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HomeMy WebLinkAboutMiscellaneous - 207 MIDDLESEX STREET 4/30/2018g =4 M M o m Location Com'©' I I'll Noa go Date bb NORTh TOWN OF NORTH ANDOVER I� 9 Certificate of Occupancy $ Building/Frame Permit Fee $ �— Foundation Permit Fee $ Other Permit Fee $ J TOTAL $ j `3 . Check # 3% G 18686 Building Inspector TOWN OF NORTH ANDOVER ]BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REP RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING R BUILDING PERMIT NUMBER O DATE ISSUED: mLlf/-40 SIGNATURE: Builkn Commissioner/129"r of Buildings Date SECTION 1- SITE INFORMATION 1.11 Property Address: 1.2 Assessors Man and Parcel Number: / Oft. o Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area Frontage(fl) ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard ReqWred Provide ReqWwd I Provided LeT±ed I Provided 1.7 Water Supply M.G.L.C.4o. 54) 1.5. Flood Zone Infos ation: 1.8 Sewerage Disposal System: Public ❑ Private 0 Zone Outside Flood Zone ❑ Municipal 0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT I Historic District: Yes _ No _ 2.1 Owner of Record Name (Print) Address for Service Signature Telephone 2.2 Owner of Record: II Name Print Address for Service: i ature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor': Not Applicable ❑ Licen Construction Supervisor. Vt f License Number Address t Expiration Date Signature rTelephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ d v, ompany Name a, (C) Registration Number Add ss _ Signature Telephone Expiration Date SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this in the denial of the issuance of the building permit. Signed affidavit Attached Yes ........❑ No ....... ❑ SECTION 5 Description of Proposed Work check all a ficable New Construction ❑ Existing Building Ie Repair(s) Al Accessory'Aldg. C� � I Demolition ❑ I Other ❑ Brief Description of Proposed Work: r C �. 1 er. �,rtr%wT c c e'Til►d ♦ TTn I-ANCTDTTrTlnV rnCTC 1 on. Failure to provide this affidavit will result Ks) ❑ Addition ❑ n Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY. 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction -P- 3 Plumbing Building Permit fee (a) x (b) 70 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNERAUTHUKIGA11UN IU 15t UVMrLV,1LJ0 WX=1`N I OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION Date Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name 54 Signature o Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS IS7 2 ND 3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 1'i 1 11 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street J Boston, MA 02111 i' www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lestibly Name (Business/Organization/Individual): "ZG��Vo-ow Address: % L %R„ L P,./L, t City/State/Zip: , Lg.•0.1 Phone #: &I (Y Are you an employer? Check the appropriate box: I . ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] f have hired the sub -contractors listed on the attached sheet. $ These sub -contractors have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § ] (4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. [J Electrical repairs or additions 1 l .❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box # I -must also fill out the section below showing their workers' compensation policy information. 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 their workers' comp. policy information. / am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. jy Insurance Company Name: "( t► ra` s{,. S Policy # or Self -ins. Lie. #: R W t- '*2a !2L t c) i 2005- Expiration Date: A Job Site Address: r090 61 Ad /to q. P tf" City/State/Zip:-)J, s." I&A 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. 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. 61R/� 0y�— 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 #: 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 may be 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 infonnation (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. