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Home My WebLink AboutBuilding Permit #538 - 85 MAPLE AVENUE 3/24/2008Permit NO: 5-3U BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received v'ttyco /a '-V e� SACH Date Issued: " or IMPORTANT: Applicant must complete all items on this page LOCA 4 P&eP_ 14 PROPERTY OWNER li/�L/ r ,�Print i'~/Sf S' Pitta MAP NO: � PARCEL: 0 f ZONING DISTRICT: Historic District Machine Shop Village yes no ves no 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 Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: L121-42 Z, 1- &-1 A 2LE-61a ey Al j7 ) em ( d cat} n Plea Type or—Print rint Clearly) OWNER: Name: � �� t�O F / *S Phone: 61 AL_, Address: CONTRACTOR Name: /T; Gl j ,l /,s Phone: '� fG —io , Address: 6� �C,7� ,�4wa 41?�e ?, Supervisor's Construction License:Exp. Date:' Home �k ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDINGPE1101 AV T: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ /r�(P 0• FEE: $ rvd Check No.: /� ?_,!� Receipt No.: & I C) ( C3 NOTE: Persons contracting with unregistered contractors do not have access to #K guaranty fund of co 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 o Copy of Contract Li 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 o Building Permit Application o 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) Li Mass check Energy Compliance Report (If Applicable) o 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 o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o 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 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 2.2007 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 PLANNING & DEVELOPMENT COMMENTS DATE APPROVED DATE REJECTED DATE APPROVED CONSERVATION COMMENTS DATE REJECTED DATE APPROVED HEALTH COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments, Comments Water & Sewer Connection/Signature & Date Driveway Permit Located at 384 Osgood Street _ FIRE DEPARTMENT Temp Dumpster on site 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 2007 Location Xc r oc-�- m 5 No. ,5Date �aRTh TOWN OF NORTH ANDOVER s s 9 _ Certificate of Occupancy $ Building/Frame Permit Fee $ J�CMUS Foundation Permit Fee Other Permit Fee $ TOTAL $ Check # 2 10 10 Building Inspector CO) m x m m m CA m v y So d 'v O CD 0 Z y 06 O =. C CL ? q O CO) � o o v CD CDCL O Q d CD CCD o CD w w a. C CD r CD CL O CO) CO CD I I 0 0 LiR to m _0. C a d0 ` O N H =00 m C) to 0 dC2 T Z CO) O .0 C ?,_ f/J Oy. �-►dJ. .dr o H T CL �* a cME � �C m d C y ti N o icDm' a co o t ZS m 1 OZ y C2 C � ' 'fl a CO) ao %co Ca oCD CD co r ccD so d) d Cr C pp — —• CL COP m m -P m ft V) CO) H� 2 m: aN gocCN ya �{ 01) F a l CD CD CD Im ate• CD M �' z -- w o o Com" tz o o a 0 G7 r c y o . a 7C n GD O H � H rz CO) x J M M • • omi 0 a O C 3ij z 33 a3?��i y 3rnqpr Ee ISSUE DATE 11/20/2007 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND Samuel J Durso Insurance CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE Agency Inc DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 198 Mass Ave Suite 101 B COMPANIES AFFORDING COVERAGE North Andover, MA 01845 INSURED Arthur Walsh dba A J Walsh & Sons COMPANY A A.I.M. Mutual Insurance Co 55 Pleasant Street LETTER North Andover, MA 01845 3 3 d �y 3 '� w. d 33A r�3333 NJi( man fi i H, '>a 3 ) 3>133r - 4fl 4 i F t y X33 L i G� y %' ...7P1. - 3A FiA>- ni <' A erg R ti Y ..�. .1.. N ,..,.. ,. h �: v3 . 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 MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS DATE (MM/DD/YY) DATE (MMIDDNY) GENERAL LIABILITY GENERAL AGGREGATE O COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG. PERSONAL & ADV. INJURY Q Q CLAIMS MADE Q OCCUR EACH OCCURRENCE Q OWNER'S & CONTRACTOR'S PROT. FIRE DAMAGE (Anyone tire) 0 MED. EXPENSE (Anyone person) AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO ALL OWNED AUTOS BODILY INJURY (Per person) SCHEDULED AUTOS HIRED AUTOS NON-OWNED AUTOS BODILY INJURY GARAGE LIABILITY (Per accident) PROPERTY DAMAGE EXCESS LIABILITY EACH OCCURRENCE UMBRELLA FORM AGGREGATE OTHER THAN UMBRELLA FORM :u. STATUTORY LIMITS » WORKERS COMPENSATION AND OTHER EMPLOYERS LIABILITY X EL EACH ACCIDENT 100,000 HE PROPRIETOR/ A ARNERS\EXECUTIVE FFICIERS ARE: 7014648012007 11/14/2007 11/14/2008 EL DISEASE--POLICY LIMIT 500,000 INCL ® EXCL EL DISEASE--EACH 100 000 EMPLOYEE COMMENTS/ DESCRIPTION OF OPERATIONS OR LOCATIONS: ARTHUR WALSH IS NOT COVERED BY THE WORKERS'COMPENSATION POLICY. i% i; 3 �r q� : r AI thud f�". 