HomeMy WebLinkAboutBuilding Permit #359 - Exception 11/7/2007 MUILuirvv
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit N0: Date Received
�SSACHUgE�
Date Issued: 6
IMPORTANT Applicant must complete all items on this age
1
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
[I Addition ❑ Two or more family ❑ Industrial
❑ Alteration No. of units: Commercial
epair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
ROOM
[�ESCRIPTI NOF WORK TO BE PREFORMED:
G22.e
1lent' icatio—n Please Type orPrint Cle�rly)
Wd
OWNER: Name: ,g &41 e � Phone:
Address
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4��� N � �' �I&I����j��I� 'K' k 5 P ����� d�'IS� P''h•'C � �.�rrirZ'^�y`,.y':
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ARCH Phone:,.! -_ 9f�
Re No.
Address: g
FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ d.Sdff " FEE: $
Check No.: 1 Receipt No.: d�
NOTE: Persons contracting with unregistered contractors do of hav acc to the guaranty fund
.nxaw,�ca aou ussaxu ,..r�. ,.n,,
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
DATE REJECTED DATE APPROVED
PLANNING &.-DEVELOPMENT ❑ ❑
COMMENTS
_ DATE REJECTED DATE APPROVED
CONSERVATION
COMMENTS
DATE REJECTED DATE APPROVE
HEALTH ❑ El
COMMENTS
Zoning Board of Appeals: Variance, Petition No: -Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/signature & nate
Located at 384 Osgood Street Driveway Permit
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Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq.A.:
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
❑ Notified for pickup - Date
Doc.Building Permit Revised 2007 �` '
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
c3 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2007
Location /Dl S ei4/ O,cfT
No. Date
NORTM TOWN OF NORTH ANDOVER
3? � . 0�
F 9
Certificate of Occupancy $
�ss+cHust Building/Frame Permit Fee $
Foundation Permit Fee $ "
Other Permit Fee $
4
TOTAL $
Check #
2071 ]
Building Inspector
V40RTII
Town of
No. o
dover, Mass. y
T O �+ LAK 1 '
.Q
COCMICKEwICK
�ipSDRATED
l BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
THIS CERTIFIES THAT..........
.....CI. .....oci Irl........ BUILDING INSPECTOR... .�..
Foundation
has permission to erect........................................ buildin s ow.. Lire! �r r#A
.. . ............ r1i ............ .... Rough
to be occupied as... �� ��ir�„ Chimney
.....0!........� I"'1.
provided that the person accepting this p d shall in every respect conform to the terms of the application on file in
this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Final
Buildings in the Town of North Andover.
PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
PERMIT EXPIRES IN 6 MONTHS Final
UNLESS CONSTRUSTARTS ELECTRICAL INSPECTOR
Rough
.......................................................................
_ ............... Service
BUILDING INS
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Display in a Conspicuous Place on the Premises — Do Not Remove Rough
Final
No Lathing or Dry Wall To Be Done
Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT
Burner
Street No.
SEE REVERSE SIDE Smoke Det.
Clio 26095 3ILVIE3
ACORD. CERTIFICATE OF LIABILi7YM,INSURANCE
o7/MT
PRooucBIe :TitIS tiR11HlICATi 101li6tlW Ai A MATTt1R a INfORUATION ;
d.K McWRhy Ins.Agcy.Inc. ONL1TANo CONPERti NO R16MT8 UPON TNR CERTUICATE
10 Centennial Drive YlN�COtTIFICw1R 0=NOTA1IIQt0,9XI OCR
Aum THE ammAOE ArPORO W BY THE POLICES BELOW.
