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HomeMy WebLinkAboutBuilding Permit #813 - 858 GREAT POND ROAD 6/2/2011g,;17 Permit NO: 5 Date Issued: _0(0 --1-- Date Z TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received IMPORTANT: Applicant must complete all items on this pate • • a WCIMAVA�� .� / • ..1 Print MAP NO: l 63 PARCEL: 3(,— ZONING DISTRICT: Historic District yes Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 0 One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: emolition ❑ Other -.�. — �® Septics � Well d ®Floodpl<etlands_W - ®I tWatershed Distris 1 Water/Sewers DESCRIPTION OF WORK TO BE PERFORMED: i, (Identification Please Type or Print Clearly) OWNER: Name: T ra C Y Address: CONTRACTOR Name: P b cp s -A CZ i I `) Ca n kd z- iyk&— Phone: 97,f Address: V 11,nr-i cV RoAd �Dx-f�' PL� lam!} O! M1 Supervisor's Construction License: C S J S- 3_Exp. Date: /-1 011 Ir Home Improvement License: Exp. Date: /2/2Z 20 If ARCHITECT/EpIGR&ER SII JvieV a� Frau e -i Phone: Address: 9.5'4 me-si .2wb[ityp r� R! (J/ 16-4 Reg. No. fv FEE SCHEDULE. BULDING PERMIT. $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COS B SED ON $125.00 PER S.F. Total Project Cost: $ f c� e o . A— FEE: $ �, Check No.: Receipt No.: a O NOTE: Persons contracting with unregistered contractors do not have access to the guaranty f #d e 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 MEALTH Reviewed on Signature "OMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes _ 1, Planning Boardbecision: Comments .i Conservation Decision: Comments Water & Sewer Connection/Signature & Date. Driveway Permit DPW Town Engineer: Signature: FIRE DEPARTMENT - Temp Dumpster on site yes Located at 124 Main Street Fire Department signature/date COMMENTS Located 384 Osgood Street no Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. it.: 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 2008mi 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 o 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 MOTE: 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) o 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 o 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: Doc.Building Permit Revised 2008mi Location T /D t� 1X, No. r- Date4--% TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 33 7 L 242-10 Building Inspector /0N The Commonwealth of Massachusetts `f Department of Industrial Accidents 1 �F ci I Office of Investigations Y I F;•:1� els �k 600 Washington Street These sub -contractors have Boston MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print'Legibl� Name (Business/Organization/Individual): �h n IeCr e -S L /12i`` dbu Cocoa r of i on Address: k1 rr Ckt - -a I City/State/Zip: M4 D ` 9 �- / Phone #: 9751-- 4�9 V Are you an employer? Check the appropriate box: I. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ 1 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. XWe 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.] employees. [No workers' comp. insurance required.] Type of project (required): 6. (X New construction 7. ❑ Remodeling 8. M Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.0 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 a»d 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. n' Insurance Company Name: 1q L1a1gJ1 C_ C a tr (.11 er svr a i ce- 0,01 Policy # or Self -ins. Lic. #: IA1 C j b © 10 0 S 0 0 Expiration Date: S /2 Job Site Address: tao- P6 a /moo a City/State/Zip: 11%�^'�i► lQy�UUvet, 04 NX— 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 fonn 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. I do hereby certify under the gains apd penj1des ofpesjury 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 offtciat 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 Informati®n 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 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 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 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 sur&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 pen-nit/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 pen -nits 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 042111 LL Tel. # 617-727-4900 ext 406 or 1-877-NIASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.govldia e 0 Cd 1 E c 'moi••. '�m c ;c o \Y O 16 - CO) N vO v •C= G y' eo m = o .r Ea m E � �• L 4,cc :.:mom r L L � "_ m G G � a = c N ea N m o. o \i v N m m w... y.. O C O Q >� CO) C. G G .m G IS NZ Y. p vO CL O V (:�- V m G ® C s Is m sca em ~ -ra o v eco �.. N �dt G � p y.