HomeMy WebLinkAboutBuilding Permit #545 - 71 SAVILLE STREET 3/26/2008BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
J�
Permit N0:
Date Issued:
Date Received
TYPE OF IMPROVEMENT I PROPOSED USE
Non- Residential
DESCRIPT ON OF/WORK TO BE PREFORMED:
:IS%N(3 WJ J3 CD�n>iAr, &&n6L)rF1nl?S*/NG S4Scam. Y*/(
i
ZX -L NoP r���i,�° rIv1.SL( /V-A`" 7 Aaom u6 1' -S 4 i�'�a►�-,
OWNER: Name:
Please Type or Print Clearly)
►GIC Phone: 97_
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.: 02 ( 0 v
NOTE: Persons contractin va nregist�redcontractors do not have access p1the uara>z rfitnd
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Publi Sewe
Tanning/Massage/Body Art
Swimming Pools
Well
Tobacco Sales
Food Packaging/Sales
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
DATE REJECTED DATE APPROVED
CONSERVATION
COMMENTS
DATE REJECTED DATE APPROVED
HEALTH
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
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
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 2007
M
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
MOTE: 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 2.2007
Location 1 v( l S
No. 5 Date
:14ORT1y TOWN OF NORTH ANDOVER
OL ►
•
Certificate of Occupancy $
�s�cMusEt� Building/Frame Permit Fee $ 1
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # C
21L2U -
Building Inspector
0
I
CONTRACT TO INSTALL OWENS CORNING BASEMENT WALL FINISHING SYSTEM
Owens Corning Basement Finishing Division (the contractor) hereby submits this proposal to sell and install the Owens Corning Basement
Wall Finishing System and related items as described herein at the residential premises set forth below. This proposal shall not become a
binding commitment unless and until it has been signed by the Contractor and the Customer.
Contractor:
Owens Corning Basement Finishing Systems
a division of Bay State Basement Systems, LLC.
60 Shawmut Road, Canton, MA 02021
Telephone # (781) 821.0060
Facsimile # (781) 821-8552
Federal Tax ID # 14.1855297
Mass. Homte, Improvement Contractor Reg. # 137943
Date
Customer:
Customer NameQI oy/ _( C V_
Street
City. S
Telept
This is a contract between the Contractor and the above named Customer to sell and install the Owens Corning Basement Wall Finishing
System and related items specified herein at the Customer's residential premises identified below:
Installation Premises:
Street Address 5�TLle
City. State, Zip
Scope of Work:
Are Sketches and/or specification sheets attached? yr Yes- ❑ No
'All attachments are incorporated into and become as part of this contract cL
Description of Work/Specifications: /Ill AL �L'�// O�Gu( ?5 S%CZ,'l S n'
j' �Ltn.tg��',7•n�r>iCS ,1�,.,✓�;,v,/ o/r-.� �'�st �n.,S/jf,rJ C�s�r�
%L I'/ G7SL / 6.1>SL _�Af� d✓%Ct%S" Sly in//t
A di4vt/
Ov✓I�, r � �'n3i f' ,��� 7�rr,� �' f,/�nc-. � f%uyT l'li� �it'�
Work Schedule":
Approximate Commencement Date:�7p
Approximate Completion Date: J 26 • �U
"The proposed work schedule is approximate and subject to change
Contract Price:
Total Contract Price: $ z 3 bop t)
Deposit with order: $ •1 ?� JJ
Balance Due: $
Terms: trash /, ash El Finance
(Cash terms ar/e d7eposit, 50% on commencement, 40% on completion)
S ` 7 S . U Due on Commencement
S ! Z UU Due on Completion
❑ Cash heck # .10C?
DO NOT SIGN THIS CONTRACT UNTIL ALL APPLICABLE BLANKS ARE COMPLETELY FILLED IN AND UNTIL YOU FIRST READ
AND UNDERSTAND THE ENTIRE CONTRACT, INCLUDING ANY ADDENDUM ATTACHED HERETO, AS WELL AS ANY ATTACHED
SKETCHES, MATERIAL LISTS OR THE LIKE, AND THE TERMS AND CONDITIONS ON THE BACK OF THIS CONTRACT DOCUMENT.
