HomeMy WebLinkAboutBuilding Permit #538 - 885 FOREST STREET 1/28/2013TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: 5�9—
Date Received
Date Issued: f�e /--�
IMPORTANT: Applicant must complete all items on this page
LOCATION.
_ Print
PROPERTY OWNER. P/.~ A4 _ A l nY
• Print 100 Year Old Structure yes.
MAP NO/0S PARCEL: ZONING DISTRICT: Historic District yes nn
' Machine Shop Village yes `Fo
TYPE OF IMPROVEMENT
PROPOSED USE
Phone:
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
C� Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Well
❑ floodplain ❑ Wetlands
❑ Watershed District,
Water ewer
DESCRIPTION OF WORK TO BE PERFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: l t k 8 Al liar, l5 GN r x Phone: 77? 3 I V,�
Address: � Y � F6 � /` 9 i ` /Y6 . A NDG kr 4 -
CONTRACTOR
Name:
Phone:
Address:
Supervisor's Construction License: C S 8 -V'132 Exp. Date: /; 1// 17r /�
Home Improvement License: / Y
ARCHITECT/ENGINEER
Address:
. Date: / of ` ��~ a
Phone:
Reg. N
9
FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $
t? (2/7-----7
FEE: $ G
Check No.: Receipt No.: 16�
NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund
4
Signature of Agent/Owner ' Signatureof.contract�/�-/4 ,`_4� %,
Plans Submitted 11 Plans Waived 11 Certified Plot Plan ❑ / S/'Kmped Plans 0
Locationsr-
No.-
r --
No. Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #i-lvd-1 F--11�
26120
Building Inspector
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 ❑
DATE APPROVED
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Siqnature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comme
Commen
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Tovdn. Engineer: Signature:
FIRE DEPARTMENT -Temp -Du
mpster on site
Located at-124Wai Street
Fire . pai•tment�signatureldate `
COMMENTS
Located 384 Osgood Street
yes no
M1
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
DANDER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
NOTES and DATA — (For department use
Ll 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 appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be subm'Ated with the building application
Doc: Doc.Building permit Revised 2012
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA. 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: `r� �G %� l� /�`��� �� 24i`%S`
City/State/Zip 0 Phone
kre you an employer? Check the appropriate box:
❑ I am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
1 am a sole proprietor or partner-
listed on the attached sheet. t
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
❑ 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.] i
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. aRemodeling
8. [] Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
Ly applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information.
:)meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
ntractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, poli6y information.
W irn employer that is providing workers' compensation insurance for my employees. Below is the policy anti job site
jrmation. /fj - ii
urance Company Name: r`'� �IC f/o �`)G OL—
icy # or Self -ins. Lid. #: Expiration Date:
Site Address: G r`c S J /1i6 City/State/Zip:
ach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
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
Lp to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
estigations of the DIA for insurance coverage verification.
�herelycerflf&a ler the pains and penalties of perjury that the information provided above is true and correct
iature I ��f�%2�i�Z Date: Q l
)fficial use only. Do not write in this area, to be completed by city or town official.
;ity or Town: Permit/License #
ssuing Authority (circle one):
. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
Other
'.nntart Parenn• Phnnr #-
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 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 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,
Tease do not hesitate to give us a call.
'he Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
TO. ## 617-727-4900 ext 406 or 1.877-MASSAFE
R'a-r V 617_777-7749
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Jan 24 2013 18: 43 P.02
cORly CERTIFICATE QF LIABILITY INSURANCE1/2IMDDN
4/ D/24/ 220101'3 Y)
3
THIS.'CERFr.ICATE ISAS8UED AS A MATTER OF INFORMATION ONLY -.AND CONFERS, NO RIGHTS UPON THE CERTIFICATE HOLDER: *THIS
CERTIFICATE. DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, XTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES:
SELOW...THIS. CERTIFICATE -OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED ,••
_.
REP.RE§ENTATIVE.OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If tl,e ceirtifuate holder Is an:ADDITIONAL INSURED, the olicy(ies) must be endorsed. If SU13ROGATION IS WAIVED, suq)ect to
P..
.........:::-:-.,.;.. ..... . .
the,terms and conr3itions.of tna'polPcy;'ceital'n pollcles,inay raqulre an andorsemant. A statement on this certificate does not confer rights t0 the
certifiitate holder in lieu of such eridorsemen s '.
PRODUCFJ!
IN$VRA%TCE SOLUTIONS CORPORATION
N NE CT Kathleen Millar, CISR, CPIW
PHONE (603382"9600 FAX (609)982-2034
60. Wad.tvil.le Rd
ft
E-MAIL'dU. kmillAr@ isci.naures . con
INSURER(S) AFFORDING COVERAGE NAIC'8 '
INSURERA:Trav Cas & surety COjR Of IL 19046.
