HomeMy WebLinkAboutBuilding Permit #460 - 9 BEACON HILL BOULEVARD 11/25/2013bUILUINV 1'tKMI I
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO - o Date Received
Date
IMPORTANT: Aoolicant must complete all items on this
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LOCATION `i h: 131 ,,c►
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PROPERTY OWNER 1oc7 11-3s, -
Print
MAP N0: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
Alteration
No. of units: I
Commercial
Repair, replacement ✓
Assessory Bldg
Others:
Demolition
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
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Identification Please Type or Print Clearly)
OWNER: Name: 10!w M'.kso-, Phone:
Address: Wvd
CONTRACTOR Name: Phone:
Address:
Supervisor's Construction License: Exp. Date:
C5-05a3gV I11.)fI.-)
Home Improvement License: Exp. Date:
'ir S'3 i J e 2ci_v
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: $ Jgoc,.oe FEE: $
Check No.:— .1& 110 Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have acc ss to a gua my fund
ignature o A
re of contractor
Permit NO:
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
IMPORTANT: Applicant must complete all items on this page
r
=LOCATION.
Print
EPROPERTY OWNER
MAP NO: -PAR CEIts ZONING, DI
Histone District
yes - rto'
yes no
TYPE OF IMPROVEMENT.
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
p Septic ❑ 1Nell
Floodplain: ❑'Weltllands
Watershed District
Water/Sewer
UESCRiPTiON OF WORK TO BE PERFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
Address:
ARCHITECT/ENGINEER
Address:
Phone:
FEE SCHEDULE: BOLDING PERMIT: $12,00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ FEE: $
Check No.: Receipt No.:
NOTE: Persons: contracting with unregistered contractors do not have access to the guaranty fund
Sgnature;,of�Agent/Owner�,', - t. w '
Plans Submitted FJ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
Location • 1� v`, --
No. 7 Date
TOWN OF NORTH ANDOVER
f
Certificate of Occupancy $
Building/Frame Permit Fee $v '—`
Foundation Permit Fee t,
Other Permit Fee $
TOTAL $
Check #R76
2713" 4
Building Inspector
Plans Submitted ❑ -,Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE -QF ,SEWERAGEDISPDSAL
Public Sewer ❑
Tauning/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 ❑
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE.APPROVED
Reviewed on Signature
Reviewed on Signature
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 Tow;! Engineer: Signature:
Located 3M Usg000 ,street
FIRE DEPARTI:LIVT = Temp Dumpste_"r on. site .yes no
Located at-,124Mair Street - :_ _ '�`
ire' Departmeng_
• r,
COMMENTS
-Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions._
Total land area; sq. ft.:
I
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
.Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL-.Chapter166.Section. 21A -F and G min.$10041000:fine
NOTES and DATA — (For cle artment use
® Notified for pickup - Date
Doc.Building Permit Revised 2010
Building Department
`rhe foli'owing 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)
o 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 casts if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the apoaal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be subm.tted with the building application
Doc: Doc.Building permit Revised 2012
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11/18/2013 10:33 7812462611 J A CORSON INS PAGE 01/02
AcRo• CERTIFICATE OF LIABILITY INSURANCE
'' /°°f"""'
11/18/13
THS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON 111E CERTIRCATE HOLDER, THIS
CER11FICAIE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED 13Y T14E POUCZ3
BELOW. TAMS CERTIFICATE OF INSURANCE DOES MDT CONSTITUIE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESEt#ATIVE OR PRODUCER AND THE CERTIRCATE HOLDER.
IMPORT : d t11a certificate holder Is an ADDITIONAL. INSURE , the policy(les) must be en arse". If S A APM, ®ubjw tv
the terms add owditians of the policy, certain policle® my nmpile an endorsenrorM. A Buiemem oa this certificate does not confer rights to file
certificate hP ider in lieu of such endorsemen so.
PROMCERNT
J.A. Corson ins. Agancy
380 Loweal Street
Wakefield, MA 01080
T
NAME.
Fm—m . (781) 216-2611
781) 246-5077
A u corsonilr►suXauTce.eom
INSIAE S AFFDRdtrO COVE RAGE MAIC I!