3.' Y O ',SER , , ..n.3 3r r v.Y<s.'a$a.).�.„ 3,. %f" 4r ,0' i33�vk, SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE TOWN OF NORTH ANDOVER THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 15 WRITTEN NOTICE TO THE CERTIFICAT OLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION R LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. SUTTON STREET C�k NORTH ANDOVER, MA 01845 UTHORIZED REPRESENTATIVE L he commonweatin of 1vLussucrnu sctta Department of Industrial Accidents Office of Investigations 600 Washington Street Boston; MA 02111 . ,a^Mw•,- www.mass.gov/din Workers' Compensation Insurance Affidavit: Builders/Contractors/Eiectriciaas/Plunalbers Applicant Information Please Print Legibly Name (Business/organization/individual): (�/ !�`l �� Address: City/State/Zip: 41,d Al�l>d Vee /"hone #: ff % 3 7 Are you an employer? Check the -appropriate r1am. 1 _.❑ I am a employer with 4. a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2-11 I am a sole proprietor or partner- listed on the attached sheet t ship and have no employees working for me in any capacity. [No workers'. comp. insurance required.] 3. ❑ I am a homeowner doing all work myself [No workers' comp_ insurance required.] t These sub -contractors have workers' comp. insurance. ❑ 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)_ 6. ❑ New construction 7. ❑ Remodeling 8- ❑ Demolition 9- ❑ Building addition 10.❑ Electrical repairs or additions 11_❑ Plumbing repairs or additions 12. oof repairs 13.❑ Other *Any applicant that checks box #t miust also fill out the section below showing their workers' compensation policy information: f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such lCohtractors that check this box must attached an additional sheet showing the name of the sub-contYactors and their workers' comp- policy information: I ani an employer that is providing workers' compensation insurance for my employees. Below is the.policy and job site information. 1`,,,/ Insurance Company Name: �� .-/ y L 1,A/ 00 Policy # or Self -ins. Lic. #: ?Q� yG 0 Expiration Date: �� U Job Site Address: �� /f✓ / L /' City/State/Zip: �/ 6/)' 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'!he violator:- Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA -for imurance coveragg-verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct: 1-f Oficial use only. Do not write in this area, to be completed by city or town official. City or Town: Perrnit/License # z 0� Issuing Authority (circle one): 1_ Board of Health 2. Building Department 3_ City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6_.. Other ,r'—f—f P.,Cnn- 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 orbuilding 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 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.. Re 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 hould-be returned to the city or town that the application for.the permit or license is being iecjuested, 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 permst/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 (Le- a dog license or permit to bum leaves etc_) said person is NOT required to complete this affidavit- Tic ffidavit 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 CS # 022680 HIC# 103358 ro oml = A. J. Walsh & Sons 55 Pleasant Street North Andover, MA 01845 Proposal Sub d To: � Job Name Address(� Job Location 4 V ` �1 -.)f, 141W %rk'N` irY/� Date Phone # G Wa harahv si ihmit # of 978-688-6737 or 1-866-AJWALSH Job # Date of Plans 19r� Architect We propose hereby to furnish material and labor -- complete in accordance with the abecifications for the sum of: $ Dollars with payments to be made as follows: Any alteration or deviation from above specifications involving extra costs will be Respectfully executed only upon written order, and will become an extra charge over and submitted above the estimate. All agreements contingent upon strikes, accidents, or delays beyond our control. Note — this proposal may be with rawn by us if not acc ted within days. acceptance of Propogar The above prices, specifications and conditions are satisfactory and are ignature hereby accepted. You are authorized to do the work as specified. Payments will be made as outlined above. Date of Acceptance Signature 071 Board or Building Rculations and Standards HOME iMPF VEMENT CONTRACTOR Registtata03358 �t-hi 8 Corporation A. J. VUi1LSH & SOIV� =r f -'t i Wash, �v . ....�..,� ....._....:fir=,•�::' ...::�' c� 'I# n