HomeMy WebLinkAboutBuilding Permit #459-13 - 78 SUTTON STREET 12/10/2012r/
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received 1 Z 1 O I Z
Date Issued: 1 V1 I L11 I V
IMPORTANT: Applicant must complete all items on this page
LOCATION' �2&,ea;;2 K -S
PROPERTY`OWN ER,. / r�� '� Z L✓ ,o
v Print' 100 Year,Old-St[ucture yes nog
MAP NOJ) 12,. .PARCEL.M7-2 ZONING DISTRICT. Historic. District yes.. no
Machine; Shop. Village yes, o
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
❑ Two or more family
❑ Industrial
%iteration
No. of units: q
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septic ❑ Well,
❑,.Floodplain ❑ We- tlands.
❑ Watershed, District
❑ Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED: 1
OWNER: Name:
Address:
CONTRACTOR. Name: -
n Please Type or Print rly)
asoPhone
Address: ) %_.. 722 n..o�G,
Supervisor's Construction License: X/ z� Exp. Date:
Home. Improvementl
IN
ARCHITECT/ENGINEER Phone:
Address:
Reg. No.
FEE SCHEDULE. BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST ASED ON $125.00 PER S.F.
Total Project Cost: $ 3-5-0 ®� - FEE: $
Check No.: Receipt No.: aLa 0 2IC4�z
NOTE: Pers ns contracting with unregistered contractors do not have access to the guarantyfund ,
Si
Signature
gnature of Agent/OwnerAr
'of contractor
;:.
_ 1
Plans Submitted ❑ Plans Waived ❑ Certified Piot Plan 11 Stamped Plans ❑
s
a
It
4
Type of Sewerage Disposal - Public'Sewer
Type of Water Supply - Town Water_
Septic Tank.
Well
COMMERCIAL SIGN OFFS
DPW: Approved Rejected
Engineering: Driveway Approved Rejected
Comment
Fire Department: Review
124 Main Street
Comment
_ Planning Department
Comment
Approved Rejected
Approved Rejected
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date
DPW Town Engineer: Signature:
Locaiea ou4 us ooa bireei
FIREDEPARTMENT'- Temp Qumpster,on site yes no
Located at 124 Maini Street
Fire: Department,signature/date.
COMMENTS,
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF
_ Historic District:
Approved
Rejected
— Subdivision:
Approved
Rejected
Water Shed:
Approved
Rejected
Health:
Approved
Rejected
_ Conservation:
Approved
Rejected
Comment
COMMERCIAL SIGN OFFS
DPW: Approved Rejected
Engineering: Driveway Approved Rejected
Comment
Fire Department: Review
124 Main Street
Comment
_ Planning Department
Comment
Approved Rejected
Approved Rejected
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date
DPW Town Engineer: Signature:
Locaiea ou4 us ooa bireei
FIREDEPARTMENT'- Temp Qumpster,on site yes no
Located at 124 Maini Street
Fire: Department,signature/date.
COMMENTS,
Permit NO:
Date Issued:
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
IMPORTANT: Applicant must complete all items on this page
LOCATION!
PROPERTY OWNE.R,-
P. [int 100 Yek old Structure yes Oo..
MAP'NO: PARCEL ZONING DiSTIRICT. _._ Historic District' yes nog
Machine_ ShopVillage yes., no,,.,
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
0 Addition
0 Two or more family
❑ Industrial
❑ Alteration
No. of units:
0 Commercial
❑ Repair, replacement
❑ Assessory Bldg
0 Others:
0 Demolition
❑ Other
[].Septic.,, ❑Well¢
:0 Floodplain D Wetlartds,
❑ Watershed: District
❑':Water/Sewer,
DESCRIPTION OF WORK TO BE PERFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
Arlrlracc-
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: $ FEE: $
Check No.: Receipt No. -
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
�Slg'n to ure•of�Agent/Owner��.3 �w' :�''�: e'Signature1of co�ntractor� '� r _ - " µgl
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
v
f
1
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ `
TYPE OF SEWERAGE DISPOSAL
'a Siqnature.'
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
'a Siqnature.'
COMMENTS L4)cck
AEALTH - - -. on
Si-qnature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision:
Com
Q Water & Sewer Connection/Signature &Date Driveway Permit
V DPW 'Town Engineer: Signature:
'FIRE -:DEPARTMENT - Temp Dumpster on site yes
Located at 124 MainStreet
Fire Depart menfssignatureldate
COMMENTS
Dimension
Number of Stories:
Total land area, sq. ft.:
Total square feet of floor area, based on Exterior dimensions.
ELECTRICAL: Movement of fleeter 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 2010
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
o 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
o 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 appal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be subm'ated with the building application
Doc: Doc.Building Permit Revised 2012
Location N ! `
No.
-469
Date 12 I
TOWN OF NORTH ANDOVER
Certificate of Occupancy $ ND
Building/Frame Permit Fee $'� ,
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
A
Check #
26026 0 --.Building Inspector
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Massachusetts -Department of 'Public Safeh
Board of Building Regulations and Standards
Construction Supervisor License
License: CS 48040 st
TgbEUSZ DOWGIERT
17& BRADY AVE k,
SALEM, NH 03079 -
,y-15� Expiration: 10/29/2013
Commissioner Tr#: 5561
The Commonwealth of Massachusetts
Department of Industrial Accidents
Ii Office of Investigations
-1 ,-�;..��; 1 � .ff g
1 °�'?U i 600 Washington Street
9lil; : _�
VIN, 1f �``v` Boston, MA 02111
°'f f www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print'Leaibly
Name (Business/Organization/Individual): 1 )1.:2�� r f �(� 2
Address:
City/State/Zip: ,_ �r , ��-�'/"� Phone #: �j' 2,C E`__,�"3 c
Are you an employer? Check the appropriate box:
1. I ama. employer with t "' j
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I am: a sole proprietor or partner-
listed on the attached sheet. #
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ I ain a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.]
