HomeMy WebLinkAboutBuilding Permit #681-11 - 89 OLD VILLAGE LANE 4/8/2011Permit NO: 6 I
Date Issued:
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
ORTANT: Al
old U;
Date Received
must complete all items on this
L-�e
1 Lllll
�A� I i� n w,
`-' Print
MAP NO: PARCEL: �� ZONING DISTRICT: Historic District yes no
Machine Shop Village ye no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
p<One family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
P<Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑M1Sephc Q,Well�
q Floodplam� ®Wetlands
D WatershediDistnct;
❑Water/Sewer:° . _
; z _ .:
7 e.=
VENUtur i 1UN UP W UKK �1 U BE PIJKFORMED:
2enno� eoc�5 \In c t�oc , rnove e�,\-nor Aoar ►0"
C`OSe�- S-IZe Kp��c� +� n �Gn`r, e i4
(Identification Please Type or Print Clearly)
OWNER: Name: 't. S Phone: !R� 0276
v -
Address: 4Rq 0l c� Lane�
CONTRACTOR Name: t AeyuxS 7 Seri %cGS Phone: 7V 1760 2o3 l
Address: DSC ;6-23 . VJ MA o I FFiF
Supervisor's Construction License: `7399 ( Exp. Date: -7 2,01 2.
Home Improvement License: 12.q 17] Exp. Date: 1.1 q 2 d I
ARCHITECT/ENGINEER tJ I A Phone:
Address: Reg. No
FEE SCHEDULE: BULDING PERMIT. $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COSTSED ON $125.00 PER S.F.
Total Project Cost: $ 12, 000 '� FEE: $ 1 :B'�—
Check No.: `Z —' Receipt No.:
NOTE: Persons contracting with unregis4ereV contractors do not have access to the guaranty fund
re).ofi
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
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE REJECTED
❑-
DATE APPROVED
Reviewed on Signature
Reviewed on Signature
Zoning Board°,of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision
Comments
Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
FIRE DEPARTMENT - Temp Dumpster on site
Located at 124 Main Street
Fire Department signature/date
COMMENTS
W
Located 384 Osgood Street
yes no
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
Ll Notified for pickup - Date
Doc:.Building Permit Revised 2008mi
r
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 submitted with the building application
Doc: Doc.Building Permit Revised 2008mi
CCD
"
m C
c
O `
o
C c�
.a c
CL
ev
co 00
co
h =
Ea
.- c
mM
CD a
�X h
CD
oa
:nom E
CO) CD
q m
o Z' CO)
.� y 0:12.
as
C m y
•O C m O
co
H Wcm
O
MILCD
w CD
o c
M t o cmc a c
� o a ;n
Cy •7
D m
ca L-
�•�Z O
o c
Q yCL.
m c O
= m CCDLyt 'Z N
, O
►- H m o f- o
s
W O ' 4:
.. c 4-
Go az `� c Z
°C •E CS .y o
ti a m'� °v
= go a ` ca O
D aw m
co
O
O
O
w
Z °D
CL
O h
o S
CD cm
c
c
CO2 c-0
•CO3 CD
g m m
CD 0 CD
CL _~ y=..•
CD
3�
O
O c O
L
O O Q
CL Ca
CO3
caC
•G.CO) Z
O y0,.,�
CL
C.3 co)
O C
C •=
• C
CO)
LU
U)
W
W
W
U)
lO
x
p
w
y
cn
O
v�
co
0
w
p
r.2
C
u
G
X.
p
n:
G
w
F
W
p
c�
v�
C
w
:jw
a9
w
w.
�2
z
cn
cn
CCD
"
m C
c
O `
o
C c�
.a c
CL
ev
co 00
co
h =
Ea
.- c
mM
CD a
�X h
CD
oa
:nom E
CO) CD
q m
o Z' CO)
.� y 0:12.
as
C m y
•O C m O
co
H Wcm
O
MILCD
w CD
o c
M t o cmc a c
� o a ;n
Cy •7
D m
ca L-
�•�Z O
o c
Q yCL.
m c O
= m CCDLyt 'Z N
, O
►- H m o f- o
s
W O ' 4:
.. c 4-
Go az `� c Z
°C •E CS .y o
ti a m'� °v
= go a ` ca O
D aw m
co
O
O
O
w
Z °D
CL
O h
o S
CD cm
c
c
CO2 c-0
•CO3 CD
g m m
CD 0 CD
CL _~ y=..•
CD
3�
O
O c O
L
O O Q
CL Ca
CO3
caC
•G.CO) Z
O y0,.,�
CL
C.3 co)
O C
C •=
• C
CO)
LU
U)
W
W
W
U)
8
CD
9-
0
O
O
0
-f) 7- - -� t -I - -x Tr)
11
CD
Y� s` --r>
9-
0
w
c:
.9,
�
O
Cs�
u
w
c:
.9,
� a s 2 iitx-Si:fls -.
