HomeMy WebLinkAboutBuilding Permit #711 - 81 STAGE COACH ROAD 6/2/2008BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued: --L- l Oi--'
IMPORTANT: Applicant must complete all items on this page
LOCATI
PROPEL
MAP NO
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PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no,
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One family
Addition
Two or more family
Industrial
Alteration L/
No. of units:
Commercial
Repair, replacement
Assessory Bldg
Others:
Demolition
Other
Septic Well
Floodplain Wetlands
Watershed District
Water -gwer
DESCRIPTION OF WORK TO BE PREFORMED:
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Identification Please Type or Print Clearly)
OWNER: Name: PEW 0,2151m,4J Phone: 9l� 7qf /
Address: &a")
CONTRACTOR Name:U,6js [_ iii AIRY- U Phone: `moi -fir l-+ Y
Address 0lu� +Z i
- _
Supervisor's Construction License 7041 Exp. ` Date:
Home Improvement License: 13 V3 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: $ 3 FEE: $
Check No.: Receipt No.: i q
NOTE: Persons contracting p rth nr%e fV cors do not have acces to the gr�a� y fund
//
Signature of contracr ,� /�
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
L3Certified 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
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
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
r
HEALTH Reviewed on Signature
c -
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 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
NOTES and DATA — For department use
❑ Notified for pickup - Date
Doc.Building Permit Revised 2008
Location
No. Date a ��
h
N°ITh TOWN OF NORTH ANDOVER
° Certificate of Occupancy $
Building/Frame Permit Fee $
�cHus
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
2, 98
Building Inspector
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www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): 61'1 j 64jme
Address: 66/��,� �G
City/State/Zip: �,A/.10 ?n)} 07.621 Phone #: `7V
Are yo an employer? Check the appropriate box:
1. I am a employer with 4. ❑ 1 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 am a homeowner doing all work right of exemption per MGL
myself. [No workers' comp. c. 152, § 1(4), and we have no
insurance required.] t employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. [ -modeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
I I.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
*Any applicant that checks box # I 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.
am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: ;S7Z f
Policy # or Self -ins. Lic. #: tt% /) Expiration Date: A__2_ i{
Job Site Address: o S719`66 c~ 4434 � City/State/Zip: A) A✓1 Y,6C /%r olgq ,--
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.
/ do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date:
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 #:
The Commonwealth of Massachusetts
I
Department of Industrial Accidents
Office of Investigations
'. a PV iu J
600 Washington Street
M ,
11 "
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): 61'1 j 64jme
Address: 66/��,� �G
City/State/Zip: �,A/.10 ?n)} 07.621 Phone #: `7V
Are yo an employer? Check the appropriate box:
1. I am a employer with 4. ❑ 1 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 am a homeowner doing all work right of exemption per MGL
myself. [No workers' comp. c. 152, § 1(4), and we have no
insurance required.] t employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. [ -modeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
I I.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
*Any applicant that checks box # I 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.
am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: ;S7Z f
Policy # or Self -ins. Lic. #: tt% /) Expiration Date: A__2_ i{
Job Site Address: o S719`66 c~ 4434 � City/State/Zip: A) A✓1 Y,6C /%r olgq ,--
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.
/ do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date:
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 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. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26-05.
www.mass.gov/dia
AC—ORP. CERTIFICATE OF LII
PRODUCER (781) 659-2262 FAX: (781) 659-4725
Andrew G. Gordon, Inc.
690 Main Street
P. O. Hax 299
Norwell MA 02061
INSURED
Bay State Basement Systems, LLC
60 Shawmut Road
Canton MA 02021
ILIT
Y INSURANCE DATE15i2oos '
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
ALLTLER THE IOVERAGEICATE AFFORDED BY THE POLICIS NOT ES EXTEND OR
S BELOW.
INSURERS AFFORDING COVERAGE NAIC #
INSURER A. Star InSuranCe CO an
INSURER B:
INSURER C:
INSURER D:
INSURER E:
RHE POLICIES OF INSURANCE LISTED EQUIREMENT, TERM b CONDITION OF ANY CONTRACT OR HAVE BEE
ISSUOTHER DOCUMENT VNTHHMRES 15CT TO WHICHETHISICERTIFICATE MAY BE ISSUED OR MAY PERTAIN,
THE INSURANCE AFFORDED BY THE POLICIES DESCRIBEO HEREIN 15 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.
Ll VdNMAY-HAYRED LAIMS
pOLICYEF �ECEYE TIONI LIMITS
GENERAL UABIIIfY
COMMERCIAL GENERAL LIABIUTY
CLAIMS MADE 1:1 OCCUP
QESCRIPTION OF OPERATiONSILOCATiONSIYENICLESIEXCWSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
SAWLS USE ONLY
GtK I Irp.0A 1 C r7UWCR
— — — —
GEWL AGGREGATE LIMIT APPLIES PER:
