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HomeMy WebLinkAboutBuilding Permit #689-16 - 9 CHATHAM CIRCLE 12/7/2015BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received Permit No#&:—� Date Issued: IMPORTANT: Applicant must complete all items on this page LOCA ION , 0' ILE!D 0 Contractor Nam', one4,L Residential Us no go TYPE OF IMPROVEMENT PROPOSED USE Contractor Nam', one4,L Residential Non- Residential El New Building El Addition WAIteration 0"One family El Two or more family No. of units: 0 Industrial El Commercial 0 Repair, replacement El Demolition El Assessory Bldg ri Other El Others: 51 Seteell -V­ITl,-i1 RVatr - I , la OF 3 OWNER: Name: Arldrncc- 1PTION Ut- VVL)KK rl L) bt VtKrUK�1A1=L): 91 ldentificatiQn - Plea Type or Print Clearly Phone: V79 6e 9 -,3 4�1 Contractor Nam', one4,L Erna I M, e Fi! si --Z J Ifl! c.–,e n 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: $ 3, eno do FEE: $ Check No:: —Receipt No.: NOTE: Persons coiltracting with unregistered contra o do z as access to the guaranty fund / :-7': ------- 7 ur W- 4 i'FZ; in, f r, "a' 1�1 .11 a :'fic'o' cor.:..­�.-. hb r Location c. 1 No. Date v Check T 29775 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ r Foundation Permit Fee $ t Other Permit Fee $ TOTAL $ Building Inspector Plans Submitted ❑ Plans Waived. F1 Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISP Public Sewer Tanning/Massage/Body Art ❑ Swimming Pools El Well El Tobacco Sales El Food Packaging/Sales 11 Private (septic tank, etc. El Permanent Dumpster on Site El THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH = Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comm Conservation Decision: Comments Water & Sewer Connection/Signature & Date Drivewav Permit DPW Town Engineer: Signature: LOcaiea io4 usgooci jtreer Temp IDE R,oumpsteron,�itb es,�'.g&yjy.jxt&�4, 11 Yj Located a Streets n sire Department 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 Nki I It5 and UA I A — (11 -or dleparitment use a I ® Notified for pickup Call Email I Date Time Contact Name - Doc.Building Permit Revised 2014 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 o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract ❑ Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks a Building Permit Application ❑ Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Cross SectionlElevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o Engineering Affidavits for Engineered products DTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) o Building Perm it'Application ❑ Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o 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 o Engineering Affidavits for Engineered products ATE: 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: Building Permit Revised 2014 C � N `..' O CD O CL miollL c. CL�• N .a co a O vCD CY CD O wD c CD o °. C' C � v o z CD 0 .�* 0 X CD 0 CD O ��•(rDL° !4 n Oro Z � p c N. m o Pte' cc T o_o rto. m ir CD W CD Cl) N = D ID CD 2 O CR z'EL -ao� CO) �, .0 n=2 -i � _�rr cn ._ T < Q U) C C/) s 0 y W CD —i z �` N fl1 0 !214) z 0 " o Cl) s CD co �CA o o. a� CO) CD s �• Q 1 J (n a ° 0 (n rt m z WT 3 0/ Z7 o ago T °' (n m° < A ago T ;a o a=o T °— () ' 3 (p o ago T ° c N O VI m N T o0 a 7C T R+ m D a 1 zO r m n m 0 C m 0 C z m 0 M 3 S : W O m D S CD c c� a c5iWoess ak)s� Propoot Page# of PROPOSAL SUBMITTED T0: �: V S �� �/ $ JOB NAME JOB # ADDRESS JOB LOCATION DATE DATE OF PLANS # FAX # )Ve hereby submit specifications and estimates for:it�lsf? >s�. pages "Ve propose hereby to furnish material and labor — complete in accordance with the above specifications for the sum of: 1i $ $ Dollars with payments to be made as follows:SL�©D n Any alteration or deviation from above specifications involving extra costs Respectfully f will be executed only upon written order, and will become an extra charge submitted Y ,( ll over and above the estimate. All agreements contingent upon strikes, accidents, or delays beyond our control. Note — this proposal maVye withdrawn by us if not accepted within days. 01creptance of Vropozal The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. j Payments will be made as outlined above. Signature Date of Acceptance Signature A-NC3819/T-3850 09-11 I � I it I I � I. I 4 �,i L-a t� a► i l l i , 4-77 eT + it I i Lkl5�Nf��- �. I ' I The Commonwealth of Massachusetts Department of IndustrialAceldents 1 Congress Street, Suite 100 ' Boston, MA 02114-2017 www mass.gov/dna Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individnal): Address: nn� _ U'u- 7 City/State/Zip: C.:/I,04s)& d N Phone #: f7? 