a i � r
iq fiifa
ni Building Relsusiifions and SianQii rds
License: CS 73991
Restrict= -Ll 00
GERALD WHITE
23 GLENDALE DR
DANVERS, MA 01923
DPS -CAI 0 50M -04104-G101216
✓/e �a»tnza�au�eall� o�✓�rvtac%udeC/d
_ Office of Consumer Affairs & Business Regulation
HOME IMPROVEMENT CONTRACTOR
Registration:. 129177
m _ - Expiration:: 7/19/2011 Tr# 287930
Type: Individual
Gerald White
Gerald White
54 Emerald Drive
Lynn, MA 01904 Undersecretary
N,: tion: 4/7/2012
,r-: 22470
Gl Address Renewal (-� Employment
License or registration valid for individul use only y
before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, MA 02116
Not veli without signature
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Prinf'Legibly
C-��CUI c
Name (BusinesslOrganization/Individual): S � &C v t a.S
Address: 0 , So oc .2'a2.3
City/State/Zip:Woburn. MA MIRE- Phone #: __791 %6o 2.03 i
Are you an employer? Check the appropriate box:
The Commonwealth of Massachusetts
r
Department oflndustrialAccidents
have hired the sub -contractors
Office of Investigations
listed on the attached sheet. #
600 Washington Street
"'
Boston, MA 0211-1
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Prinf'Legibly
C-��CUI c
Name (BusinesslOrganization/Individual): S � &C v t a.S
Address: 0 , So oc .2'a2.3
City/State/Zip:Woburn. MA MIRE- Phone #: __791 %6o 2.03 i
Are you an employer? Check the appropriate box:
L ❑ I ama' employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2 -KI atm a sole or 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. ❑ We 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.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. 04 Remodeling
8. W Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.0 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.
$Contractors that check this box must attached an additional sheet showing the name of the sub -contractors acid 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;
Policy # or Self -ins. Lic.
Expiration Date:,
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Sedtion 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 tke pains and penalties of perjury that the information provided above is true and correct
ect.
Phone #: 7F 1 760' 2031
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 C dwelling house having notmore 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."
s
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 nurnber(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 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 pennit/]icense number which will be used as a reference number. In addition, an applicant
that must submit multiple•-penmit/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 pen -nit 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 1Vlassachu Qtts _
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877 MA.SSAFB
Revised 5-26-05 Fax # 617-727-7749
www.mass.govv/dia
ACC>RhPCERTIFICATE OF LIABILITY°,°°I,yYYY)
INSURANCE
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the Certificate holder Is an ADDITIONAL INSURED, the policy(ies) must he endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsement(s).
PRODUCER CONTA
NAME: Lauren Goldman
Cross Insurance -Peabody PHONE (978) 532-5445
.(AIGo F.M, (9 NNot: (979)531.1717
139 Lynnfield Street EMaI 1 olt91nanBcrossa eu
tZ4.8ESs: 5 q cy•com
PRo02c--;.00080172
ye-apqdy INA 0I960 INSURER(S) AFFORDING COVERAGE NAK r _
INSURED INSURER A Western World Ind. Co. -
INSURERB:SafetY Tridemnity
Nexua lI Services LLC INSURERC:
P -O- Box 2823
INSURER 7E::
Woburn 74A 01$8$INSURER : -
COVERAGES CERTIFICATE NUMBER:CL113943409 REVISION 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.
NSR' j� - _
LTR TYPE OF INSURANCE INWV POLICY NUMBER NM GDY EFF MM DD EXP LIMBS
GENERAL UABU M
EACH OCCURRENCE § 11000,000
A IJ COMMERCIAL GENERAL LIABILITY PREMISE!fi (EBAMITO.C.1 S
• 1� CLAIMS.MAD6 F� OCCUR PP1286453 /12/2010 /12/2021 MEDExP(Any one peram) S _ 51000
`'• • " - — •• PERSONAL&ADV INJURY S 1,000,000
1 - -• GENERAL AGGREGATE It 2 000 000
LAGGRWATELIMITAPPL_IESPER;
`f!WL POUCY 7 MLOC
X (—S
-.COMP/OP
PRODUCTSAGO 5 1,000,000
- _ ---
AUTOMOBILE LIASIUTY
COMBINED SINGLE LIMIT
I I ANY AUTO
(Es aeddevu) S
B ALLOWNEDAUTOS
116632
1/10/201011/10/2011
BODILY INJURY(Pcrpers(n) s 290,000
�
X SCHEDULED
_
BODILY 00 , dem) S 5 000
X HIRED AUTOS
I
•_
PROPERTY DAMAGE
(Perkdoent) S 100,000
I X NON-0WNEDAUTOS
MedW payment- S _ 5, 000
I i UMBRELLA LIAR
Welve Corasipi DeduatNe s -
OCCUR
EACH OCCURRENCE §
l i EXCESS UAB CLAIMS -MADE
- - -
• • -I -- -
AGGREGATE §
DFDUCTIBLE
--
S
RETENTION S
WORKERS COMPENSATION
S
AND EMPLOYERS' LIABILITY
WC STATU- OTFI
S_
ANV PROPRIETOrVPARTNEWEXECUTIVE YIN
OFF10ERLMEMREREX(CLUDED? ❑
NIA
EI. EACH ACCIDENT
CCIDENT §
(Mandatory In NH)
_ -
It yes, de9t 6be under
E.L DISEASE - EA EMPLOYE S
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POI Iry I ..IT e
DESCRIPTION OF OPERATIONS I L.00AT)ONS I VEHICLES (AtOch ACORD 101, Addtltoml Remarks Schodulo, at #Ram Space to Mqulrcd)
Refer to policy for excluaionary endoraeanentB end special provisions.
CERTIFICATE HOLDER CANCELLATION
(978)975-1263
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL. BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZEDREPREBENTATIVE
Timothy Tri monte/T>®1 Y4-11� ol. X4L,1120-rf�
ACORD oo (21)09/09)
lNS025 (zop®1986-2009 ACORD CORPORATION. All rights reserved.
9oR) The ACORD name and logo are registered marks of ACORD
T00 Z 331sMISNI SSOHO LTZZ US OL6 %V3 W ST TTOZ/60/CO
Location faJ117 1, v/
No. _ Date /Zh/W
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee. $
Foundation Permit Fee $
Other Permit Fee $ _
TOTAL $
Check #
24651
Building Inspector