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HomeMy WebLinkAboutBuilding Permit #532 - 968 SALEM STREET 1/30/2007Permit NO: J �� Date Issued: TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received 3v " O -;?- IMPORTANT: Applicant must complete all items on this page LOCATION 76 ? 94 /C Print 1 PROPERTY OWNER e Q d, h R� c i( Well Print MAP NO.: /. S PARCEL: TYPE, AND USE OF BUILDING ZONING DISTRICT: HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Exp. Date: Ft Residential Non- Residential ❑ New Building ❑ Addition X.Alteration O'One family ❑ Two or more family No. of units: ❑ Industrial ❑ Repair, replacement ❑ Demolition ❑ Assessory Bldg ❑ Commercial ❑ Moving (relocation) ❑ Other ❑ Others: ❑ Foundation only DESCRIPTION OF WORK TO BE PREFORM Identification Please Type or Print Clearly) OWNER: Name: VU04\ RC'e-k lU Phone: Address: G g S rte► CONTRACTOR Name: Jo r-, p y T Phone: Address: 0 ff a ult L I/ '� wtzx- Gf tolls Supervisor's Construction License: © f G Z Exp. Date: Ft Home Improvement License: 1 Z le ( ( Exp. Date: c' 1? ARCHITECT/ENGINEER Name: Phone: Address: Reg. No FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.P. Total Project Cost :$_'�!S D6 FEE:$ A2 -- Check No.: Receipt No.: / 9gs Page I of 4 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 Addition Or Decks ❑ Building Permit Application ❑ 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) 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 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:BPFORM05 Page 4 of 4 TYPE OF SEWERAGE DISPOSAL Tanning/Massage/Body Art ❑ Swimming Pools 11❑ Public Sewer Well F1_ Tobacco Sales ❑ _ Food Packaging/Sales ❑ Private ❑ Permanent Dumpster on Site ❑ (septic tank, etc. Electric Meter location to project AU 1 L : Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner. Plans Submitted ❑ Plans Waived ❑ Signature of contractor Certified Plot Plan ❑ Stamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT ❑ COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS DATE REJECTED DATE REJECTED 11 91 DATE REJECTED IN LI U DATE APPROVED DATE APPROVED DATE APPROVED FIRE DEPARTMENT - Temp Dumpster on site yes no Fire Department signature/date COMMENTS 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 Building Setback (ft.) Front Yard Side Yard Rear Yard Required Provided Required Provides Required Provided Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: lV U I LN and UA I A — (tor department use Page 3 of 4 Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORMOS Created IMC. Jan.2006 Location No. 53 ,-�" Date &OWTN TOWN OF NORTH ANDOVER 9 Certificate of Occupancy $ Lis' °''tom Building/Frame Permit Fee $ s�CHU Foundation Permit Fee $ n Other Permit Fee $ TOTAL $ Check # 19957 Building 9957Building Inspector BOARD OF BUILDING REGULATIONS j License: CONSTRUCTION SUPERVISOR Number , CS, 060112 Birthdate_,.^081Q4N 956 E08 Tr. no: 28784 xpires 08!04124 �I Restricted:. 00 , THOMAS T DOYLE 8 WEST NH 03079 s �ne SALEM, Commissioner i. • �iie �aanr9nots�!�� �`�aoiael�lo' , HOME IMPROVEMENT CONTRACTOR Reylstratli5� 128612 acpiral3 +1812007 E 1 �--liftar }� THOMPSON S ROOFIF G:,t—_ THOMAS DOYLE`=,' ` 8 WEST ST r SALEM, NH 03079 Adi�IMratvr `� ---- 0 h 0 z /o 14Y a a c� a o ` C y O C Uw 'ate CL. Cc o m C ;Z O U w chi w a U w w Ea w � C o rw m O ca ° cn cn 14Y c� o ` C y O C Uw 'ate CL. Cc o m C ;Z O O CD Ea � C m O ON m lam` a n H V: E� z C 0. _1 o `mom E o H V CD z •• O: c o H ' o y c H C o a cm C C w c S Q `6 c z �m m is o CJ coo `�` CIM a m m� S _ rr a •-• o ti W c O••.m R= s Z "r . o y LD Isc H O.ZyS Z C.3 a m�llS CM 5 CL 14Y ACORDTMCERTIFICATE OF LIABILITY INSURANCE DATE(/DD PRODUCER Pelham Insurance Services, Inc. P.O. Box 960 122 Bridge Street 10/277/2006006 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Pelham NH 03076 INSURERS AFFORDING COVERAGE MAIC # INSURED POLICY NUMBER INSURER A: Nautilus Thomas Doyle LIMITS INSURER B: Associated Industries dba Thompson Construction & 8 West St. Salem NH 03079 GENERAL LIABILITY INSURER C: INSURER D: 1 INSURER E: 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. AGGREGATE LIMITS SHOWNMAY-HAVEBEEN REDUCED BY PAID CLAIMS. INSR LTR ADD'L INS 'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MM/DD/VY POLICY EXPIRATION DATE (MM/DD/YY) LIMITS A GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000' ,000,000 X COMMERCIAL GENERAL LIABILITY NC 532152 04/15/2006 04/15/2007 pREMISES(E.