Peabody .MA 01960
978$32-U" IN81lRERS AMRD811G COVERAGE �NAJC
INVAGO INsURER k, ArmrlCar+States Insurance Company 33618
Silverio Construction Inc. ;N3uaERa The Charter Oak Fre Insurance Compa
543 Woburn Street INSUIIERD: 30oq Indemnity Insurance Co.
Wilmington,MA 01887 I,eURERD,
IIALNIBR Q
COVERAGES
THE POLICIES OF INSURANCE U4T33O BELOW HAVE OWN 133UEO TO THE INSURED NAMED ADOBE FOIL THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHIP DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUGD OR
MAY PERTAIN.THE INSURANGS AFFORDED SY THE POLICIES OESCri10E0 HERRN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITICNS OF SUCH
POLIC43.AGGREGATE LIMITS SHOWN MAY MAK SEEN REDUCED YY PAID CLAIMS,
TYPE OF BISURANOE POLCY WISER tT1v! 04 LIMRi
A GENERAL L.IA AFY 01COSS49183 07131/07 07/31/08 FAC+OCCUaaENOE $1,000,000
AMA r NTED
X CGMMERGAL GENERAL LIABILITY 3000
CLAIMS MADE a OCCUR MED EXP( arm WMI) $10,000
PERSONAL LADY INJURY S1.000.000
3ENERALAOCREGATE s2.000.000
GEYL AGOR90ATE UNIT APPLIES PER PRODUCTS•COM►IOP ADO s2.000.000
POLICY LOC
C AUTOMOBILE LIABILITY 3116540 07/31/07 07131MS COMBINED SINGLELIMR $
(EA sdddsn0
ANY ALTO
ALL OWNED AUT03 SOGLY INJURY 32501000
X scnEDULEDAuros (Pu ww)
X 1«aED AUTOS iK dm)INJURY
$500,000
X NON.OVVNEO AUTOS
PROPERTY DAMAGE $100.000
(ru wadant)
GARA*E LIA HUTY AUTO ONLY-CA ACCIDENT 1
ANY AUTO OTHER THAN EA ACC $
AUTO CNLY: AGG f
Exca6VUNIBRELLA LIABINTY EACH CCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE S
$
cEOUCT SLE j
FM'ENTION 3 $
B woRlcEasco.PENaATaN AND XOU84833Y93707 07/31!07 07!31!06 X wC STA u- crn•
EwLOYERs LIABILITY E.L.EACH ACCIDENT 3100 000
ANY PRcpmjfTOR/PARTNER'EXECUTIVE
O"ICEIVMEMBER EXCLUDED? j E.L.CIFAASE-EA EMPLOYEE1$100,000
If yes,doWto VidaE,L.CISEASE-POLICY LIMIT 3500 000
b
SPE I v IONS bew
OTNEN
I
I
0M RIPTION OF OPERATIONS)LACAnom I vaKcLBs I EXCL.USION3 ADOEO BY ENOMEkWAT I SMCLAL PROVI=-%*
CERTIFICATE MOLDER CANCELLAT N
SrWULD ANY OF THE ABOVE DESCRIBED POUCIEE BE CANCELLED KFONE THE EXPIRATION
For Insured's Purposes DATE THEREOF,TNEKiU1NGINSVRER'MLLENCEAVORTOWAIL _Ifi— 0AY3Vvm TEN
Nonc&TO THE CERTIFICATS HOWIR NAMED TO THE LER,BUT FAILURE TO 00$0 31MLL
NrPOE!MO DOUGATION OR UAYIUTY OF ANT 0M UPON THE IN3UREa-ITS AGENTS OR
RE►RQEENTATMES.
O M'�• TATTVE
ACORD 25(2001109) 1 o(2 It54M LEG 0 ACORD CORPORATION 1IIIB8
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,operaWa 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, §25CM 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-contiactor(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 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:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. #k 6.17-727-4900 ext 406 or 1-877-MASSAFE
` Fax# 617-727-7749
Revised 1122-06
www.mass_gov/dia
The Commonwealth of Massachusetts
Department of Industrial Accidents
W Office of Investigations
w
600 Washington Street
Boston,MA 02111
� <W
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print):,e ibl
Name(Business/Organization/Individual):
Address:
City/State/Zip: Phone.#:
Are on an employer?Check the/appropriate box: Type of project(required):,,
1. I am a employer with 4. E] I am a general contractor and I
employees(full and/or part-hme).* have hired the sub-contractors 6. ❑New construction
2.❑ Lam a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑Demolition
working for me in any capacity. employees and have workers9. ❑Building addition
[No workers' comp, insurance comp. insurance.$
required.] 5. ❑ We are a corporation and its 10.E]Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.r_1 Other
comp. insurance required.]
*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:,
Policy#or Self-ins. Lic.#: Q_ 3� e.�? 7� Expiration Date:� �
c
Job Site Address�����iri � 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 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 pa' s a penalties of perjury that the information provided above is true and correct.