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roofrepairs
13.❑ Other
*Any applicant that checks box #1 must also fill out the section below showing 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 sub -contractors acid their workers' comp. policy information.
1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. I
Insurance Company Name:.
!! i,4 _ L l.�
Policy # or Self -ins. Lie. #: Q C-9 C s—�. `7 % Expiration Date:
Job Site Address: % " i T CLZ 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 maybe forwarded to the Office of
Investigations of the DIA for insurance•coverage verification.
1 do hereby certify under the pains and penaltiespeijury that the information provided above is true and correct
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
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 -contractors) name(s), address(es) and phone numbers) along with their certificate(s) of w
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the j
members or partners, are not required to cavy 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 confinnation 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 pen -nit 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' III
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 pennit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple-pen-nit/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 marred by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future pen -nits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or pen -nit 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 Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MA.SSAFE
Revised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia
03/23/2012 14:05 9786833147
r_f4%M U41 C"
4 CERTIFICATE OF LIABILITY INSURANCE DAM (MM/DDYV Y)
3/23/:
TMS CERTIFICATE IS ISSUED AS A MATTER OF INFORIIIIATION ONLY AND CONFERS NA RIGHTS UPON THE CERTIFICATE HOLDER IM
CERTIFICATE DOES NOT AFFIFNAIMLY OR NEGAMMY AMEND, EXTEND OR ALTER THE CO MPAGE AFFORDED BY YHE POLICIES
BELOW. THS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT W MEEN THE ISSUING IMURER{s), ALITHORIZED
REPRESENTA-MME OR PRODUCER, AND THE CERTIFICATE HOLDER,
terms and cGlndifions airthe ppilcK CerRaiR policies may require an endorsemeltt A gatement On this certifi9ate does nal canfar righ14UWL &V
ts to the
certificate holder in frau of such eroorsemen 81.
PRODUCER NCONTACT
M. P, Roberts insurance Agency NAME:10 1_-
1060 Osgood
Street
North Andoviar, MA 01945 s:
tNSURI;RfS1�iFFDRp_ IAC c0_VERgtpE NAICq
IMRER.A� Q.�t4.. u41
INSURED RERa;Guard insurance_- -
nolavG2ERT CONSTRUCTION CC). , INC INsu>9o:
�
616 3SSEX STREET LWRR2R D • -
LAwR13NCz, MA 01841 L�LNSjR1_RE;
nHv '-' Inc rVL.yi rGml%ju
INDICATED. NOTIAATHSTANDING ANY REQUIREMENT, TERM OR CQNOIT6 OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE MUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONCITIONS OFSUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
.. A� . B _ . . ........ .. .._. R LICA F P F .._._.._.._-.. .
TR' .p�
1'YREOPINBURIWCE P LY � 1Y GIYYYY .... ._. LA fi
py oENariAi.dueeiLrrr CMP9151606 3/23/12 3/23/x3 EACMOCCURRENCE 91 1,,000•COI
X cDMMHRCIALI'aENErIgLL648aITY DCMISEit�A °naal s 100.00,.t
G6+41MSaV1ADE OCCUR I MED OP tAruerw A_.—I rc M nnv
LAGGRtGATG LNTAPPLf6S PEPe
ANY A UTO
ALLOWNEO SCHEDULED
AUTOS AUTOS
nIRE0aUT08 _ AIITOSEO
PRODUM . COMP/017 AGG
a
B
BODILY INJURY (Per peman) S
BODILY INJURY (Per ecmIdent) S
FR
ant
�gUA3 �[ OCCUR
A u10'IZ ?� C[JP9142034 3/23/12 3/231
E=9691.Uka Manse .u. �
H bWRIKEM COMPEMIATION
AND EMPLOYERS' LMMILITY ;ucwC122432 iD/2
NI
E
DESCRIPTION OF OPERATIONS f LOC MNS I VENICLES (Adaeh ACOFM 909, Add WM R Mft 3d-Atla, if mora apaee ImmgdMd)
70VZR-TNG OPER&TIONS OF THE RAMI) INSURED AS REQUIRED 9'OR WORK PERFORMED AT HERITAGE PLACE
239 SOUTH UNION STREET LA,MmNca. MA -
3ERITA3E PLA(=,, LLC .AM OZZY PROPERTIES, INC. ARE LIS'T'ED AS AN AtOZTIONAL INSURED
HERITA..GE PLACE, LLC SHOULD ANY OF THE ABOVE MaCRIBED POLICIES BE CANCELLED 1100ir
C/O OZZY PROPERTIES, INC. THr; EXPIRATION DATE THEREOF. IMICE WILL BE GEWEFfE4 N
A�ORQANCE WITH THE POLICY PROV►SIOMB.
1600 C'SGOOD STREET
NORTH ANODVER, MA 01845 AUTNORIZEDREPRESENTATNE
ACORD 25 {Z07 DIO$) F1988The ACORD name and logo are registered mark of ACORD RD OORPORATI4N, A!i rights fre�rved.
Phone: Fax:
E -Mail:
Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
$ 35,000.00
m
$ -
$
420.00
Plumbing Fee
$
52.50
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
52.50
Total fees collected
$
625.00
72-78 Sutton Street
459-13 on 12/10/2012
Interior Renovations