HomeMy WebLinkAboutBuilding Permit #223 - 87 HAY MEADOW ROAD 9/30/2008 OORTH
BUILDING PERMIT 0 ,.TURD 06�h
TOWN OF NORTH ANDOVER o
APPLICATION FOR PLAN EXAMINATION * _
+ ? e«
Permit NO: Date Received 04
�9SSACHUS t�
Date Issued:
IMPORTANT:Applicant must complete all items on this page
LOCATIONJ7
Print
PROPERTY OWNER ze—,)
Print
MAP NO: b 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 wo or more family Industrial
n No. of units: Commercial
Re air r placement Assessory Bldg Others:
Demolition Other
Septic Well Floodplain Wetlands Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
Zat If 10 iecu F1
Identification Please Typeor Print Clearly)
OWNER: Name: ei9A914RA W EIS S Phone:
Address: 6c
CONTRACTOR 'Name: ( � Phone:
Address: yo k-D
Supervisor's Construction License: d 6 �3 `� Exp. Date:
Home Improvement License:=--=/= 33 Exp. Date: co -.;7.3::;2 /O
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: $ 7 BOG FEE: $
Check No.: U Receipt No.: oc
NOTE: Persons contracting with unregistered contractors do not have access to the guarantKnd
Signature of Agent/Owner Signature of contracto
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
i
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 Siqnature
COMMENTS
HEt4LTH Reviewed on Signature
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 MainStreet
,Fire Department signature/date
COMMENTS -
I
i
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
Building Department
The followingis a list of the required forms to be filled out for theappropriate ermit to in .
qp 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 Pp 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
Location cN
No. 2 2 :9 Date
NORT1y TOWN OF NORTH ANDOVER
Certificate of Occupancy $
9
Buildin /Frame Permit Fee $
snc►N,st
Foundation Permit Fee $
Other Permit Fee $
d.
TOTAL $
Check #
21 5t,8
Building Inspector
1-9'78-687-1443 ' r.,
Sep 18 08 C5: 1p AB CARNES INC
Proposal
30 Arrowhead farm Rd
Boxford, Ma.0'1921 page,1 of 1
973-8B7-1431 or 781-599-9197
Barry Games,fres.
Mass,ijut9ders Licenu WAN= Cva-actors Raglstratior.No 1017:3:3
Fmp;r�z=Subrrril�af Tu:
BARBARA WEISS, : Dere August 26,2008
87 HAY MEADOW RD '10D Nam
NORTH ANDOVER,MA 31645-1405 Jou iwoc Om SAME
97686-3035 `Nosy!Fhme
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SPECIAL INSTRUCTIONS:
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Gate 4AA�capt
PLEASE SEE REVERSE StDE
i
NORTH
Town of Andover
No. 20 -
7
yy o dover, Mass.,
T O LAKE 1. T
COCMICMEWICK V
�y
`S BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
_- BUILDING INSPECTOR
.
THIS CERTIFIES THAT............. 0.r.6rN4.P............. .e_.I.S.4.::. .....�:`............................................................
Foundation
hashas
permission to erect........................................ buildings on .... ':...... .�.y.Y.Ie.QdA.V.o................................. Rough
to be occupied as -t C -1�L.� ............................................. Chimney
......................... . ............................................................
provided that the person acce in this permit shall leve respect conform to the terms of the application on file in
P P g P ry P PP Final
this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of
Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS
ELECTRICAL INSPECTOR
UNLESS CONSTRU O S ARTS Rough
.......... . ...................................................:...........N ..........................
Service
- BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final T
No Lathing or Dry Wall o Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector-. Burner
Street No.
SEE REVERSE SIDE Smoke Det.
Boar o . ui din egulat�ons and tan a
g
r One Ashburton.Place -- Room 1301
Boston. Massachusetts 021.08
Dome Improvement Contractor Registration
Registration: 100733
Type: private Corporation
Expiration: 612312010 Tr# 267195
A. B. CARNES, INC. .—
Barry Cames -
30 Arrowhead Farre Rd.
Boxford,MA 01921 _Update Address and return card.Mark reason for change.
Address Renewal Employment " -1 Lost Card
otx c.As 0 50s47M7-CWS0
soardarfluitding Regulations and Standards
Construction Supervisor License
License: CS 68139
Expiration: 1111412010 Tr# 1207
Restriction: 00
KENNETH R CARNES
8 DORIS ST
GROVELAND.MA 0183c 4 amrnl1sinuer
A�� CERTIFICATE OF LIABILITY INSURANCE oils%o s'
PRODUCER (751)439-5000 FAX (751)439-S025 THIS CERTIMATE IS ISSUED AS A MATTER OF INFORMATION
New England Heritage Insurance Agency Group, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
333 Main Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Stoneham, NA 02290
WSUFdERS AFFORDING COVERAGE NAIL#
INSURED A 8 Ca-rnes,Uc. wammk Essex Insurance Co..
