Loading...
HomeMy WebLinkAboutBuilding Permit #608 - 70 PLEASANT STREET 3/19/2007BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: IS Date Received Date Issued: v ' `� ^� CocMK.NwK• by � TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial �9 Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other • Sep #o el��i � �:ON,G� y %} .'�f Nus z�1 Y{ l�•," }}��Y Fppm1'^^'' RAO 'WI; Oro 6. /fib �,. ! Hca d 2? GtW� f�?'/� DESCRIPTION OF WORK TO BE PREFORMED: 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: $ FEE: $ Check No.:�� Receipt No.:a NOTE: Persons contracting with unregistered contractors do not have accesatothe:arantyifunad Signature of Agent/Owner Signature of contractor 7 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 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 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 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 2.2007 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS HEALTH COMMENTS DATE.REJECTED DATE APPROVED ❑ ❑ 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 ❑ ,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 Located at 384 Osgood 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 2 1 A —F and G min.$100-$1000 fine NOTES and DATA — For department use ❑ Notified for pickup - Date ......... ....................................................................................... ........................................... ................................................. ................ _................................................................ ............................................ _.... ......... _......... ................................................................................................................. .................. Locaiio 0 — �Ia-164hv I No. '60e Date c'? TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ CH Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 20U52 Building Inspector NThe Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Bi Address: City/State/Z* �If „t,� �%il D ?Q'79Phone.#: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. E] I am a general contractor and I employees (full and/or part-time). * ? I am a sole proprietor or partner- have hired the sub -contractors 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.$ required.] 5.0 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. E] Remodeling 8. ❑ Demolition 9. Building addition 10.0 Electrical repairs or additions 11.[I Plumbing repairs or additions 12.E] Roof repairs 13. (] Other — - a .t" uuc me secnon oerow snowing 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 subcontractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: a = S Policy # or Self -ins. Lic. #: S_ Zc/ -> Expiration Date: Job Site Address:_ % — % �t ca 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 $1,500.00 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 Ido hereby certify,#n�he pains that t e information provided above is true and correct vprcrar use only. Do not write fn tMs area, to be completed y city or town ofJiclai 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 �mPIOY�so °�lOvide workers' compensation for their �e service of another under any cpntractnopflhire'g Pursuant to this statute, an employee is define "...every P express or implied, oral or written." the An employer is defined as "an individual, ParinershiP, association, corporation or other legal entity, or any two r more of the foregoing engaged in a joint enterprise, and inc rion or otherg the alegalrentityhemploying employeves of a deceased es or the receiver or trustee of an individual, Partnership, 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 thereto g�doumaintenance, ac because of construction ch emplooyment be deemed to be ar repair work on such n employer.Iling " or on the grounds or building appurtenant 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 ter have been presented to the contracting authority." requirements of this chap 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 Parhierships (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 ber 1 e law or if below. you are reqSelf-insuruired edcompaniestobtain ai should enter: their a workers'- compensation policy, please call the Department at then self-insurance license number on the app nate 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 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 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. 