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HomeMy WebLinkAboutBuilding Permit #905-15 - 74 WOODSTOCK STREET 5/11/2015l BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION I �- Permit No#:ga-_Date Received Date Issued: U IMPORTANT: Applicant must complete all items on this page j LOCATION lC dd, 74GVl Pr nt PROPERTY OWNER �nyl f L) t L JACA Print 100 Year Structure yes MAP — :? : PARCEL- 2..7 ZONING DISTRICT: Historic District yes Machine Shop Village 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 E Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer 4 DESCRIPTION OF WORK TO BE PEVOR, D: (q� Ve, c e- O v ""1 j f t�� J 1Dc� \ C� 1 S�--{{��a o k, 5 x i S �2 Identification - Please Typ a or Print Clearly OWNER: Name: cuf Gk 56A K Phone: Address: 7q Wood 6"{6 ck Lo vl dotr— Contractor NamAem 1(-_cx,15+4iCe: Address: V e_ >T l V° VTyt CTov G FYI 11 Supervisor's Construction License: CS_ 076 01 Exp. Date: s (k, Home Improvement License: 10 Exp. Date: 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: $ Z 5 FEE: $ Z Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have accesAtde4Marfund Sianature of Aaent/Owner Signature of contractor 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 ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS i Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes •Planning Board Decision: Comments l Conservation Decision: Comments >r Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Locatea Jb4 Us ood street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS 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 NU I t5 and UA I A - (For department use ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 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/Cross Section/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) Li 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: Building Permit Revised 2014 Location No. Date Check # 2 8 7 � TOWN OF NORTH ANDOVER Certificate of Occupancy $- Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee TOTAL e( � 'Tuilding Inspector I : 4=4 0 0 N 2 LL O Q m L Y Y O LL E +�-+ a N CL V1 0 vai Z C7 Z m C N c 7 LL toY O d' N E U C LL O U of Z z CmC C J d O cr LL O u CL of ? Q V W W h�0 2' NZ U > 0 LL oC O d Z H Q L 7 C LL Z LU oc a NJ � LL 41 i m O Y Q1 N �+ v N O N iI n :� Y •• O �C O t � E Q in F (� W .7:0 Jo Q T. C Oci .3 U) O ** Q O E y J L � O .°0 U) .a J M Cc >_ o vQ c .2 E 0 a o .CLNz 0 0 m An 0 0 c o :v Q •� �0m 4 m `90 c° 0 c �l 00 c ® L L :� •0 �) V m �Liu W O 70 O O %f- U- UO .O , Fn EL u'E c 0 O W L 0 0 V 01 NQ F -j N) O = O t Z- CL0U > I% w E Z W .E L 0 a .m U w The Commonwealth of Massachusetts Department of IndustrialAceidents " 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual): Address: H / `J I V 0;1-v/.C'tata/lin' Are you an employer? Check the appropriate box: Phone #: 1.❑ I am a employer with employees (Rill and/or part-time).* 2.Q I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.0 I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insuranceJ 6.Q We are a corporation and its officers have exercised their right of 'exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 7. ❑ New construction 8. El Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.[] Electrical repairs or additions 12. [] Plumbing repairs or additions 13.E] Roof repairs 14.0 Other, *Any applicant that checks box #1 must also nu our me secuvii Uo V_ �__� ... 5-- " � i policy information. "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 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. r Insurance Company Name: Policy # or Self -ins. Lic. #: U — �� 9 5 Z t Expiration Date/: Q %�' Site Address: (t�'�`� �L Job Si � L, City/State/Zip: /v ' r Its l' " olicy declaration page (showing the policy number and expiration date). Attach a copy of the workers' compensation p Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify n er tl pal and penalties of perjury that the information provided above is rue and correct. Date: Si ature: Phone #: — f %� I /()/S-//5 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=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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia RightFax C3-1 3/24/2015 9:51:03 AM PAGE 2/002 a.:r ?rte rx x�� CFRTIFI(_LlTF ()F 11©RII ITV INSIIR©Nrl= Fax Server DATE (MM/DD/YYYY) wv■ aru�v� T . IFICATE 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 OftPRODUCER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require and endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: PHONE FAX GILBERT INS AGCY INC 137 MAIN STREET (A/C, No, Ext): (A/C, No): READING, MA 01867 E-MAIL ADDRESS: 246WY INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURER A: TRAVELERS INDEMNITY COMPANY OF AMERICA KEEN CONSTRUCTION CO INSURER B: INSURER C: 1175 TURNPIKE STREET INSURER D: INSURER E: NORTH ANDOVER, MA 01845 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS 6 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 CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN M SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADD L SUB R I POLICY NUMBER POLICY EFF DATE (MwDD\YYYY) POLICY EXP DATE (MM0D\YYYY) LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY ACH OCCURRENCE $ DAMAGE TO RENTED DREMISES (Ea occurrence) $ CLAIMS MADE [:] OCCUR. ED EXP (Anyone person) $ ERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: ENERALAGGREGATE $ POLICY � PROJECT LOC PRODUCTS - COMP/OP AGG $ AUTOMOBILE LIABILITY ANY AUTO COMBINEDSINGLE LIMIT (Ea accident) $ ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAB[]OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DEDUCTIBLE - $ $ RETENTION $ A WORKER'S COMPENSATION AND EMPLOYER'S LIABILITY YM UB-999IM582-14 10/08/2014 10/OW2015 X WC STATUTORY OTHER LIMITS ANY PROPERITOR PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? - N/A E. L. EACH ACCIDENT $ 100,000 (Mandatory In NH) E.L. DISEASE - EA EMPLOYEE $ 100,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERAMONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 1600 OSGOOD STREET BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. NORTH ANDOVER, MA 01$45 AUTHORIZED REPRESENT VE The ACORD name and logo are registered marks of ACORD 1966-2010 ACORD CORPORATION. All rights reserved. Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction SuperN isor License: CS -076691 ROBERT A KEEN-` k 12 E WATER ST North Andover EA 01 N45 w Expiration Commissioner 08/16/20155 ,fie CJlie �po�n�xo�rzu�P,crr!,/,l a�C%�Gczdoccc�2uaeLt D Office of Consumer Affairs & Business Regulation ME IMPROVEMENT CONTRACTOR oegistration: Q8383 Type: xpiration: :=::8[1'13%201;6. ; DBA KEEN CONSTRUCTION 71 - Kenneth Keen 1175 TURNPIKE N0. ANDOVER, g � env Undersecretary