P]tL±,6,tow. NH 03865
.INSURED'-. •
INSURER6 lG In3urance Com an 15997•
INSURER C:
Jei9Il '.MOrin dba •
INSURERD: .
Jean Morin' Constrtction
INBURER e
143 HUNT ROAD
'EAST...HZ1%STEA'D NH 03826;
COVERAGES - .. CERTIFICATENUMBER:CL1312409216 REVISION NUMBER:.
THIS 1S;TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR:THE POLICY PERIOD
INDICATED:'..NOT1AlITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR, OTHER DOCUMENT WITH RESPECT TO WHICH THIS;
rr RYIr4rATr • AAv RF IRsurD OR MAY PERTAIN- -Mrn INSURANCE AFFORDED BY THE POLICIES, DESCRIBED HEREIN IS SUBJECT TO ALL THE ?FRMS.
• .EXCLUSIONS'AND. CONDITIONS OF SUCH P.OLI.CIES.,LIMITS
SHOWN,MAY HAVE BEEN REDUCED BY
PAID.CLAIMS. .
INSR
LTR
TYPE ORINSURANCE
ADCL
SUOR
POLICY NUMBER
POLICY EFF
M/DD
POLICY EXP
MM/DD
LIMITS .
GENERAL LIABILITY '
EACH OCCURRENCE S 1,000,000
DAMAGE TO RELATE
PREMISES Eeoccurrence $ 300,00
X• COMMERCIALGENERAL,LUIBILITY
MED EXP (Any one raon $
A'•
CLAIMS -MADE � QCCUR
26808577x065
/19/2012
/19/201.3
PERSONAL B ADV INJURY $ 1,00-0 j0do
GENERAL AGGREGATE $ 2, 000, 000
GEN'IAGGREGATI: LIMIT APPLIES PER
PRODUCTS-COMP/OP AGO $ 2, 000•, 060
$
X 'tYOLICY PRO- ' LOCco
AUTOMOBILELIABILITY '•
ec 110001-00.0
BODILY INJURY (Per person) S
8
ANY AUTO
ALLOOWNED x SACHEDULED
IdON�OWNED
X HIRED AUTOS X' AUTOS
0116034
8/30/2012
8/10/2013
BODILY INJURY (Per ecclderlt) $
PROPERTY DAMAGE $
Per erx
UniTisuredmotoristcombined $ .1 000 000
UMB[FELLA LIAR
H
OCCUR
EACH OCCURRENCE $
AGGREGATE S
EXCEuIj.wAs
CLAIMS -MADE
DED RETENTIONS
S
C
WORKER$LVON1PENSATION •
ANIJEMPLpYEKS,LIABILITY YIN
ANY. PROPRIETOR/PARTN6R/EXECUTIVE
OFFICER/MEMBER EXGLVPeD9• �
• manworyIn NN),
N I A
-SEE BELOW
TORYLIMITS.OTH-
ELL EACH ACCIDENT S
EL DISEASE - EA EMPLOYE $
EL DISEASE - POLICY LIMIT 3
if *leadribe, uhder
DESCRIPTION OF OPERATIONS b.1.
,DESCRIPTION or OPERATIONS / LOOATIONS! VEHICLES ('AnitchACORD 101, Additionnl Rtinerka Schedule, H more apace la required)
;.5dd sliarpners. Town Rd,..No Andov,Or MA 01645
"The:insured'has purchaaed'Workerar Compensation coverage through the MA Workor's Compensation Assign?
Rksk. Pool.. We ' have regueeted 'the servicing carrier i0sue a Certificate of Insurance on your' behalf
Agents are',not permitted to,is'aue Certificates of: Insurance'for WoxkeraI Compensation coverage on
poliGea,iasuacl,through the MA Workar's.Compensation A�signed;Risk Pool.
CERTIFICATE HOLDER cANGtLL.A I IUN
(976) 688=9542 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE:.
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED AN
7'Oot11 of No. Andover ACCORDANCE WITH THE POLICY PROVISIONS. -
1600 OBgOOd $1~ AUTHORIZED REPRESENTATIVE
No Andover, MA 01845 ;
K Miller, CISR, CP3W/
aCORD.'.25.(2010105) -019682011) ACORD'CORPORATION. All rights' ie60ved:
IN80�5(zotDoss):lii
the, AP name'and.log'o are reglstered'marks of,AICt
I
x
House: 1-6.03-974-1193
Cell: 1-978-360-4796
lean Noel Morin
CARPENTRY CONTRACTOR
143 Hunt Rd. • East Hampstead, NH 03826
N S tc 11 S 7 0-
dump
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