HomeMy WebLinkAboutBuilding Permit #867-13 - 971 SALEM STREET 6/13/2013TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: 9 � 4 1 S Date Received
Date Issued: � — ( 3 i 1_3
IMPORTANT: Applicant must complete all items on this page
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TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
El New Building
19 One family
El Addition
D Two or more family
El Industrial
D Alteration
No. of units:
El Commercial
0 Repair, replacement
0 Assessory Bldg
D Others:
El Demolition
El Other
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I DESCRIPTIONPFWORK TqBE PERFOR ED:
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OWNER: Name:'
Address: q-7 (
Ientifition Please Type or Print Clearly)
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ARCHITECT/ENGINEER Ph
Address: — Reg. No.
FEE SCHEDULE: BULDING PERMIT. $12.00PER $1000.00 OF THE TOTAL ESTIMATED COST BASED 0N$125.00PER S.F.
'Total Project Cost:$ FEE: $ 0
Check No.:- Receipt No..
NOTE: Persons contracting with iinregistered contractors do not have access to the guaranty fund
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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
TOTE: 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
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
Q 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)
o Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
OTE: 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 apt)>>al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
rrnist be subm:Ated with the building application
Doc: Doc.Buildffig permit Revised 2012
Plans Submitted ❑ Plans Waived❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OYSEWERAGE.DISPOSAL
Public Sewer ❑
Tanning/Massage/BodyArt ❑ ..
.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 Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes _
Planning Board Decision: Comments
Conservation Decision: Comments
A
Water & Sewer Connect! onisignatiare & Date Driveway Permit
t
DPW Town ]Engineer: Signature:
FIRE .DEPA'RTMF:NT - Temp Dumpster on site
Located at 124 Main' Street
Fire ®eparrr�ert sigriafiire/date
COMMENTS
Located 384 Osgood Street
yes no
Amension
Dumber of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
aLECTRICAL: Movement of Meter location, mast or service drop requires approval of
=lectrical Inspector Yes No
)ANGER ZONE LITERATURE: Yes No
IGL Chapter 166 Section 21A -F and G min.$100-$1000 fine
loc.Building Permit Revised 2010
Location &
No. h6_0 �— Date , A?
Check #
26511
TOWN OF NORTH ANDOVER
r
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee
Other Permit Fee
TOTAL $
6 V�4� �i
Building Inspector
ujjice of investigations
600 Washington Street
Boston, Mass. 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractor-s/Electricians/Plumbel-s
Applicant Information Please Print Lehibly,
Name (Business/organization/individual): _ SIC A6 (soy I FVC
Address: �,gk CO Pi] C O TC' �-� !----_.---
City/State/Zip: t�e\InAS `�V_A Phone#: q 2— `" 2
Are you an employer? Check the appropriate box:
1.0 1 am an employer with 2i
4.0 1 am a general contractor and I
employees (fill] and/or part time).*
have hired the sub -contractors
2. 1=1 1 am a sole proprietor or partner-
listed on the attached sheet.
snip and have no employees
These sub -contractors have
working for me in any capacity.
employees and have workers'
[No workers' comp. insurance
comp. insurance. I
required]
510 We area corporation and its
3. ❑ I am a homeowner doing all work
officers have exercised their
myself [No workers' comp.
right of exemption perm MGL
insurance required] t
c. 152, § 1(4), and we have no
employees. [no workers'
comp, insurance required.]
Type of project (required):
6. 0 New construction
7. LI Remodeling
8. 0 Dernoliiton
9, 0 Building addition
10. 0 Electrical repairs or additions
11. 0 Plumbing repairs or additions
12. 0 Roof repairs
13. 0 Other_SZ
"Any applicant that checks box NI must also rill out the section below showing their workers' compensation policy information.
t1•lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contactors that check Ihis'box must attach 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 # or Self -ins. Lic. #: Expirati n Date: " /o — l
Job Site Address: (� � f Q(/� 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 Section 25a of MGL 152 can lead to the imposition of criminal penalties of a fine
Lip 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
$250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the
DIA for coverage verification.
I do herby certify under the pains and penalties of perjury that the information provided above is true and correct.
Date:
Print Name: / �6 t W (Vi K_ Phone #. '7-7 g ( 21— 67 2 -
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):
LBoard of Heath 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact person:
Phone #:
.
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PRODUCER
JAMES SULLIVAN INSURANCE AGENCY
885 Main Street
Tewksbury, MA 01876
(978) 851-9600 ~5
INSURED The Ridina Guv Tnc _
181 Concord Road
Chelmsford, MA 01824
ftnVGRAf:FLC
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.
