The URL can be used to link to this page

Home My WebLink AboutBuilding Permit #590 - 75 BRIDLE PATH 5/6/2009 BUILDING PERMIT o� 14O C. "�ti TOWN OF NORTH ANDOVER o ` p APPLICATION FOR PLAN EXAMINATION Permit NO: l/ Date Received ��°�gATED►�"cy �SSACHUS�� Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION S`,A lrF'c Pnnt PROPERTY OWNER Print MAP NO.1 PARCEL: ZONING DISTRICT. Historic District yes no !Machine Shop Village ye no I TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial air, replaceme Assessory Bldg Others: emo i ion Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION F WORK O BE PREFO1a I enti6c tion Please Type or Print Clearly) OWNER: Name: ��°��-`'' ��` <C'�y'/J• Phone: Address: CONTRACTOR Name: % ' �fI r�/��, Phone: ` y Address:_ Supervisor's Construction License: /0/0 70 Exp. Date: Home Improvement License: 74 Exp. Dater ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ /e2 FEE: $ Check No.: Receipt No.�2 NOTE: Persons contracting with un on ctors do not have access to the guaranty fund w 8 ig_nature of Agent/Owner Signature of contractor - Location 4 ! �2� � %14— No. 1 —No. A Date NORTH TOWN OF NORTH ANDOVER � n i Certificate of Occupancy $ ss� •'+ �cA,..Hu•Eta Building/Frame Permit Fee $ ss Foundation Permit Fee $ Y' Other Permit Fee $ TOTAL $ Check # �1�y 2 2 U u 4 �"-- Building Inspector 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS 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 384 Osgood Street -FIRE .DEPARTMENT . Temp Du_rnpste_r on sit,e yes no L&cated:-at 12 .Mam Street p "' FtreDepartment signaturefdate - CON�TS T� "_ 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 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 o 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 FORTH Town of ? t" 4 L Andover 0'? 0 O ]� - = dover, Mass., T Q LAKE r COCHICHEWICK V �qs RATED BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System THIS CERTIFIES THAT............6.410.14�........6.W. ................... BUILDING INSPECTOR """"':.... Foundation has permission to erect ........... 0 .. buildings on 7,� !� ... .. ................. Rough .... .... .. ........ .... to be Occupied as.....(5.... .... ...... .. Chimney .................................................................................................... provided that the person opting this permit shall very respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU ON STS Rough .................... .................................. Service BUIL CTOR Final Occupancy Permit Required to Ocmpy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. • • Page No. of Pages ,gill, A Company You Can Count Ont 7 EDEN GLEN AVE. DANVERS, MA 01923 (970) 423-3881 c Fist (978) 774-1520 ftV,VjrradCrkcdacn.fa PROPOUBMITTED TO PHONE DATE ;�(,, V\ J S'C� STREET JOB NAME CITY,STATE and \1ZIP CODE JOB LOCATION �1t1 t oJ e kA ct ARCHITECT DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for: ADk Jct �� `�-�� t �'C� - t -�V\tA v C�A` e�S. J \� BUJ<-'(c� c{� �`r,� \��.yJ<C 'ces�.< C'_A�� 1\ C ��kit c\ PCAoeS . v�,�C- Cx, 5 J We Propose hereby to furnish material and labor—complete in accordance with above specifications, for the sum of: 0 dollars($ Payment to be made as follows: Dc ° All material is guaranteed to be as specified. All work to be completed in a workmanlike ✓ manner according to standard practices. Any alteration or deviation from above specifications Authorized �t involving extra costs will be executed only upon written orders, and will become an extra Signature charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado and other necessary insurance. Our Note:This proposal may be workers are fully covered by Workman's Compensation Insurance. withdrawn by us if not acreed within days. Acceptance of Proposal —The above prices,specifications and conditions are satisfactory and are hereby accepted.You are authorized to do the Signat A&Z work as specified.Payment will bead as outlined above. y �/ Date of Acceptance:� Signature Iw The Commonwealth of Massachusetts kj ! Department of Industrial Accidents Office of Investigations 600 ff rashingtnn Street Boston, MA 02111 www_nms govIdaaa . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers APRliumt Information Please Print LeQibl Nami Business�Or ) t' �JZa moi. ( ganirdtion/Individual ; Gym l //� a & Address: 17 City/State/Zip: �/�'� -�1' . Phone#: . � Are you an employer?Cheektthe appropriate box: I.9 I aro a em to er with Type of proles(requires: P Y � 4. ❑ I am a general contractor and[ � ❑- employees(full and/or part-time).* have hired the sub-contractors b. New construction 2.