HomeMy WebLinkAboutBuilding Permit #481 - 86 MILLPOND 12/27/2006Permit NO:
Date Issued:
LOCATION,
PROPERTY
MAP NO.:G
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
IMPORTANT: A
a
Date Receivedjj-� � d
must complete all items on this
Print
PARCEL: -Z( ---ZONING DISTRICT:
TYPE AND USE OF BUILDING HISTORIC DISTRICT
TYPE OF IMPROVEMENT PROPOSED USE
❑ New Building
❑ Addition
'9 Alteration --4
'V. Repair, replacement
❑ Demolition
❑ M win relocation
❑ Foundation onl
,FcrRIPTION OF WORK TO BE
u
%One family ��V`)
❑ Two or more'family
No. of units:
❑ Assessory Bldg
❑ Other
YES ❑
Non- Residential
❑ Industrial
❑ Commercial
❑ Others:
kaa2–�=Q
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ation Please Type or Print Clearly) � �1 o
TVL . W� - k C )O
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- - - — - /11 _ 4 _ (ln s J1 10n I i
Address: '10 Ex Date:®I
Supervisor's Construction License: p'
Home Improvement License:
� C � ��y Exp. Date:
ARCHITECT/ENGINEER Name: Phone: L-�/
Address:
N Reg. No. A
FEE SCHEDULE: BOLDING P RMIT: S12.00 PER 1000.00 OF T E TOTAL ESTIMATD C ST BASED ON x125.00 PER SF.
FEE:$
Total Project Cost
44�—
Check No.: ���Y Receipt No.:
Page 1 of 4
J
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
Addition Or Decks
❑ Building Permit Application
❑ Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Crossection/ElevationPian Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
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
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 DEPARTMENTMFORMOS
Page 4 of 4
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/Massage/Body Art ❑ Swimming Pools ❑
Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑
Permanent Dumpster on Site ❑
Private (septic tank, etc. ❑ Electric Meter location to
project
NOTE: Persons contracting with unregistered contractors do not have access to the gfWrantyfund
Signature of Agent/Owner Signature of contractor
Mjf
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑
Stam ed Plans ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
DATE REJECTED DATE APPROVED
CONSERVATION
COMMENTS
❑ ❑
HEALTH
DATE REJECTED DATE APPROVED
❑ �
COMMENTS
r
;FIRE DEPARTMENT - Temp Dumpster on site yes
no
Fire Department signature/date
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
nrivnww De....:.
Buildin Setback (ft.
Front Yard Side Yard
ed Provided Re uired Provides Rear Yard
/ Re uired Provided
Dimension
Number of Stories: _ Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
Wf% rrc , — . — .
iI
Location,ll& n7r�%arr�l
No. 5! Date d
MORTq
TOWN OF NORTH ANDOVER
Of
•
s
• i : ,
Certificate of Occupancy
$
cMus t�
Building/Frame Permit Fee
$ 77,E
Foundation Permit Fee
$ z—
Other Permit Fee
$
TOTAL
$
Check #
19899
_
Building Inspector "�
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SOD 06606F
4
JAMES JAXVORSICI
DBA COASTAL REIiODELLNG
0 A(ADC ST
GROI'LLA.\'D, ILA 01834
Pay ro rh,
Order of
TD Benknorth
MASSACHUSETTS
250
,
o53.7054!2113 ec i
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1:2113705451: 8244043464u� D25
!10000010000,1'
Account: 8244043464
Amount: 100.00
DIN:301011616
i
301 O f t 61 b 20061211-3 00
1 NCLEAR I PIGS 02 056
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SITE -RED LBX: '14,976"—A -UP, 30-4L
Account: 8244043464
Amount: 100.00
DIN:301011616
9/t e -ol
Boar o uil m e la��ns an
g gutan ar s
One Ashburton Place - Room 1301
Boston, Massachusetts 02108
Home Improvement Contractor Registration =
Registration: 151234
Type:. Individual
expiration 5/23/,2008
COASTAL REMODELING
JAMES JAWORSKI �- -- --
70 MAIN ST -- - -- - —
GROVELAND, MA 01834 -------.- ---- - -_
Update Address and return card. Mark reason for change.
^^^ F-] Address ❑ Renewal r_ Employment Lost Card
From: "Merchant, Cindy (DPS)" <Cindy. Merchant@state. ma. us>
To: <JPSKI4347@comcast.net>
Date: Thursday, December 21, 2006 9:54:46 AM
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-- CAPS P#JM
COASTAL REMODELING
Jim Jaworski
70 Main Street
Groveland, MA 01834
(978) 372-9862
Page No. I of 15 Pages
Em
Hem0deling Proposal
ONTRACTO SRims JO 1� I Z(4
JOB NAME / NO.
JOB LOCATION
As Amms-)
ARCHITECT DATE OF
?PANS
l�
APPROXIMATE STARTING DATE APPROXIMATE COMPLETION DATE
This Propo al does of iinclude:- 9
........................ _ .....:......��.. .3 A1_.'i'�i�l t.l: t(r ..... ..._N ................
�►�'1't�]rCt1�111'�t. u 11�1•rcY�1+�1►Z���asZ'.r
All material is guaranteed to be as specified. All work to be com-
pleted in a workmanlike manner according to standard practices.
Any alteration or deviation from the above specifications involving
extra costs will be done only upon a written change order. The costs
will become an extra charge over and above the estimate. This is
toinclude, but is not limited to, hidden damages that are uncovered
during the course of the job and additional work required by local
building inspectors.
All elements of this agreement are contingent upon strikes, accidents
or delays beyond our control. The estimate does not include material
price increases, or additional labor and materials which may be
required should unforeseen problems arise after the work has started.
You, the buyer, may cancel this transaction
at any time prior to midnight of the third
business day after the date of this trans-
action. Cancellation must be done in writing.
Signature
We Propose hereby to furnish material and labor - complete in accordance with
above specifications, for the sum of:
I. -
laymen( to be made as follows:
§ 1A, Q,"'I A,�,2
dollars
0 aug"!
t
�` A RSiI.. C ,�,.. + �:' aid_ ►►
Signature
Note: This proposal
may be withdraw
by us if not accepted within -7— days.
of Proposal: The above prices, specifications and conditions are satisfactory and are hereby accepted. You are
authorized to do the work as specified. Payment will be made as outlined above. F
Date '� Signature
Date
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
a 600 Washington Street
,W
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Larne (Business/Organization/Individual):
Address:
City/State/Zip: Q2.6VELA ) MA 2" Phone .#:
Are you an employer? Check the appropriate box:
1.19 I am a employer with 1
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
!. ❑ 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.
employees and have workers'
[No workers' comp. insurance
comp. insurance.$
required.]
5. ❑ We are a corporation and its
S. ❑ I am a homeowner doing all work
officers have exercised their
myself. [No workers' comp.
right of exemption per MGL
insurance required.] t
c. 152, § 1(4), and we have no
employees. [No workers'
insurance
i�
Type of project (required):.
6. ❑ New construction
7. Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.tg Electrical repairs or additions
I LK Plumbing repairs or additions
12. ❑ Roof repairs
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.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:�Agr f-oyo I)M1 )6rM'_"g GO
Policy # or Self-ins.
®Lic.. #: j(7�� -1 CJ ���(� Expiration Date: 6
Job Site Address: Ub IMiL , QWo City/State/Zip: r, 16ON1601-4 MA 01845
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
Ido hereby cei unde
_rpains and penalties of perjury that the information provided above is true and correct.
n
use
City or Town:
area, to
or town offtciaL
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 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
Fax # 617-727-7749
Revised 11-22-06
www.mass.gov/dia
r
d
r V DAC
q TT
Ian FORD WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (GS60UB-5339C38-2-06)
NEW -06
INSURER: HARTFORD UNDERWRITERS INSURANCE COMPANY
1 NCCI CO CODE: 80411
INSURED: PRODUCER:
JAWORSKI, JAMES DBA NORWOOD INS AGENCY INC
COSTAL REMODELING 293 MAIN STREET*
70 MAIN ST GROVELAND MA 01834
GROVELAND MA 01834
Insured is AN INDIVIDUAL
Other work places and identification numbers are shown in the schedule(s) attached.
2. The policy period is from 07-04-06 to 07-04-07 12:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
m
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in
item 3.A. The limits of our liability under Part Two are:
m—
O Bodily Injury by Accident: $ 100000 Each Accident
Bodily Injury by Disease: $ 500000 Policy Limit
o.
Bodily Injury by Disease: $ 100000 Each Employee
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
m
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A
N
O
D. This policy includes these endorsements and schedules:
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
0
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Q Plans. All required information is subject to verification and change by audit to be made ANNUALLY.