+ m 'N W .E CS .0 ca CD c y _ d m: O_ -S _ co L- = y �� F— ' .r0.. Cm P U O v 0 Z O s � O i7 CO) O CO) O cc C cc CO)CL w CO CM C O C c m m 0 CD .0 "0 �D O L O C' Q ca O O I I O O Z 4DCL y C ui cl U) LU U) Im W LU 19 W O O A v cz w° w° � U w 1 E c 'moi••. '�m c ;c o \Y O 16 - CO) N vO v •C= G y' eo m = o .r Ea m E � �• L 4,cc :.:mom r L L � "_ m G G � a = c N ea N m o. o \i v N m m w... y.. O C O Q >� CO) C. G G .m G IS NZ Y. p vO CL O V (:�- V m G ® C s Is m sca em ~ -ra o v eco �.. N �dt G � p y.+ m 'N W .E CS .0 ca CD c y _ d m: O_ -S _ co L- = y �� F— ' .r0.. Cm P U O v 0 Z O s � O i7 CO) O CO) O cc C cc CO)CL w CO CM C O C c m m 0 CD .0 "0 �D O L O C' Q ca O O I I O O Z 4DCL y C ui cl U) LU U) Im W LU 19 W CERTIFICATE OF LIAE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLI CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITU' REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the the terms and conditions of the policy, certain policies may require an of certificate holder in lieu of such endorsement(s). PRODUCER 781-729-9200 Scott! & Company Inc. 19 Mount Vernon Street 781-729-9500 P.O. Box 1000 Winchester, MA 01890-8300 Michael R Scotts INSURED Annecrest Building Corp. P.O. Box 290 Boxford, MA 01921 COVFRAGFR t%c0T101t1ATo \II IAAMB1. KtVIJIUN 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 MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRPOLICY LTR TYPE OF INSURANCE POLICY NUMBER EFF MM/DDNYYY POLICY EXP MM/DDNYYY LIMITS GENERAL LIABILITY A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR 3DE2272 07/30/10 07/30/11 EACH OCCURRENCE $ 1,000,00 PREMISES (Ea occurrence) $ 100,00 MED EXP (Any one person) $ PERSONAL & ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY PRO LOC PRODUCTS - COMP/OP AGG $ 1,000,00 $ AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT (Ea accident) $ ALL OWNED AUTOS BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ SCHEDULEDAUTOS HIRED AUTOS PROPERTY DAMAGE (Per accident) $ NON -OWNED AUTOS $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DEDUCTIBLE B RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY OFFICER/MEMBER/ EXCLUDED? ECUTIVE YFRI (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A WC100100300 05/19/11 05/IN 19/12 WC STATU- OTH- X TORY LIMIT ER E.L. EACH ACCIDENT $ 500,00 E.L, DISEASE - EA EMPLOYE $ 500100 E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) rGRTIFICATC uni nro NANDOVE Town of North Andover Building Department 1600 Osgood Street Building 20, Ste. 2-36 North Andover, MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD Massachusetts - Department of Public SafetN Board of Building Regulations and Standards Construction Supervisor License License: CS 34453 Restricted to: 00 T BASIL E CONSTANTINE 81 HERRICK RD BOXFORD, MA 01921 c— J� Expiration: 12/21/201.1, Commissioner Tr#: 10133 ✓ize-Uainin ���� ,,� Officeoi'ConsumerA�frt� �Viness eguaho THOME IMPROVEMENT CONTRACTOR Registration: '412418 Type: Expiration: ,12/22�2012 Private Corporatic ACRE ST BUILQINGnR`P BASIL CONS" 81 HERRICK F BOXFORD, % Undersecretary GENERAL ENVIRONMENTAL SERVICES, INC. \� Diversified Exterminating Co. 930 EASTERN AVENUE • MALDEN, MA 02148 (781)321-4633 (800)343-8278 (781)321-9159 SERVICE ORDER / INVOICE NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: i- rea ea is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 10A. The debris will be disposed of in: Z001S a 0111F �- A (Location of Facility) Signature of Permit Applicant — , / t 9-aoll Date -' . ` rhe D ehis r5SKC 4 ��� Town'of North Andover Building Department 1600 Osgood Street North Andover MA 01845 Tel: 978-688-9545 Fax: 978-688-9542 DEMOLITION OF BUILDING AFFIDAVIT 0,0`t_kORTlj q E D 1 O ?, my o # coc"IC"IWICK 1. 4'0c TED RAit.? �y �SSAC HUS�'L OWNER'S NAME & ADDRESS Dr, a,4414rcDa te/ d j ra c se n LOCATION OF PROPERTY TO DEMOLISH DESCRIPTION ` 7ealke 6ou s e Sowy. 4.- v �' i r -s �oa.r ��c c ®Kly CONTRACTOR'S NAME &ADDRESS O&TkI 'E, CoAAa." vie AA.wecreSt ulkai^6 Core 91 pert- c.k Roar DEPT. OF PUBLIC WORKS - WA DEPAR NT GN -OFFS ) l SEWE DEPT OF CONSERVATION t_k HEALTH DEPT: Septic Well / �?✓ �� G`�� HISTORIC COMMISSION v� �,��2 N1,W 717 GASf---` ELECTRIC TELEPHONE FI Al o ✓` APl9e/e,4134r DUMPSTER - ON/OFF STREET DIG SAFE NUMBER - -- 1 DATE REC'D Doc.form demolition of building affidavit �f BLDG. INSPECTOR J"�d