SHOULD ANY OF THE ABOVE DESCRIBED POLIOS OE CANCELLED BEFORE THE
Bay State $asement Systems, LLC
60 Shawmut Rd.
EXPIRATION DATE THEREOF. THE ISSUING INSURER VALL ENDEAVOR TO MAIL
10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. BUT
Canton, MA 02021
FAILURE TO DO SO SHAu. IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
POLICY PR LOC
AUTHORIZED REPRESENTATIVE
G Gordon/CORWIL
AUM94MLE UABILITY
COMBINED SINGLE LIMIT S
(Eq accident)
ANY AUTO
ALL OWNED AUTOS
BODILY INJURY S
(Per P—)
SCHEOULED AUTOS
HIRED AUTOS
BODILY INJURY
(Per accldent)
NON -OWNED AUTOS
PROPERTY DAMAGE _
(Pet xcident)
GARAGE LIABILITY
AUTO ONLY - EA AQCIDENT S
ANY AUTO
OTHER THAN S
AUTO ONLY-. A G S
EXCESS/UM8RELLA IJABIUTY
EACH nccjjRRENerS
AGGREGATE S
OCCUR CLAIMS MADE
S
3
DEDUCTIBLE
RETENTION
TA OTH
A
WORKERS COMPENSATION AND
E.L, EACH ACCIDENT $ 1,000,000
EMPLOYER$ LIABILITY
ANY PROPRIETORIPARTNERIWCUTIVE
OFFICERIIMEMWREXCLUDED?
T4C 0371527
5/24/2008
5/24/2009
E.L.DISFIISE- EAEMPLOYEES 1,000,000
E.LDISEASE - POLIO IMIT I ! 1,000,000
ifyee,descrbeunder
SPECUU- PROVISI
OTHER
QESCRIPTION OF OPERATiONSILOCATiONSIYENICLESIEXCWSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
SAWLS USE ONLY
GtK I Irp.0A 1 C r7UWCR
— — — —
SHOULD ANY OF THE ABOVE DESCRIBED POLIOS OE CANCELLED BEFORE THE
Bay State $asement Systems, LLC
60 Shawmut Rd.
EXPIRATION DATE THEREOF. THE ISSUING INSURER VALL ENDEAVOR TO MAIL
10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. BUT
Canton, MA 02021
FAILURE TO DO SO SHAu. IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
INSURER, ITS AGENTS OR REMESENTATNES,
AUTHORIZED REPRESENTATIVE
G Gordon/CORWIL
ACORD 26 (2001100)
2008-05-1609:02 7816594725 Page 1
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. Home Improvement Contractor Reg. # 137943
Date S t i!F ` V D
Customer:
Customer Name f♦ t°�++ W e l SS y,,, 4 rs
Street Address ` _l la- r D A r� Y d -
City, State,
Telephone ( ) Mel w k 0179— D' %,q 5— It 3.3
This is a contract between the Contractor and the above named Customer to sell and install the Owens Coming Basement Wall Finishing
System and related items specified herein at the Customer's residential premises identified below:
Installation Premises:
Street Address �) a r" 1 P
City, State, Zip SrkYn-P
Scope of Work:
Are Sketches and/or specification sheets attached?XYes- ❑ No
'All attachments are incorporated into and become a part of this contract
Description of Work/Specifications: $ h �(Z I I (.-,eh S pAS Pmen 7 5 ys lrm Per
iJrL,w;n1 r:\i�a(At°f1. It, 61CA It noflPk Ili lOdP, .Ln51411 steel
511dt1561r .t, P)ejrA CZA&rad/Yl,.'kh,5101(564/:°fC a.1\1 Arntsfron5
Cp�1r'rt ih on+;rP PrtJerk rnsfAll rerested enn en{rrel rcrh514U
C0,11t° dc(< , plane^ sak r,j AmnVe r. Remora ctrl AL-A"s
preM C,Ae. ,R ")wC.SA no' useA
Work Schedule**: G
Approximate Commencement Date:
Approximate Completion Date: ( 2 —[to V
"The proposed work schedule is approximate and subject to change
Contract Price:
Total Contract Price: $ J ( % 9cy
Deposit with order: $ -3,5-7s, ❑ Cash )(Check If
Balance Due: $ 3z l -Z((3
Terms: Cash ❑ Finance
(Cash terms—a7re 0 . ddeposit, 50% on commencement, 40% on completion)
$ 17, 8'-�1 (y� Due on Commencement
$ j Y t <, Sp Due on Completion
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.
Witness our hand(s) and seal(s) below on this / (e day of
Bay State Base m t Systeras, LLC./A horizad Representative:
oil
Signaturre—and Title
-1—e
r
Print Name
DO NOIWN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
Cus
r Signature -
E F2 wBesr T qa
`Print Name
Y
stomer 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.
AV,Ttf^C AC f` A Klt%Ct 1 A'rl^ .t
�B i"dff oVVf-WIinga ulat ns and =anar s
g
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 WALSH
60 SHAWMUT PARK :.
CANTON, MA 02021 Update Address and return card. Mark reason for change.
Address "' ` Renewal ' Employment ' Lost Card
s-cA1 0.50µ-05roe-p 90
r B0Ard o[ i3uuu a gfohs as tsa aids
r 4 Construction Supervisor License
Liot ase: CS 79893
Birt: 10/5/1962
/2009 Tr# 4794
rr ;;
DANIEL F WALE h _
488 KE LL Rl&
TEWKSBURY, fVIA Olg 6'-" Commissioner
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