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia DATE (MM/DD/YYYY) ACORD- CERTIFICATE OF LIABILITY INSURANCE 06/20/2005 PRODUCER THIS CTT ERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Pelham Insurance Services, Inc. I HOLDER. THIS ALTER THE COVERAGE IAFFORDED BY THE POLICATE DOES NOT 4CIES BELOW. , EXTEND OR P.O. Box 960 122 Bridge Street Pelham NH 03076 INSURED Thomas Doyle dba Thompson's Construction & 8 West St Salem NH 03079 INSURERS AFFORDING COVERAGE NAIC # INSURER A. Nautilus INSURER B: Associated Industries INSURER C: :OVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING AN 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. PO!,ICY F.FFFrTIVE POI.Ir.Y Fy.PIRATIQN LIMITS 'SR ADD'MCLAIMSMADE NCE POLICY NUMBER DATE (MM/DD/YY) DATE (MMIDD/YY) TR INSR04/15/2005 04/15/2006 1,000,000 NC 330578 EACH OCCURRENCE S A DAMAGE TO RENTED $ 50,000 PREMISES Ea occurrence AL LIABILITY 1,000 MED EXP (Any one person) $ a OCCUR 1,000,000 , 000 , 000 ffGEN:ER:A�LLA",:G:"R:E:G::,:T:E'�: RSONAV INJUY $ $ 2,000,000 oonni irTs . rnMP/OP AGG $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRO - POLICY JECT LOC SINGLE LIMIT AUTOMOBILE LIABILITY $ t) P(��11�URY ANY AUTO ALL OWNED AUTOS 5 (ep) SCHEDULED AUTOS BODILY INJURY $ HIRED AUTOS (Per accident) NON -OWNED AUTOS PROPERTY DAMAGE 9 (Per accident) AUTO ONLY - EA ACCIDENT s GARAGE LIABILITY OTHER THAN EA ACC $ ANY AUTO AUTO ONLY: AGG $ EACH OCCURRENCE s EXCESSIUMBRELLA LIABILITY ° nGGaEG47E nrrU^ F7 CLA.!AS MAC!P $ S DEDUCTIBLE S RETENTIONS 04/21/2005 04/21/2006 WC STATU- OTH- x TORYLIMITS ER B WORKERS COMPENSATION AND AWC7012214012005 $ 100,00( EMPLOYERS' LIABILITY E L. EACH ACCIDENT ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. DISEASE - EA EMPLOYEE $ 100,00( OFFICER/MEMBEREXCLUDED? 500,00( II yes, describe under E.L. DISEASE - POLICY LIMIT S SPECIAL PROVISIONS below OTHER DESCRIPTION OF 0PERATIONSILOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Job: Various roofing and construction CANCELLATION CERTIFICATE HOLDER Wynwood Associates 19 Basswood Lane Andover MA 01810 ACORD 25 (2001108) �-- INS025 (0108) 05 T ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE ION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZE 4 REPRESENTATIVE ©ACORD CORPORATION 19 Page 1 ELECTRONIC LASER FORMS, INC. - (800)327-0545 �, ? �- x/ 7 5 - <3 / & DL- NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL 11,S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 10A. The debris will be disposed of in: Fire Department Sign off: Dumpster Permit 0 Y 1�- 4� S (Location of Facility) Signature of Permit Applicant `-- 0 % Date Vrapogat rage o� Free Estimates 105 Haverhill Street Fully Insured Methuen, MA 01844 �T(� THOMPSON ' S ROOFING <J (978) 691-1355 Shingles — Slate — Rubber Roof Single Ply — Copper Work PROPOSAL SUBMITTED TO PHONE DATE Ann Ro 8-16-05 STREET JOB NAME 207 Middlesex Road CITY. STATE AND ZIP CODE JOB LOCATION North Andover MA 01845 ARCHITECT DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for: Strip off all roof shingles on house Renail all loose boards Install aluinum drip edge around roof line Apply ice and water shield 6 ft. up all along edge and in valleys Apply 151b. felt paper on rest of roof area with a 30 year Architect shingle ,Reshingle Install new flange around soil pipe ,Cut in 4 roof.vents ' On flat roof fasten down � inch insulation Apply .060 Manville rubber fully adhered Install metal around edge Glue and caulk all seams Remove all work related debris 30 year warranty on material 5 year guarantee on labor construction lic. #060112 improvement #128612 M PrOP00 hereby to furnish material and labor — complete in accordance with above specifications, for the sum of: Thirteen thousand five hundred dollars ($ 13,500.00 Payment to be made as follows: 84.500.00 start of iob balance upon completion All material is guaranteed to be as speoMbd. All work to be cornplaW In a workmanlike manner according to standard Practices. Any alteration or deviation from above specMlcetkm I wv" {� extra costs will be executed only upon wNten orders, and wIN becortn an a" a" over and above the estimate. All agreetrriarb ao 0go upon strikes, sccidmta or delays beyond our conroi. Owner to carry in, Corrado and other necessary Insane. Our workers am fully Note: This proposal may be e..4 r,„ VA.4 —1. r•..I.. W.1r4.n Iur.r.ry withdrawn by us If riot accented within days. Zicceptance of %9ropogat —The above prices, specifications and conditions are satisfactory and aro hereby accepted. You are authorized to do the Signature work as specified. PaymMt will be made as outlined above. 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