$ 50,000 occurrence) MED EXP (Any oneperson) $ 1,000 CLAIMS MADE D OCCUR PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEML AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/OP AGG $ 1,000,000 RO POLICY JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY NON -OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ AGGREGATE $ OCCUR FICLAIMS MADE DEDUCTIBLE $ RETENTION $ B WORKERS COMPENSATION AND AWC7012214012006 04/21/2006 04/21/2007 TORS AMTTS OT EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $ 100,000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ 100,000 If yes, describe under E.L. DISEASE -POLICY LIMIT $ 500,000 SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS Residential Roofing CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED 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, BUT Ron Grecco FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE 27 Reed Street INSURER, ITS AGENTS OR REPRESENTATIVES. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' d 600 Washington Street 7 ,yam Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): %—j��,,,, 42 S Address: /u s— h/t City/State/Zip: v1? --( gt-� Phone.M 69�-res-s­ Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hued the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These .sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.# required.] 5. E]We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' insurance Type of project (required):. 6. ❑ New construction 7. ❑ Remodeling 8. ❑ 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 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: q5_5 Policy # or Self -ins. Lic. r7 ! Z Z! 4° o 1 'ZOri 4- Expiration Date: Ll ' Zl — y `! Job Site Address: ,7 g-i�- 5 �i- S� City/State/Zip: /�/� ��/v-e^ 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 the pains and penalties of perjury that the information provided above is true and correct. Phone #: use only. Do not write in this area, to City or Town: or town official, 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 fm 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 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, please do not hesitate to give us a call. The Department's address, telephone and fax number: Revised 11-22-06 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 604 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext.406 or 1-877-MASSAFE Fwc#-frr'�72-7=7749 -- www.mass.gov/dia Kai Free Estimates Fully Insured Page 105 Haverhill Street Methuen, MA 01844 T O N'S ING (978) 691-1355 Shingles - Slate - Rubber Roof Single Ply - Copper Work PROPOSAL SUBMITTED TO PHONE GATE /07 STREET JOB NAME CITY, STATE AN ZIP C DE JOB LOCATION ARCHITECT DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for: 5-` � ►qty, Sc*? e�3 CAI, 13,a-lV4'�- 5� 1-el3 s up AlaVA9 a'A 'jJ1-(Y'5 C' I jyl� '0 j 4-t o, /A i� T "ei- 3oy(,. i ttj (wjo, Afpl f lty '%wt13� 3 0 yr, 00'(4 a" '*'/ a tri M, I C, �c\ 3c, c�Sar0C�;�� ��� . �Go t t't ftOJ _e PJti i'� We VropM hereby to furnish material and labor — com}plete in accordance with above specifications, for the sum of: Oa o n l��_ � L'Tt-e 1-K uy,<)vt ( a 6-10 It "t� dollars ($ Payment to be made as follows: All material is guaranteed to be as specified. Ail work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado and other necessary insurance. Our workers are fully covered by Workmen's Compensation Insurance. 2cre Stance of j9r®plooal — The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. Date of Acceptance: �j 1 0 Authorized W V Signature Note: This proposal may be withdrawn by us if not accepted within Signature p}! /,�/1, /% Slgnaturec .rit,(� z— /L.A T �� �' days.