INSURERS AFFORDING COVERAGE NAIC#
INSURER A Scottsdale Insurance Company
INSURERS: AIG Insurance Company
INSURER C: Pilgrim Insurance Company
INSURER D:
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 SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IINSR
LTi? tNSRD
poD'�
TYPE OF INSURANCE
POLICY NUMBER I
POLICY EFFECTIVE
DATEfMMroD
POLICY EXPIRATION
DATEIMMIDDIYY
LIMITS
AUTHqRtZED REPRESENTATIVE
Lam{
GENERAL LIABILITY
EACH OCCURRENCE S 1,000,000
X COMMERCIAL GENERAL LIABILITY
CLAIMSMADE L =I OCCUR
PREMISES Ea occurence $ 50,000
MED EXP (Any one person) S 5,000
A
CLS -1198503
03/22/13
03/22/14
PERSONALS ADV INJURY $ 1,000,000
GENERAL AGGREGATE S 2,000,000,
GENL AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMPIOP AGG S 2,000,000
7 POLICY n JECOT- n LOC
AUTOMOBILE
LIABILITY
ANYAUTO
COMBINEDSINGLE LIMIT $ 1,000,000
(Eaaccident)
Q
BODILY INJURY
(Per person) S
X
ALL OWNED AUTOS
SCHEDULED AUTOS
C
HIRED AUTOS
NON-OWNEDAUTOS
PGC10009664632
09/21/12
09/21/13
BODILY INJURY
(PeracadenX) 5
PROPERTY DAMAGE
(Peraccident) $ 100,000
GARAGE LIABILITY
AUTO ONLY -EA ACCIDENT $
OTHER THAN EAACC S
AUTOONLY: AGG I S
ANYAUTO
EXCESSIUMBRELLA LIABILITY
EACH OCCURRENCE is
OCCUR CI CLAIMS MADE
AGGREGATE S
j
j S
I S
DEDUCTIBLE
I S
RETENTION $
B
WORKERS COMPENSATIONAND
EMPLOYERS LIABILITY
OFMCBLMEMBER EXCLUDED?
ffyesdescribe under
SPECIAL PROVISIONSbelow
WC 895-88-38
04/10/13
( 04/10/14
{ WCSTATUOTB- -
I X TORYLIMd ER
E.L. EACH ACCIDENT $ 100,000
E.L. DISEASE - EA EMPLOYE $ 100,000
r DISEASE-POLICY LIMIT I S 500,000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS
Joseph Wink is covered by the workers compensation policy.
CFRTIFICATF Hf -11 ITFR !`AKIPCI I ATIl1W
Joseph Wink
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
THE SIDING GUY
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MP30 DAYS WRITTEN
181 Concord Road
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE .TO DO SO SHALL
Chelmsford, MA 01824
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
i
AUTHqRtZED REPRESENTATIVE
Lam{
A6UKUz0(ZUU1/Utf)/ I (DAGORO CORPORATION 1988
,: i -% _ r %- V /- — R Q_— -i C". ---
Name
Companym/in�G�!
SIDING GUY, INC.
Street Address (do not use a Post Office Box address)
Contractor/ Salesperson/ Owner Name
9 7
jeG✓ 5 r AJ &U evz
Joe Wink 976-621-0729
City/Town
State Zip Code
Business Address (must include a street address)
q oud
t/.e/Z
181 Concord Road
Daytime Phone
Evening Phone
City/Town State Zip Code
Chelmsford, MA 01624
Mailing Address (It different from above)
Fax 978-256-0606 1 Federal Employer ID or S.S. Number 043502484
Home Improvement Contractor Reg. Number
Expiration date
Law requires that most home
improvement contractors have
294377
a valid registration number
The Contractor agrees to do the following work for the Homeowner:
(Describe in detail the work to ompleted, spec'fying the type, brand, and grad of
R,e (Ch' J -e62- 190 V1
materials t be used, use.additional sheets if necessa .)
Ce rZ C Cop(:I_ iA.t0a
jov C
Required Permits - The following building permits are required Proposed Start and Completion Schedule - The following schedule will
and will be secured by the contractor as the homeowner's agent: be adhered to unless circu stances beyond the contractor's control arise
(Owners Who secure their own permits Will be ���� G ��
excluded from the Guaranty Fund provisions of _Date when contractor will begin contracted work.
MGL chapter 142A.)� -Z
l�P ate when contracted work will be substantially completed.
Total Contract Price and Payment Schedule
The Contractor agrees to perform the work, furnish the material and labor specified above for the total sum of: Ll 7/0 d (*)
Paymepts will be made according to the following schedule:
$ AT START
$ by HALFWAY
f
$ upon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction)
The following material/equipment must be special $ to be paid for
ordered before the contracted work begins in order
to meet the completion schedule.(**) $ to be paid for
NOTES: (*) Including all finance charges (**) Law requires that any deposit or down -payment required by the contractor before work begins may
not exceed the greater of (a) one-third of the total contract price or (b) the actual cost of any special equipment or custom made material
which must be special ordered in advance to meet the completion schedule.
Express Warranty - Is an express warranty being provided by the contractor? ❑ No ❑ Yes (all terms of the warranty must be attached to the contract)
Subcontractors - The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third
party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for
materials and labor under this agreement Siding Guy work guaranteed as long as we're in business
Contract Acceptance - Upon signing, this document becomes a binding contract under law. Unless otherwise noted within this document, the
contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices
carefully before signing this contract.
® Don't be pressured into signing the contract. Take time to read and fully understand it. Ask questions if something is unclear.
o Make sure the contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and
subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor
registration by writing to the Director at 10 Park Plaza, Room 5170, Boston, MA 02116 or by calling 617-973-8787 or 888-283-3757.
® Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage, or ask to
see a copy of a "proof of insurance" document.
® Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer
Guide to the Home Improvement Contractor Law.
You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business, provided you notify the
contractor in writing at his/her main office or branch office by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the
third business day following the signing of this agreement. See the attached notice of cancellation form for an explanation of this right.
SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!!
Two ident' I copie o the contract must be comple an7s' ed. One copy should go to the homeowner. The other copy, should be kept by the contractor. ZA
Homeowner's Signature Date Con actor's Signature Date