 Q �� Q/�i�1 T�/. &QW--r, City/State/Zip:. 1Y OlC�7'f 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 and he pains pen s of perjury that the information provided above is true and correct Si ature: Date: _ Phone#: 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-contiactor(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 maybe 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 permittlicense number which will be used as a reference number. In addition,an applicant that must submit multiple permittlicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address" the applicant shouldl 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 Sheet Boston,MA 02111 Tel. # 6.17-727-4900 ext 406 or 1-877-MASSAFE Revised 11822-06 Fax#617-727-7749 www.mass.gov/dia Board of Building Regulations and Standards License or registration valid for inclividul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: ' Board of Building Regulations and Standards Registration:,"153094 One Ashburton Place Rm 1301 Expiration:.. 10/27/2008 Tr# 253140 5 1� t Boston,Ma.02108 Type: Ltd Liability Corporation e: NORTH SHORE PROPERTY SERVICES LLC DENNIS DROGGITS' �''y ` / ✓" 484 LOWELL ST SUIS E 1C �. �p2� •w PEABODY, MA 01960 Administrator Not valid without signature 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: 6?--21 e is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section l OA. The debris will be disposed of in: pc--� 0C1 y4 (Location of Facility) Signature of Permit Applicant - /'za� Date RUV-13-Z007 05:36PM FROM-Phil Richard Ins 9787741318 T-307 P.003/003 P-203 AgODCERTIFICATE OF LIABILrrY INSURANCE 24/07 PRt)DII� THIS CMFICATE IS I DASA EA PROF ID=EATION Flail RichardAssociatesONLYAND CONFMNORIt M UPONTHECERTFI;ATE 491 Maple street HOWM THIS CERMICATEOMNOr AMHID EXTEmOR Suite 102 ALTER TFECOVMGEAFFORIMByTHI_FOLK� Danvers, Nom, 01923 WLIRM AFMIXIING COVEPAGE MAIC 0 INwiRo� INSURr3RA:Na>3tilus Ins%wanae Co North Shore Property services Atlantic Charter LLCLLCINSURER& _ 484 LowQii. street INSURER C Peabody, MSL 01960 T13URE R D: INSURM E COVEPAGM THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVENOTWITHSTANDING FOR THE POLICY PERIOD INDICATED.NOTHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DMUMENT 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. INS in PDLICYMUTASM R�ucvCT F6I.714E PBUCY eC N LBIIITa COI dALIJI10mm MR OCCURRENCE S 1,0 0,000 A X COMmVRCmGENmALLm8UTY MC661415 5/3/07 5/3/08 Pg,R�g� s 50,000 cowls m DE ❑X OccuR Mm G(P(ftg—Par—) $ 5.000 PMSONAL 3 PDV INJURY s 1,000,000 crNaRa.Ar�RFGpTE s 2.000-000 CEN'LAGG1EGATEIpytItAPR7.ESPER r4RCaLrGTS-COMPIOPAR $ 2,000,000 PQ= +mac — AUTOWKWULLASUff COMBINED SINGLE Lldrr AN1'AUTD (Faaooiaerlp $ ALLO EDAUTOS RY �IRHlt1tIDAUTO& (mi,i wig) i HIR®AUTOS NON-UNNM AUTOS Y S - PROPERTYDAMAGEGARACE3 LMOILRY AUTODNLY-GAAcCfdENT = ANYAUTO $ ACC $J1A!CC MOS?_" F EMMI IMBROAAUINSIMY EACH OCCURRENCE g OCCUR CLANG MADE ACS( WATE $ $ DEDUCTTSSE $ RAN — WORK IRSCONPEIIWIG NAND A FI 8 ENFLOYE3 ,LMELRY WCV00788100 6/19/07 6/19/08 .41Tuarr ANYM)MIETOR11VIRTNEWEXE mm EL EACH ACCIDENNI' S 100,000 OWICEWM1E11101HEt EIM 001-> EL OSFIW_FAtNMUM: $ 100,000 W 00,000W A NS6ebw EL DIS-POUCYIJMIT $ 500,000 C rFMR Viii�IWMNOFDFHUMONSIUMWMIVENEUMICOLt=MMMMBYDmCRSEMBfflgpoobALPRCNEOM EVIEDKNCE OF INSURANCE LI'TCR>c'I M COMPANY, INC. IS IN'GLUDED AS AMITICNAL INSUNW. CERTIFICATEH®LO R CANCELLATION SHOULD ANYOF THE/OWE OEMM EM POLICWSBE CANCOA.W BEFME TH@= RATET7 BtMF.THEMUUCINSUR6R1N4a.131DMMTOUft LI15 DAISN/QtrTTBI TCIIIT , NOWETOTHECERTw-irwTENO1 ERNmmToTHELEp7guTFaLQREToDOgOSwi 2 A 01 3 INMENOODLICTIONCRUGRMCF NYKMUrONTHEwWR®t.msAGENnsgR RE MSENrMI+M ALrr►IDIa� TTHF ♦ 'i ACOM 25(2001)M O ACOW COFIPMnM ISO