162/ -43 Are you an employer? Check the appiopriate box: 'Type of project (required): Lam a employer with / ..: employees (full and/or part-time).* %. ❑ New construction 2. ❑ I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity. [No workers' comp. insurance required.] 9. El Demolition 3.❑ I am a homeowner doing all work myself [No workers' comp. insurance required.] t 10E] Building addition 4.Q I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole 11. [❑ Electrical repairs or additions proprietors with no employees. 1,2.E] Plumbing repairs or additions ors listed on e attached sheet. 5.❑ I am a general contractor and I have hired the sub-cintractlid th g. �o 13. [] Roof repairs These sub -contractors have employees and have workers' comp. insurance.t exemption MGL 14. Other h4t 6. ❑ We are a corporation and its officers have exercised their right of per c. 152, §1(4), and we have ng employees. [No workers' comp. insurance required.] �(p,�%j A{6&xb,( � *Any applicant that checks box 41 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:— Policy #orSelf-ins.Lic. 4: U/�iG'/OD-/ot9/9b01-20%SiK1 Expiration Date: Job Site Address: C#s�� � City/State/Zip: ,x.190 �%JCX&J/& . , �j��� Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. Ido hereby certify,uder the az d penalties o1 peryury haat the information proviaea aoov is true ana correcr- 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. CitylTown Clerk 4. Electrical laspector 5. Plumbing Inspector 6. Other Contact Person: Phone 4: Information and Instruction 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 6f liire, 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 bd 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 -contractors) name(s), address(es) and phone number(s) along with their certificates) 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. Tlie 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 yoti'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 permitilicense 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MA.SS.AFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia 11/30/2015 3;01:38 PM 8620 ® 02/02 CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 11 /3 012 01 5 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(les) must be 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 02916 _ 001 ACT NAME: tPA No. Ext): (781) 581-3100 Fplc. No.: Pantano Vonkahle Insurance EMAIL ADDRESS: 220 Broadway #220 Lynnfield, MA 01940 INSURERS AFFORDING COVERAGE NAIC # INSURERA : A.I.M. Mutual Insurance Company 33758 MED EXP (Any one person) $ INSURED Charles Burgess INSURER B GENERAL AGGREGATE $ EN'L AGGREGATE LIMIT APPLIES PER: OLICY RCT F-toc SURER C INSURER D, 3 Latch Road Chelmsford, MA 01824 AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS INSURER E INSURER F' COVERAGES CERTIFICATE NUMBER: 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. ILTR TYPE OF INSURANCE Vj,Qs POLICY NUMBER (MMILDIDNYYYJ (MMILDI �NYYY)LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑ OCCUR EACH OCCURRENCE $ DAMAGE TO RENTED $ PREMISES Ea occurrence MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ EN'L AGGREGATE LIMIT APPLIES PER: OLICY RCT F-toc PRODUCTS- COMP/OP AGG $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident UMBRELLA LIAR EXCESS LIAB HOCCUR CLAIMSMADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE YIN OFFICER/MEMBER EXCLUDED? �(ffMYYandatoSryf in NH) DESCR P I ION OF OPERATIONS below N/A VWC-100-6019601-2015A 11/14/2015 11/14/2016 X TORY LIMITS OER E.L. EACH ACCIDENT $ 100,000.00 E.L. DISEASE- EA EMPLOYEE $ 100,000.00 E.L. DISEASE - POLICY LIMIT $ 500,000,00 DESCRIPTION OF OPERATIONS / LOCATIONS! VEHICLES (A-LLttach ACORD 101, Additional Remarks Schedule, If more space is required) The workers compensation policy does not provide coverage for Charles Burgess CERTIFICATE HOLDER CANCELLATION Town Of North Andover 1600 Osgood Street North Andover, MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD 4542 Massachusetts - Department of Public Safety_.' Board Of Building Regulations and Standards Construction superi"lsor License: CS -068820 P C'HARLEs J BIIR E$S_ 3 LATCH RD 0' =' Chelmsford MA 8182 , i I ' Expiration Commissioner t 01/13/2017 C�fe �parn�narncvea� a�C/j�o�-uaeG� Office of Consumer Affairs & Business Regulation HOME IMPROVEMENT CONTRACTOR Registration: 'P 124728 . Type: �J� Expiration:==''SM412_01.7 DBA C.J. Burgess Charles Burgess Zicr 3 LATCH ROAD CHELMFORD, MA 01824 Undersecretary i