30 Arrowhead Fares ltd. wslNIFR a AIG AMERICAN INTERNI. GROUP INC
Boxford, ANA 01921 mac:
LIiSYE�Ot
IN�HxRL3R e
THE POLICIES OF II+i$URANCE LISTED BI I.OW HAVE BEEN 9a)ED TO THE IA UPED NAMM ABOVE FOR THE POLICY PERIOD INDICATED_NOTWITHSTANDING
ANY REOUIREMENT.TERM OR CONDMON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CEFMFICATE MAY BE ISSUED OR
MAY PERTAIN,THE r4SURANCE AFFORDED By THE POLICIES DESCWBED HSI IS SUBJECT TO ALL.THE TERMS,EXCLUSIONS AND CONOITIONS OF SUCH
POLICIES_AGGREGATE LvAffS SHOWN MAY HAVE BEEN REDUCED BY PAK CLAW.
MiSR TYPE OF NOSURANKE POLICYPOLICY EXPIPATION LIMITS
GENERAL LIABILITY TSD 03/18/20D8 03/13/2009 EACH occUiamNCE $ 1,000,001
X COMMERCIAL GENERAL LIABILITY DAUNGE TO RENTED $ S0,001
�� �IEa�reoa
CLAIMSMADE I I OCCUR - MED EXP(AiV one person) S S'00
A PERSONAL A AM INJURY $ 1,000,001
GeNDIAL AGGREGATE s 2,000,00(
GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPMP AGG S 1,000,001
POLICY � F1 LOC
AUTOMOBILE LIABILITY
CAMS SINGLE LM.IIT S
ANY AUTO (Fa acckkW)
ALL OWNED AUTOS BODILY IHLtURY
SCHEDULED AUTOS IPe►person) S
HIRED AUTOS
BODILY INJURY S
Nlk1�WNE0 AUTOS (per acadeM)
PROPERTY DAMAGE $
(Per as kkwd)
GARAGE LIASUM AUTO ONLY-EA ACCIDENT S
ANY AUTO
OTHER THAN EA ACC S
AUTO ONLY: AGG S
V^BN-W EACH OCCURRENCE $
OCCUR ❑CLAM MADE AGGREGATE S
S
DEDUCTIBLE $
RETENTION S $
WORKERS COMPENSATION AM VC $44-90-75 03/31/2x08 03/31/2009 WcsrATu oTH-
EL+HPLOVERS'LIABILITY
gANY am? EL.EACH ACCIDENTs 1,000,00(
OFFICEPJAfEMSER� EL DISEASE-Ell EMPLOYE S 11000,00(
"`�C'r `' M oelonr E.I.DISEASE-POLICY LIMIT S 1 000,009
OTHER
DESCRIPTION OF OPERATiow f LOCATIONS!VEHICLES I EXCLU SHM ADDED BY ENDD1lMWIT!'SPEQAL PvtownKm
retractor Subject to twv s, conditions, endorsements and exclusions on the Policy.
CER'nBIGATE CANCELLATION
SHOULD ANY OF THE ABOVE MSG 1 POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL
_10_DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
SLIT FAIIAWA TO MAJL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
"PROOF OF INSURANCE COVERAM ONLY" OF ANY MW UPON THE POSUFA 4 ITS AGENTS OR REPRESENTATIVES.
SPECIMEN COPY ONLY AUTHORIMMOPRES81TATIVE �
Millias Kell la!m
ACORD 25 12001=1 &+el'nOn rnDPAPATInM=22I
i
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
� Boston, MA 02111
t � w
w w.
1nass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibiv
Name(Business/Organization/Individual): i j
—T'
Address:
li City/State/Zip: 01�— . Phone #: =/
Are you an em Vec c t e appropriate box: Type of project(required):
1. a employer with 4. ❑ I am a general contractor and 1 6. ❑ New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. $ 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10:❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work 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.] t employees. [No workers' 13.0 Other
comp. insurance required.]
}Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
Homeowners who submit.inis aeeidavit indicating ti:ey are doing an work all-ad 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.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: / Cj
�L
Policy#or Self-ins. Lic.#: L!/C 70'- 7 4 Expiration Date:
Job Site Address:2it 2 Al A20yJ 97) City/State/Zip:. AV; �
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.
I do hereby certify under a pains and penalties of perjury that the information provided above is true and correct
Siartatur i Date: '76
Phone#: 5-3
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 cavy 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 i,n (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 4.06 or 1-877-MASSAFE
Revised 5-26-05 Fax# 617-727-7749
www.mass.gov/dia