YOU ARE ENTITLED TO A COMPLETE, FULLY EXECUTED
COPY OF THIS CONTRACT AT THE TIME OF EXECUTION. C/
Witness our hand(s) and seal(s) below on this /—r day of
Bay StateB t S ste s, LLC./Authorized Representative:
7��c�' d"� ocs, Grl 4: ;
Signature atTitle
�-
Print Name
CO tome ***: THIS ¢ONJRA I XHE"E ANY BLANK SPACES
'tiZusto r Signature
�c✓6
Print Name
Customer Signature
Print Name
Contractor may have certain lien rights in the premises until the price is paid in full. You have the right to cancel this contract, without any
penalty or obligation, at any time prior to midnight of the third business day after the date you signed this contract. See the notice of cancellation
below for an explanation of this right.
"'Customer acknowledges receipt of a true copy of this contract which was completely filled in prior to customer's execution hereof.
ACORD. CERTIFICATE OF LIABILITY INSURANCE OP ID $
BAYST-1
DATE(MMIDD/YYYY)
05/24/07
PRODUCER
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Andrew G. Gordon, Inc.
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
680 Main Street
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
PO Box 299
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Norwell MA 02061
Phone: 781-659-2262 Fax:781-659-4725
INSURERS AFFORDING COVERAGE NAIC#
INSURED Bay State Basement
INSURERA Renaissance Chou
INSl1REER B:
Systems , LLC
dba Owens Corning Finished
Basement System
INSURER c.
60 Shawmut Road
Canton MA 02021
INSURER D:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED RAX ED 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. '
LTR
INSR
TYPE OF 14SURANCE
POLICY NUMBER
DATE (MM/DD/YY)
DATE (MMIDD/YY)
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE i
COMMERCIAL GENERAL LIABILITY
PREMISES (Ea ocarence) Z
CLAIMS MADE F-1 OCCUR
MED EXP (Any one person) _
PERSONAL & ADV INJURY $
GENERAL AGGREGATE $
GEN`L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG $
POLICY PERCOT LOC
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT =
ANY AUTO
(Es eccidert)
ALL OWNED AUTOS
BODILY INJURY f
SCHEDULED AUTOS
(Per person)
HIRED NJTOS
BODILY INJURY $
NON -OWNED AUTOS
(Per eccidert)
PROPERTY DAMAGE s
(Per ecddert)
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT S
ANY AUTO
OTHER THAN EA ADCC s
AUTO ONLY: AGG $
EXCESSAIMBRELLA LIABILITY
EACH OCCURRENCE $
OCCUR E1CLAIMS MADE
AGGREGATE i
S
DEDUCTIBLE
$
RETENTION $
$
WORKERS COMPENSATION AND
IJ -
TORY LIMITS ER
A
s �
ANY PROPRIETOR/PARTNEFtIEXECUTIVE PLDv��
AN
WC 0371527
05/ 24/07
05 24
/ / 08
E.L. EACH ACCIDENT $ 1000000
OFFICER/MEMBER EXCLUDED?
E.L. DISEASE - EA EMPLOYEE $1000000
It es describe under
E.L. DISEASE - POLICY LIMIT 1 $ 10 0 O O O 0
SPECIAL. PROVISIONS belay
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
CER "FICA 1 t HULUtK CANCFI 1 ATIAN
MISCET.T.
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
Bay State Basements
for record purposes
DATE THEREOF. THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABIL.RY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
House Account
Awnu 43 t4vvuuo) 0 ACORD. CORPORATION 1988
i"cd1ouiTrizzznnnn*g9e"gu1at. ns and i�ar s
One AshburtorrPlace - Room 1301
Boston. Massachusetts 02108
Home Improvement Contractor Registration
Registration: -137943
Type: Supplement Card
Expiration: 1/29/2009
OWENS CORNING BASEMENT FINISHING-
DANIEL
INISHING DANIEL WALSH
60 SHAWMUT PARK
CANTON, MA 02021 Update Address and return card. Mark reason for change.