INOURW A! AIbe11A
IiJIMIS YORK OONSTRUCTION
57 SOUTH RD
kPPERBLL, MA 01463
Imum a: Libartsv Mutual
INWRINC
IMU ER D:
L" LRA E:
COVERAGEGEKTIP IIIA I It A L IMC K- ..� • w.v....v....•�• v
THIS IS TO CERTIFY THAT THE POLICEES OF INSURANCE USTED 9ELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PR3ilOD
INDICATED. ? NOTWATHSTANDNIG ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTFICAT MAY (IE ISSUED OR MAY PERTAIN, THE INSURANCE: AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSION ANDCONOITIONS OF SUCH POUCIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAD CLAIMS -_---_._. ......
L J TYPE Of INSURANCE IN Sub - POLICY NUMBER MICU II 1 UkIiB
AGENERAL60LITY I 8500043812 6/27/13 6/27/11 EACtloccuNRQNCE s 1,000 000
JERGIAL OENERAt,I,wBLLITY
MAINS WDE EI OCCUR
WN'LAGOREGATE LPAT'APPLIES PER
-] Parr f -I PERc°T
n LOC
A MWOBILE UAEIUTY
ANY AUTO
�Lrr0rED
AUTOSULED
NONQVVNED
MIREDAUTOS _
AUTOS
UNISMELLAUAS
000VR
MwasLIA6
riA,Ucy
13 nvr
AND
NI
5/21
GBSCRIpiTON ($F OPERATIONS I LACATIDNS IVEMCLES (Ath AOS //M, AeRMOnol Ranenm'9cI 0,1., jr1AO1e *goes I&mgd ftQ
JOB LOC.P now. 4 BEACON Hn.J. BLVD. NORTH ANDOVER
LED ITE (Aro one p_-cn) $
PER90ML✓j,ADVIPWRY $
GE IFIALAOOR[GATF S
PRODUCTS - 09IIP/OP AGG S
WED SINGLE LWI
e eceldBn S
130okY INJURY (Por pDrAn) S
eODILYINJURY (Per xWwA) S
��ecdu�ant i
S
EACH OCCURRENCE $
100
SHOULDANY OF 1HE ABOVE DESCRIBED POLICIES Me CANCELLED BEP ORE
THE El(PlRATION DATE THER 60r, BOTWE WILL BE DEUV6'RFD N
NORTH ANDOVER BUILDING DEP. AOCOROANCEWITH THE POLICYpROVIIDIONS•
NORTH ANDOVER, mh 01845
AUD40MZM M 881117A
JUDITH A CORSON
®1988.2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (201 Oft rm ACORD mme and logo are register=d malts of ACORD
Phone: Fax: E-mail.
The Commonwealth of Massachusetts
Department ofIndustrla[Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): r• s qa (-k 6o S --r ,r c 4 ,-u-
Address: 5-1 'LcJ
City/State/Zip: %acs s 61 X63 Phone #:
Are you an employer? Check the appropriate box:
L 1 am employer with 4. ❑ I am a general contractor and I
Type of project (required):
a _1
6. ❑ New construction
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet. #
7. F1 Remodeling
ship and'have no employees
These sub -contractors have
8. ❑ Demolition
working for me in any capacity.
workers' comp. insurance.g
❑Building addition
[No workers' comp. insurance
5. El We are a corporation and its
10.❑ 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.❑Roofrepairs
insurance required.] r
employees. [No workers'
13.❑Other
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
I Homeowners who submit this affidavit indicating they hie 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 formy employees. Below is thepolicy and job site
information.
Insurance Company Name:. (o 1647 —
Policy # or S el£ -ins. Lia #: W G5 3 15 3 S y 3) 30 1 3 Expiration Date: _'51201Y
Job Site Address: q Btc c 14 61 �U1 City/StatelZip: j)(,, ,� A,6, )7, iS
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 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 may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certifv under the pains a/nd penalties ofperjury that the information provided above is true and correct.
Signature: PLa-,�O� �L?/ Date: id.>b'r?
Phone #• 1- h-91--3s'i. JS -7Y
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 Pers
Phone M
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 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 be.
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 Massachusetts
Department of Industrial Accidents
Office of avestigatiom
600 Wasbiagton. Street
Boston., M.A. 02111
Tel, # 61.7-727-4900 at 406 or 1-877�MASS.A.FB
Revised 5-26-05 Fax # 617-727-7749
www-mass,govfdza
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