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 - Fax # 617427-7749--- Revised 17=727-7 _.Revised 11-22-06 www.mass.gov/dia Date:: 3/5r,007 05.40 PM Sender's Fa)< ID: 603-890-F121 Page 1 of I ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDYYYYY) OP 0 N1 JOHNS -1 03/05/D7 PRODUCER Santo Insurance - Salem 224 Main Street Salem NH 03079 Phone:603-890-6439 Fax:603-890-0315 John Berthold Construction John Berthold 43 Ticklefam Lane Salem NH 03C7 COVERAGES THIS CERTIFICATE IS ISSUED AS A MATTER OF INf ORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POL!CIES BELOW. INSURERS AFFORDING COVERAGE MAIC - 11t, I -P - - ---------- Western World Insurance 1:'o 11,(,UPER F,Nationwide Companies_______ D P E OF I L'JSU. ANC E LIS --D BE C)',"" H-qVE EHE TC "-E N-1 .� P�D_' 3 -C)' REOUIREk!E;,:., TEEM -F C')r,iDIT!CN --F AN- k­'D.%-.. L -T CO.­UMFI�, -C _,H 'IC4TE MA e PE OP MAY PEPT,' 'IN, THE 11SURANCE -`.FPCjRDE_L'EV 1HE r" LlcE'CIP,-_ T ��­, .-'.L F Lj c,!ONIS AND LMiTS SH`A ' bAV_- `E_;, RELCw-_ Pt'SIR, U LTR NLSRI n'PE OF INSURAHCE POLI CYNUMBEP EFFECTI)75 �P_OUIIIIICYSKM I DATE Ar,VDD;rY*'',, I DATE -'MIV1iDDM) GEIJEf<AL LIABILITY A -_0M.l,1EP_1L!L G E;E�Al Li'_';.;T� XNPE1951473 7f T I- F - 03/29/06 031/2 9/07 :500000 50000 CLAIMS NIP', c ljpr: ......... .. 5000 500000 1000000 107: L,!C-G:,'EG'. __1M1TAl:,P'LiESPE_"' F -POD 500000 PE"' � -7 PRO- r7r.,LiCY jE7 1 _-`Y'F!. 1 AUTOMOBILE LIABILITY 300 Ou') B ANYAUTO 51BA00738630,i1 09/03/05 C,9/03/06 I X ALL BuDIL.Y�;JURY SCHEDULED AU-1 0 0P,r re�r;l�;n) 'i!RFD �.,j Fos (Per acci',jarq F'F,' PEF7%' E (Per 7 GARAGE LIABILITY ACC 1: .11HERTH.A [� AUT,:, ONLY Ar6 EXCESSWIVIBRELLA LIABILITY EH 1)C,-URPFN1_E I$ L.'.; 11S MADE AGGPEGAT- -- WORKERS COMPE1,1SATION AND EMPLOYEIRSLIABILITY — GF FIC EC 1 I L' M 1i E P E (CL E D ? EL EcC'HA,C,-_1DFN-, s lcscnbe unde, ----------- SPECAL PRGV!:1-'1,)NS 1)e:,)!: El DISEASE - L10,111T fi OTHER 7- 'IS AGDFD BY ENDC- R E;Fr.IFI J7 J SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION TCjWTlNAN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN F NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. BUT FAiLURE TO DO SO SHALL. Town of North Andover 1600 Osgood St North Andover IYA101845 iMPOSENIO OBL ATiGPi OR LIABILITY OF ANY KIND 101`01-4 THE INSURER. ITS AGENTS OR REPRESENTATIVES. UTHORIZED REPRESENTATIVE FIF CO) m m m x CA EP y C � d CA n Cl C.�► Z y CL O C CL y aco �go- O v CD CD o Q �dCD CD o C OCD N1� =0 y U2 C I C2 H Cl 'o Z CD � O � O CD O z rrn cn O cn 0 w fie m x O a�` c o y m m CaC m c2 0 c ?.o 9c ro = T '- e m y � y 1 OE � m i =mo-a-� Z�.n'� e cs o e =r _ ! a y,o � oa"�Ci c CD ow CLC, ?: Q CL 3< m CA C to m � oC. m o COD CD c05 CD: CD deyI ;V c D !� o.'s F o BE ca_ 102 o =c H 0 9 -so"4�4 • 0 �l O O C fD El -to ;005' o �' 0 Q -so"4�4 • 0 �l O O C fD Page No. of Pages PROPOSAL Zo dj MA Lic. # 122153 CONSTRUCTION 1-L.C. FL 1PBERTHOLD Lic. # P`1`38• Int./Ext. Painting (603) 339-1465 • Siding and Soffit • Windows• Carpentry •Doors•Renovations Fully Insured • Over 15 years Experience • Free Estimate PROPOSAL SUBMITTED TO // Q ec) PHONE DATE STRE M JOB NA - CITY, STATE AND CODE JOB LOCATION We hereby submit specifications and estimates for: k eve ®•j t,,; / T��� ,��� _"-, r �1 W —/�P WE PROPOSE herebyto fumish material and labor—complete in accordance with above specifications, for the sum of: !,/ P "` / t� S �c O� /('-�j dollars ($ Payment to be made follows: as All material is guaranteed to be as specified. All work to be completed in a Authorized workmanlike manner according to standard practices. Any alteration or Signature: deviation from above specifications involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond ote: This proposal may be our control. withdrawn by us if not accepted within days. ACCEPTANCE OF PROPOSAL—The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as o tlined above. Date of Acceptance: J/uSignature: a \ 9 7 03 7%»% / > \ \z § ■ A % 2 � °©� y � ■ n B . z / I 4 . .i. , . :