Address ` Renewal ' Employment ' Lost Card
SCA1 fl 50M45ros41C 00
i B�rn oolu dd ni�u ti s au tAn a s
Construction Supervisor License
~ LloInse: CS 79893
Tr# 4794
DANIEL F A
488 KENDALL RU..
J
TEWKSBURY,MA01$ A... Commissioner
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The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
600 Washington Street
.Boston, MDQ 02111
www.mass.gov/dia '
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electric ansMumbers
nniine..+ T..F .......st__
Name (Business/Organi7a on/Individual):
Address:
City/State/Zip:
0
s)hW1nL47_ e�
4W /0%/
Phone.#: . 7 9/— jfc?/—C 6
Type of project (required):.`
6. 0 New construction
7. 0-1t.'odeling
8. Demolition
9. ❑ Building. addition ,
10,0 .Electrical repairs or additions
11.0 Plumbing repairs or additions
12.0 Roof repairs
13.0 Other
ung their workers compensation policy information.
t Hamv,:
coeras who su>; :xt this affida-vit indicating they are doing all work and then hire outside contcn_tors must submit a new affidavit indicating such.
+Contractors that check this box must attached showing the name of the
an additional sheet sub -contractors and state whether or not those entities have
employees. If the sub-contractorshave employees, they must provide their workers'
COMP. policy number.
I am. an employer that is providing workers'
information. compensation insurance for my employees. Below is thepolicy.and job site
QQ
Insurance Company Name: LV (/ ;S;9,NC6
Policy # or Self -ins. Lic. #:' �% 03_71fQ Expiration Date:
Sob Site Address: ST City/State/Zip: /U. #0)q C -j( O) 1
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration dad
Failure, to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalizes 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 5250.00 a day. against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investiations of for insurance covera a verification.
Ido hereby ify and th n penalties of perjury that the information provided above is true and correct
Si
• Date: GLS
Phone #: —7 i(% 'fz K)6 U
FOther
only. Do not write in this area, to be completed by city or town official
n:' Pere-duLicense #
use
(circle one):
Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
son• Phone #:
Areyou an employer? Check the appropriate box:
1.97 am a employer with ' 4. Q I am a general contractor and I
employees (hill and/or part-time).
have hired the sub -contractors
2.0 I am a sole proprietor or partner-
listed on the attached sheet
ship and have no employees
'These sub -contractors have
working forme in any capacity.
employees and have workers'
[No workers' comp, insurance
comp• insurance.:
required.]
S. We are a corporation and its
3. ❑ 1 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 ]
*Any applicant that checks box #1 must also fill out the section beiow sho
Type of project (required):.`
6. 0 New construction
7. 0-1t.'odeling
8. Demolition
9. ❑ Building. addition ,
10,0 .Electrical repairs or additions
11.0 Plumbing repairs or additions
12.0 Roof repairs
13.0 Other
ung their workers compensation policy information.
t Hamv,:
coeras who su>; :xt this affida-vit indicating they are doing all work and then hire outside contcn_tors must submit a new affidavit indicating such.
+Contractors that check this box must attached showing the name of the
an additional sheet sub -contractors and state whether or not those entities have
employees. If the sub-contractorshave employees, they must provide their workers'
COMP. policy number.
I am. an employer that is providing workers'
information. compensation insurance for my employees. Below is thepolicy.and job site
QQ
Insurance Company Name: LV (/ ;S;9,NC6
Policy # or Self -ins. Lic. #:' �% 03_71fQ Expiration Date:
Sob Site Address: ST City/State/Zip: /U. #0)q C -j( O) 1
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration dad
Failure, to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalizes 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 5250.00 a day. against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investiations of for insurance covera a verification.
Ido hereby ify and th n penalties of perjury that the information provided above is true and correct
Si
• Date: GLS
Phone #: —7 i(% 'fz K)6 U
FOther
only. Do not write in this area, to be completed by city or town official
n:' Pere-duLicense #
use
(circle one):
Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
son• 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." r
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 Iicense or permit to,bperatte�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 1.52, §25CO) 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(t) 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 youare required to obtain a workers'
compensation policy, please callthe 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 sureto 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
apptcant 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 Qf Industrial Accidents
Ogee of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-7274900 ext.4.06 or 1-877 MASSAFE
Revised 11-X22-06
Fax # 617-727-7749
wwru.mass_govldia