HomeMy WebLinkAboutMiscellaneous - 655 WAVERLY ROAD 4/30/2018N)
Location—� & ,
No. A Date
7/
TOWN OF NORTH ANDOVER
0
6�- , 2
Certificate of Occupancy $
0 41
Building/Frame Permit Fee $
14U
Foundation Permit Fee $
Other Permit Fee
TOTAL
Check #
18722
Building Inspece—
t TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER:
DATE ISSUED:
SIGNATURE:
Building Co missionerfl
Ispector of Buildings Date
SECTION I- SITE INFORMATION
1. 1 Property Address:
1.2 Usessm Map and ParcelNumber:
L9
Map Number Parcel Number
alwpo "/,�F
1.3 Zoning hiformation:
Zoning District Proposed Use
1.4 Property Dimensions:
�-(Sf) fr � �ge a 0
1.6 BURDING SETBACKS (ft)
Front Yard Side Yard
Rear Yard
Required Provide ReqWred. Provided
ReqWred Provided
1.7 Water Supply M.G.I-�.i&-§54) 1.5. Flood Zone Information:
11b I
Public 0 Private Zone 0
1.9 SeweNe Disposal System:
unl= 1 0 On Site Disposal System 0
SECTION 2 - PROPERTY OWNERS111P/tft—THORIZED AGENT
1911storic District Yp-s'—Fo
2.1 Owner of Record
d141m //i/z(
Name (Print) Address for Service
A -4-'P, go
Sigh'ature Telephone
2.2 Owner of Record:
". Name Print Address for Service:
J�S'-t—n,tu, Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
/l/ q""p —'1,V /- ,
Licensed Construction Supervisor:
Address
Z, 2? �L 63
Nignature Telephone
Not Applicable 0
License Number
Expiration Date
3.2 Registered Home Improvement Contractor
1 -31 -Ab
Not Applicable 0
WV
Company Name
pv Ale
Registration Number
Expiration Date
Addr��
Signature ____Iqephone
SECTION 4 -WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) 1 2
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes ....... 0 No ....... 0
SECTION 5 Description of Proposed Work (check all applicable)
New Construction 11 Existing F�iilding 0 Repair(s) 0 Alteration s) 0 Addition 0
Accessory Bldg. 11 Dim iit"' n- other t9e' specify
o ion
Brief Description of Proposed Work:
LT 0
I SECTION 6 - ESTMATED CONSTRUCTION COSTS I
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
OFFICIAL USE ONLY
I Building
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) x (b)
4 Mechanical (11VAC)
5 Fire Protection
6 Total (1+24-3+4+5)
Check Number
SECTION 7a OWNER AUTHORITATION 'rO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERNnT
as Owner/ALIthorized Agent of subject property
Hereby authorize to act on
Mly behalf', inall matters relative to work authorized by this building pennitapplication.
Signature of Owner Date
SFCTION7h OWNER/AUTHORIZEDACEN*F DECLARATION
1, 1,31,,�4_las Own
property - P er/dEEE�)f subject
Hereby declare that the statements and inforination on the foregoing application tire true and accurate, to the best of my knowledge
and belief
5
19R 14
Print Name
Sipature of ffwnerj&e__n Date
NO. OF STORIES SIZE
BASENIJ;NT OR SI,AB
SIZE OF Fl,(.X:)R TIMBERS -)ND 30
spy'"N
DIMENSIONS OF SlJJ,S
PfTMENSIONS OFPOSTS
DINIENSIONS OF CilRDERS
I-U�_'IGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
NIATERIAL OF Cf IDT%4NE Y
IS BUILDING ON SOLID OR FrLLI-,*D LAND
IS 13UILDINCrCoNNI---,CTEDI'ONATTJRALCIAS LINE
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Proposal Submitted To:
Addre ss
Phone #
We
.,We herebypsuhmot
Page# ... .... . ... ....... of ............. LaLes
0
,,..Nonnan L Blad Construction — 978.687.6263
40 Ferriview Ave. #10, N. