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HomeMy WebLinkAboutBuilding Permit #795 - 863 WINTER STREET 5/20/2013BUILDING PERMIT 3� ae%,,- .::`' TOWN OF NORTH ANDOVER / APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received l _ Date Issued: IMPORTANT: ADDlicant must complete all items on this LOCA' Print 1 PROPERTY OWNER_ `?4l►kN, Print MAP NO: /14 b PARCEL:�� ZONING DISTRICT: Historic District yes Machine Shop Villaae ves TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial cwAIteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer Identification Identification Please Type or Print Clearly) OWNER: Name: Address -f- W 1-131-g3�1 CONTRACTOR Name: Phone: 7 6 S= 3 I /?: Address: w v � f � �, k� S i G` --" b,-vt v, Supervisor's Construction License: Exp. Date: 0 �a f b� l2f G f!q Home Improvement License: `` 17 Exp. Date: `7 y / ' 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: $ ,0 0 d FEE: $ Check No.: 6� ��l _f Receipt No.: NOTE: Persons contracting with unregistered contractors do not have , Signature. of Agent/Owner Signature of contractor guaranty fu)Ad Plans Submitted ❑ Plans Waived❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE.DISPOSAL Pu$lic Sewer ❑ Tanning/Massage/Body Art ❑ .. .Swimming Pools ❑ Weil ❑ 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 ❑ ❑ COMMEN CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Siqnature f 's 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 Drivewav Permit DPW Town ]Engineer: Signature: Located 384 Osgood Street FIREDEPART�f t,NT - Temp Dumpster on site yes no Located al' 124 Main Street Fire Departine► t-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 foto DANGER ZONE LITERATURE: Yes foto MGL Chapter 166 Section 21A -F and G min.$100-$1000 fine NOTES and DATA — (For department use D Notified for pickup - Date Doe.Building Permit Revised 2010 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 ❑ 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) .. ❑ 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 app. al 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.Buil;iing permit Revised 2012 Location4&a5 (-x 2t -C T No. Date —42 Check # -05v IT 3 / a Building Inspector TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee t$ Other Permit Fee $ TOTAL 26424 Enter construction cost for fee'cal - North Andover Fee Calculation Construction Cost $ 30,000.00 m $ - $ 360.00 Plumbing Fee $ 45.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 45.00 Total fees collected $ 550.00 863 Winter Street 795-13 on 5/20/2013 Kitchen Renovation r L' O J W x LL Q m C L +u_' Y ON LL E acu v In `N (~j d z Z �_ m O O � O LL O OC T O t U _ O LL O a z Z CC G J d O CC C LL 0 a z U V � W O OC N v (n O LL H a H ZLU O w C LL W Q W 0 25 LL O m O z +-+ N N o Y N C � O v 0 •: •Q L CL • 0 :o E Q. L y CD 1+ � O = v � • V N { O O U J m _ 0-0 c �V _ t Q N as .� E 0 .Q O z �_� N _ c'oH L Q CL Qi m 5 m 0 'y _ -0 tm O = _ Q L 12cv �a H O y C 0 O. ) m umlW = -a - O O ti ••2 rn = wLU c --P4. v m OM cn Q- 0.5cn c 2 cco O = O O IL M t N cn _ tm rn m O tm _ .E O N d s 0 z 0 Q J 0 i i m CDz W 0 - LU W CL 0 : U W :a z o J m ce V / U Cl) O U) J t 5' Z W O Ci O z N CD CM ^I, 0 W Q ,}VrA.I �W •� • Y • .. m m O+ d CD 0 O C. a 0 CL �a O c� V J -a �O. O d; U)z � U ci' N 0 11 Grant Street PMA Woburn, MA 01890 Builders, Inc. PH: (781) 608-3113 JOB IOCATION: PROJECT DESCRIPTION: DAVID GIULIANO 863 WINTER STREET NORTH ANDOVER MA, 01845 KITCHEN REMODEL TO REPLACE FOR NEW LAYOUT, INSTALATION OF NEW CABINETS AND ALL APPLIANCES. AND ALL FINISH WORK TO INCLUSED NEW BASE BOARD AND CROWN MOULDINGS. PAYMENTS DUE IN 1/4 PAYMENTS LABOR AND MATERIALCOST: CABNETS AND COUNTER TOP: Q -V -- S 4, p, Ipw HOME OWNER $14,000.00 $16,000.00 TOTAL: $30.000 PAUL M AHLIN CONTRACTOR KITCHEN G BATH REMODELING - NEW CONSTRUCTION - ADDITIONS The Commonwealth of Massachusetts Department oflndustriglAccldie is Office of Investigations 600 Washington Street .Boston, MA 02111 UIV www.mass gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ILA i Address: fl If 1 S City/State/Zip: aJ d' (n� , 01210 Phone #: ` E ( — 6 W — 311 3 Are you an employer? Check the appropriate box: Typo of project (required): l.�i am a employer with � 4 . ❑ I am a general contractor and I 6. [1 New construction ` employees (full and/orpatt-time).* 2. El am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. ?• Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. g• El Building addition [No workers' comp. insurance 5. El We area corporation and its 10.0 Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised their 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.) q ] employees. [No workers' 1311 other comp. insurance required.] '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 tie 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 their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. r ,_ A Insurance Company Policy # or Self -ins. Lic. B L4 Expiration Date: c Job Site Address. - In � L',(� (� . .5 City/State/Zi):_ W OU CK I /� a k U145. Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL o. 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 maybe forwarded to the Office of Investigations of the DTA for insurance coverage verification. I do hereby certlo under the pains andpenalties ofperjury that the information provided above is true and correct. 'hone #• �i - -7 K { " 60 Y_ 3 111 F ` 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 Instruction's 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 ofhire, 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 ofpublic 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. Be advised that this affidavit maybe 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�assachvsPtts Department of Indusidal ,Accidents ofaceofIlvestigatxow • 600 WashiVoa Street Boston? MA. 021 X X TO. # 617-727,4900 ext 406 or 1.-877,7MASSA.FF, Revised 5-26-05 Fax # 617-727-7749 ttFttFitF YNnnn r....s�.a.:.. f----------- Massachusetts �Department of Public Safety "Board of Building Regulations and Standards Const ucti6n Supervisor License: CS -040162 4`\``..s I rti r, � PAUL M AIMIN ,.r 11 GRANT ST, '! WOBIRN MA 01801 w f` ✓'�*� �` Expiration Commissioner 12/06/2014 ° Office of Consnrorrc.•vrz tr� ��r mer Affairs & Busines 'MPs aJrrrr rssr�f 1 ME tOVEMENTCONTR�ICiO�gulation 136313 K xpiration: 7/,11- 2 Type: PAUL AHLIN Individual PAUL AHLIN 11 GPA N I ST. WOBURN MA 01801 P Undcrsecretary� l� '`%C_"ffC " CERTIFICATE OF LIABILITY INSURANCE r DA20/2DD/01 2/20/23 3 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THI CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIE BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZE REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. 'IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject t the terms and conditions of the policy, certain .policies may require an endorsement. A statement on this certificate does not confer rights to tt certificate holder in lieu of such endorsement(s). PRODUCER Saltmarsh Insurance Agency 751 Main Street-MAILADDRSS P.O. Box 458 CONTACT NAME: Susan. Rubin PHONE (781) 729-4615 IFAAI&o (7@1)729-3756 :susan@saltmarshinsurarice.com MM/DD/YYXIPY Winchester MA 01890 INSURED PMA BUILDERS INC 11 GRANT $T INSURER(S) AFFORDING COVERAGE NAIC # INSURER A:Arbella Indemnity Insurance CO. 10017 INSURER B :ACE Grou INSURERC: INSURER D: INSURER E: WOBURN MA 01801 INSURER F: t.1/VtKAhr:S r`CDTICInATG wu uanc�.nr � o� � wn� nnn --- ----- - ICCYIJIVPI IVUMOr-11: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIO INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH TH CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERM: EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 'NSR TR TYPE OF INSURANCE POLICY NUMBER MM/LDIDYIYEYYY MM/DD/YYXIPY LIMITS GENERAL LIABILITY A COMMERCIAL GENERAL LIABILITY CLAIMS -MADE Fx_1 OCCUR 1020010674 2/21/2012 2/21/2013 EACH OCCURRENCE $ 1,000,0 DAMAGE TO REPTE17— --- PREMISES Ea occurrence $ 50,0 MED EXP (Any one person) $ 5,0 PERSONAL & ADV INJURY $ 1,000,0 GENERAL AGGREGATE $ 2,000,0 GEN'L AGGREGATE LIMIT APPLIES PER: JECT F-1 PRO- 7XLOCPOLICY PRODUCTS - COMP/OP AGG $ 2,000,0 $ AUTOMOBILE LIABILITY O aBFNED SINGLE LIMIT�Ea 1,000,0 A ANY AUTO ALL OWNED X SCHEDULED AUTOS AUTOS 0200106742/21/2012 2/21/2013 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ X HIRED AUTOS X NON -OWNED AUTOS PROPERTY DAMAGE Per accident) $ Underinsured motorist BI split $ 20,0 UMBRELLA UAB EXCESS LIAB HOCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ B DED I I RETENTION$ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? a (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS Uebw N/A 4694P98-3-12 /1/2012 /1/2013 $ TWC STATU- OTH- _ E.L. EACH ACCIDENT $ 500,0 E.L. DISEASE - EA EMPLOYE $ 500 01 E.L. DISEASE - POLICY LIMIT $ 500,0 -- ------ .�., �� --u.e, n nwro space is requrrea) Evidence of Insurance (781)942-9071 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. w AUTHORIZED REPRESENTATIVE S Saltmarsh, Jr./SUSA of ACORD 25 (2010/05) ©1988-2010 ACORD CORPORATION. Alltllohts reservec INSn25 mmnnsi m Tha ArY10111 nama anti Inns era rani-arari m2r4e of A(`_non i.