DATE OF ISSUE: 08-04-06 RM ST ASSIGN: MA
OFFICE: ORLANDO DA HTFD 05G
PRODUCER: NORWOOD INS AGENCY INC 237LJ
008356
I�nnTFoan
WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
EXTENSION OF INFO PAGE—SCHEDULE WC 00 00 01 ( A)
POLICY NUMBER: (GS60UB-5339C38-2-06)
INSURER: HARTFORD UNDERWRITERS INSURANCE COMPANY
INSURED'S NAME: JAWORSKI, JAMES DBA
COSTAL REMODELING
80411 —MA
DATE OF ISSUE: 08-04-06 RM ST ASSIGN: MA SCHEDULE NO: 1 OF LAST
008357
RATE BUREAU
ID: 000308271
PREMIUM BASIS
ESTIMATED
RATES
ESTIMATED
TOTAL ANNUAL
PER $100 OF
ANNUAL
CLASSIFICATION
CODE REMUNERATION
REMUNERATION
PREMIUM
LOCATION 001 01
FEIN 204416444 ENTITY CD 001
JAWORSKI, JAMES DBA
COSTAL REMODELING
70 MAIN ST
GROVELAND, MA 01834
CARPENTRY NOC
5403 IF ANY
16.48
CARPENTRY—DETACHED ONE— OR TWO
FAMILY DWELLINGS
5645 40000
9.03
3612
CARPENTRY—DWELLINGS—THREE
m
m-
STORIES OR LESS
5651 IF ANY
9.03
0
0
0
m
m
m
m
0
------------------------------------------------------------------------------------
0
MERIT RATING/EXPERIENCE MOD: NONE MODIFIED PREMIUM $
NONE
TOTAL ESTIMATED
ANNUAL STANDARD PREMIUM
3612
EXPENSE CONSTANT(0900)
284
a
0.0300 FOREIGN
TERRORISM / TRIA (9740)
12
4.19% MA WC SPECIAL FUND AND TRUST FUND
151
TOTAL ESTIMATED PREMIUM
4059
DEPOSIT AMOUNT DUE
4059
DATE OF ISSUE: 08-04-06 RM ST ASSIGN: MA SCHEDULE NO: 1 OF LAST
008357
From: Kelly At: Norwood Insurance Agency, Inc. FaxID: Norwood Insurance Ag To: James Jaworski Date: 12/26/2006 06:25 AM Page: 2 of 3
OP ID K
ACO N. CERTIFICATE OF LIABILITY INSURANCE JAWORSK
DATE (MMIDD/YYYY)
12/26/06
PRODUCER
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
LTR
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Norwood Ins. Agency, Inc.
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
293 Main Street
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
LIMBS
Groveland, MA 01834
Bhone:978-372-5921 Fax:978-521-0242
INSURERS AFFORDING COVERAGE NAIC#
INSURED
INSURERA: National Grange Mutual
James J. Jaworski DBA
Coastal Remodeling
70 Main Street
Groveland MA 01834
INSURER B: Hartford Underwriters — VA
INSLIRERc
INSURER D:
INSURER E:
COVERAGES
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR
NSR
TYPE OF INSURANCE
POLICY NUMBER
FQLK;Y"1-E�;1IVEPOLICY
DATE (MMIDD/YY)
EXPIRATION
DATE (MM/DD/YY)
LIMBS
GENERAL LIABILITY
EACH OCCURRENCE $ 1000000
A
COMMERCIAL GENERAL LIABILITY
PREMISES (E occurence) $
aAIMS MADE [] OCCUR
MED EXP (Any one person) $5000
PERSONAL &ADV INJURY $ 1000000
X Business Owners
MS052489
05/02/06
05/02/07
GENERAL AGGREGATE $ 2 0 0 0 0 0 0
GENL AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG $2000000
POLICY JJEET LOC
AUTOMOBILE
LIABILITY
ANY AUTO
-
COMBINED SINGLE LIMIT
(Es accident) $
ALL OWNED AUTOS
SCHEDULED AUTOS
BODILY INJURY
(Per person) $
HIRED AUTOS
NON -OWNED AUTOS
BODILY INJURY $
(Per accident)
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT $
OTHER THAN EA ACC $
ANY AUTO
H
AUTO OM. Y: AGG $
EXCESS/UMBRELLA LIABILITY
EACH OCCURRENCE $
OCCUR O CLAIMS MADE
AGGREGATE $
$
DEDUCTIBLE
$
RETENTION $
B
WORKERS COMPENSATION AND
EMPLOYERS'
ANY PROPRIETOR/PARTNER/EXECUTIVE
6S60UB-5339C38-2-06
07/04/06
07/04/07
I TORY LIMITS ER
E.L. EACH ACCIDENT $ 100000
E.L. DISEASE - EA EMPLOYEE $100000
OFFICERIMEMBER EXCLUDED?
It yes, describe under
SPECIAL PROVISIONS below
E.L. DISEASE -POLICY LIMIT $500000
OTHER
DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES /EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
TOWNOFA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
Town of North Andover IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
Building inspector REPRESENTATIVES.
North Andover MA 01845 AUTHORIZED REPRESENTATIVE
ACORD 25 (2001/08) 0 ACORD CORPORATION IAAA