[] I am.a.sole proprietor or partner_ listed on the attached sheet x 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me.in any capacity, workers' comp.insurance. [No workers'comp.insurance 5. ❑ We are a corporation.and its 9 ❑Building addition 1 required.] officers have exercised their 0.0'Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself..[No•workers'comp. c. 152, §1(4),and we have no 12. Roof insurance_required.].t repairs �N ] .employees. [No workers' I3.7.0ther comp. insurance required.] r *Any applicant that checks boz#I must also fill out the section below showing their workets'compensation 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 crams of the sub-contnictors and their xrorkers'ca ffi Finita it sting ion. lam an employer that is prondtng:workers'compensation insurance for my employees: Below is(he pow,andjob site . information. / Insurance Company Name: Policy#or Self-ins.Lic.#_ rio ZZ.L1�—G )/�Z� 6 _ Expiration Date: O Job Site Address: City/state)zip. Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration dated . Failure to secure coverage as requited 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, 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. 1 do herebyc oder t nd erIoWas of perjwy that the inforn"on provided ab ve itrr� s e sour correct Siwe: ,/C/1w/ / q Date: Phone#: Officiat 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/Tovvn Clerk 4.Electrical InspectoEIrmaper-tor 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 ormore of the'foreping engaged in a joint enterprise,and includirlkg 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 an 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 insumnce'covemge required." Additionally,MOL 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 inumce requiremerrts of this chapter have been preserrmd 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)mind 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. Ifan 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,notthe 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 Departrnent at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line, City or Town Officiais 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 lnvestigations has to contact you regarding the applicant. Please be sure to fill in the permitAicense number which will be used as a reference number. In addition,an applicant that must submit multiple permit9icense 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 ofthe 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.When 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#617-7274900 eat 406 or 1-8.77-MIASSAFE Revised 5-26-05 Fax#617-727-7744 www.mem.gov/dia 3 g [ : c.: s � nu 7s_ ',`�,fir ^. moi` a %4 s s � { H �� :u• " � �Y �> � °.��,mom��.. 1 5 M. a Ys � r � 5 hezi7— 7777Zz - L •.3 "fie'4� - � a' - -}�}. .r neper .-._. ^FS 3 L - 4-1 1 s- ev in }� t 1 r: •r v; t s rw „ 7� 77777 4 `+� :, 5106/2000909 AC-ORP. CERTIFICATE OF LIABILITY INSURANCE 0M/DD 05/0 PRODUCER (978) 927-8420 THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION Lauranzano Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 107 Dodge Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Beverly MA 01915- INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A:Zurich Scott Girard INSURER B: INSURER C: 7 Eden Glen Avenue INSURER D: Danvers MA 01923— INSURER E: COVERAGES 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 IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE(MMIDD/YY) DATE IMM/DDIYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE S COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $ CLAIMS MADE F�OCCUR >' MED EXP(Any oneperson) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY JECT LOC AUTOMOBILE LIABILITY , COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS I BODILY INJURY SCHEDULEDAUTOS (Per person) $ HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE (Per accident) $ GARAGELIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION S A WORKERS COMPENSATION AND 62ZUB-0718L21-5-07 07/18/2008 07/18/2009 X I TORY LIMITS OER EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER[EXE'CUTIVE E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE$ 100,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLESfEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Building Inspector EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT City of North Andover FAILURE TO DO SOS LL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGEN R REPRESENTATIVES. AWITIORIZED REPR NTATIVE North Andover MA 01880- h/ ACORD 25(2001/08) ` ®ACORD CORPORATION 1988 ft_-INS025(mosym ELECTRONIC LASER FORMS,INC.-(8 3 -0545 Page 1 of 2