Si nate : Date: 17-115-1
Phone#: _
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#:
✓le P � 0/
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number..;O 005387
gl�fhdater
4/0:8,/1947
042008
Tr.no: 22088
RestnEt�d 00
JOHN L SILVER"-
4
845 WOBURN S 01887 " �J
WILMINGTON, Cortlmissioner
MA
✓die C�oar�n�rea�� o�✓�aoaacrLccae�4 ,
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration`-,106478
,I
Expiration 7/ 312008
Type: Private Corporation
S!LVERIO CONSTRUCTION CO _'INC..
t
John Silverio
845 WOBURN STREETS#5_, C-1
1^J!LMINGTON, MA 01887 Deputy Administrator
I
I
E S T I M A T E MOYNILAN NORTH Rb.A7TMP- TITrMM7D -T-uo
ro six 3-26 X63 CrES rsr srF] TI'. TIME 07:58
0
t7:7R'_'R AFLLITI6, M.� U15c'-g-9126 n
j
761-15�
0500 976-6o4-3310 FP1:- -97S-66--0872.
SOLD TO: £ST111
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ESTIMATE ONLY. GOOD FOR 7 DAYS '
ESRB96 DATE 10/18/07 ESTIMATE ON ONLY. GOOD FOR 7 DAYS SNIP TO.
o
0001 TIME 08 :24 0�
J SILVERIO CONST PHASE 000 T�
125 jtiTYNDEKIST FARM RD
( HORSE FARM AT END ) PACE 6 0
ANDOVER, MA
FOR: DLVD ON ORDER / T SCH D'IE:10/18/07 ORD:121415-00 YOUSILVERIO/125 WYNDEKT IN OUT
TYP: WHS OUR TRUCK ORI} DTE:10 i_8 0 7 ��m 3
/ / OTH 0EER
TER 96 06 0
-c
PRODUCTS & QUANTITIES MAY DO NOT ADD AN-Y SHIP-TO'S TO THIS ACCOUNT PER x
MARY WITH ACttJAL CONSTRUCTI0N MICHAEL MOYNIHAN �
r--
c
c
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NE ITEM I�7O_ QTY U/1d DESCRIPTION UN��RICE
EXT PRICE
x
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0
co
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IS NOT A RECEIPT*** M
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0
Go
NET SALES: 2037. 93
OT_HR CHR.G: 0.00
TAX: 101 .90
TOTAL: 2139. 83
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rn
IS LVER10
� CONSTRUCTI . .
COMMERCIAL ■ RESIDENTIAL
Board of Building Regula (ons and Standards
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement Contractor Registration
Reqistration: 106478
Type: Private Corporation
Expiration: 7/23/2008
SILVERIO CONSTRUCTION CO., INC.
John Silverio -- -
845 WORBURN STREET#5
WILMINGTON, MA 01887
Update Address and return card. Mark reason for chars .
)PS-CA1 Co 50M-05,06-PC8490
p 1 Address — Renewal - Employment Lost Card
,o, ��ce TDammaru�o.¢�z a�[� iude�6
\ Board of Building Regulations and Standards License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration: 106478 Board of Building Regulations and Standards
Expiration: 7/23/2008
One Ashburton Place Rm 1301
Type: Private Corporation
Boston,Ma.02108
SILVERIO CONSTRUCTION CO., INC.
4Silverio
854VdCBURN STREET#5
^: L;b11NGTON. MA 01887 Deputy Administrator
No valid without signatureBoard of Buildin Regulations
One Ashburton P ace, Rm 1301
Boston, Ma 02108-1618
License: CONSTRUCTION SUPERVISOR LICENSE Birthdate: 04/08/1947
Number: CS 005387 Expires: 04/08/2008 Restricted To: 00
JOHN L SILVERIO
845 WOBURN ST
WILMINGTON, MA 01887
Tr. no: 22088
Keep top for receipt and change of address notification.
)PS-CAI O 50M-04,05-PC8698
845 Woburn Street Wilmington, Massachusetts 01887
781-944-3219 978-694-4064 0 1-800-585-3219 FAX 978-694-4067
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GAURD RAIL TO 12" SONO TUBES W/ 3#5 VERTICAL ��` Yr ; m Z
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STRINGERS AT 12" O.C. 3 N 3
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