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HomeMy WebLinkAboutBuilding Permit #208-13 - 79 SALEM STREET 9/17/2012 Ct79 b 1� "'IS' 45 6A-7 YI? q 5'H? NORTFI BUILDING PERMIT FAX o� TOWN OF NORTH ANDOVER 13APPLICATION FOR PLAN EXAMINATION : 1 a Permit NO: Date Received �s�''q^reD �SSACMUS�� Date Issued: IMPORTANT Applicant must complete all items on this page Vsk:�`.���f.,rsF 1PRQPER(PPCQIWNER t, M'AP NO w t_ PARCEL s,t Z®NING ` noSTZli SliopV`,illa9e ,:YeS .�no S _ Yr — r . 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: r Demolition Other 'Flood`lain� WWbtla ds� Septic = Welly ` ,P - UUater/Sewers DESCRIPTION OF WORK TO BE PREFORMED: C.C�' y C__e- Cf-LS ST i fncr, W caa,c) Tr` M n C_l V C)e. ct C, S ® lT3 \1J.6\O CJI... kr-�i M iJ� Tln �' - Identification Please Type or Print Clearly) OWNER: Name: �,� ✓env A-^J� l© r- c� Phone: `�� y�Z � � f Address: rvt S► N• Lt,S�-t,,` ` �CONjTR�A ®R CTName Address:l f Su ervisor'.stCoristructiornLicense? n G Y.,�. ,§ f t.. -°'.+s" -r ,,. '.'• -:,�* ai _Ta+^rk Y+ ,3`'�',. '�-. ,F,.-sriv ..r,,'- x '� r o �HomeeImprovementLicense 4r— '.4 ,R�Exp, Date ARCH 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: $ y C _FEE: $ Check No.: Receipt No.: Z NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature,of Agent/Owner Signature of contractor :r 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 o Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract u 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 u 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) r; u 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) o 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 o Engineering Affidavits for Engineered products VOTE: 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 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 a �I HEALTH Reviewed on Signature COMIVENTS 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 Os ood Street FIRE DEPARTMENT, Temp'Dumpster on:site yes ono kv= ',Locate d at•124;Main tf6et a •� _ � " � }" 1 ' � �_� '_ " -'u. Fire�De.artment signature/dateM h � < �_;L'� _`>} ., Ai r Y COMMENTS NORTF/ C/�� o� ies ,6gtio Dimension �y f Number of Stories: Total square feet of floor area, based on Exterior dims. 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) i ' vt i 4 1 i ❑ Notified for pickup - Date I I Doc.Building Permit Revised 2008 I Location NGLO Date • - TOWN OF NORTH ANDOVER e Certificate of Occupancy $ Building/Frame Permit Fee $/zO . Foundation Permit Fee ,, $ Other Permit Fee $ � TOTAL .�$ 1 Check#� 25712 Building Inspector The 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 Applicant Information Please Print Legibly Name (Business/Organization/Individual): C,Cr �i2vq-1�2 / S l -0 Address: X_ City/State/Zip:G%/Y/}M 005 7 c=4 > W_/,� �3 hone 3 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.V j am a sole proprietor or partner- listed on the attached sheet. EJ Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑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 repairs insurance required.]t employees. [No workers' comp.insurance required.] 13T]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 and their workers'comp,policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: P V1' C) Gtr s Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: Z F L c.. City/State/Zip: Ite-' 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 insurance coverage verification. T do hereby cert' under the pains and penalties othat the information provided above is true and correct. Si nature:/ X2 OY Date: Phone#: J �S < 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 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 Revised 5-26-OS Fax#617-727-7749 � www,mass.gov/dia .NORTFf Tow' n of E ndover 0 - . . No. O LAKE h ver, Mass, coc"Ic Kl WIcK g04ATE 0 s U BOARD OF HEALTH Food/Kitchen PER I LD Septic System THIS CERTIFIES THAT ...... BUILDING INSPECTOR .. Foundation has permission to erect . buildings on -" Rough to be occupied as .... ... ....... ...... ...... ....... . .. ... ......4 .......... .. ... ................ .......... Chimney provided that the person accepting this permit shall in ery respect conform to the terms of the application Final on file in 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 CONSTRUCT Rough Service .............. . ...................................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. Smoke Det. SEE REVERSE SODS From:ScottA Simoes FaxID:978.688.7001 Page 2 of 2 Date:9/17/2012 01:07 PM Page:2 of 2 OP ID: SS ACORO` DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 09/17/12 THIS CERTIFICATE 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 OR PRODUCER,AND THE CERTIFICATE HOLDER. 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 an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER 978-688-7000 NAME: AX 98 MassachU etts Avenuey LLC 978-688-7001 a"CNNo Extj: AIC No): North Andover,MA 01845 ADDRESS: Charles S. Randone PRODUCER gRADI-1 CUSTOMER ID q: INSURER(S)AFFORDING COVERAGE NAIC 0 INSURED Joseph Bradish Siding, Inc INSURERA:Travelers Ins. CO. 19038 P.O. Box 448 INSURERB:M2Sa Insurance Hampstead,NH 03826 INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS 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 IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS. SRAIJUL SU1,311 POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MM DDIYYYY MM DDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO B X COMMERCIAL GENERAL LIABILITY SCO060025000501 09/04/12 09/04/13 PREMISES Ea occr rreen unce $ 50,000 CLAIMS-MADE FKOCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 POLICY PRO CT LOC $ JE AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) A ANY AUTO BA7161C76712SEL 08/11/12 08/11/13 BODILY INJURY(Per person) $ ALL OWNEDAUTOS BODILY INJURY(Per accident) $ X SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (Per accident) $ X NON-OWNED AUTOS $ UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y 1 N TORY LIMITS ER ANY PROPRIETORIPARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) SIDING CERTIFICATE HOLDER CANCELLATION NORTH13 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 384 Osgood Street North Andover, MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD C om�nrco.iureaCffz uo ��C'°�a�fu� License or registration valid for individul use only Office offC'"�onsumer Affairs&B mess Regulation HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: ,002097 Type: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Expiration: 6%30/2014 Individual Boston,MA 02116 JOSE H P.BRADISH JR4 Joseph Bradish, _ 7 Moulton Drive/ Box 448;r_ gam— E.Hampstead,NH 03826 Undersecretary Not valid without signature Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-021298 a=' Is JOSEPH P BRADt9H R� PO BOX 448/7 MOULTON° _ E HAMPSTEAD NH 6 i826' J ��� >I i'A`' Expiration - 05/21/2014 Commissioner Page No. of Pages I)raposal JOE BRADISH Vinyl and Aluminum Siding and Roofing 7 Moulton Drive, Post Office Box 448 East Hampstead, NH 03826-2416 Office (603) 893-4599 Residence (603) 382-1868 PROPOSAL SUBMITTED TO PHONE DATE Lrr,(z-v STREET f JOB NAME --? C, .5C,-ke / 5 i 5c-.-�� I CITY,STATE and ZIP CODE JOB LOCATION ARCHITECT DATE OF PLANS JOB PHONE S e We hereby submit specifications and estimates for: b /r 1...C)..�1_¢.. 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S �U v• o� ...................................................................................................................................................................... `Y- ................._ n...c_.�s. ...c�.. ......_............... . ...................................0 .. .t^......................c-.. j....................... - .t'.c:���.......................... We proPOSP hereby to furnish material and labor—complete in accordance with above specifications, for the sum of: OG� i7 7 6 kkR Sof 5 �4A 04' dollars($ ). Payment to be made as follows: 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 Authorizeye:This 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 I or delays beyond our control.Owner to carry fire,tornado and other necessary insurance. roposal may beOur workers are fully covered by Workman's Compensation Insurance. withdrawaccepted within days. Acceptance of Pro Pusttl The above prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized Signature to do the work as specified. Payment will be made as outlined above. Date of Acceptance: Signature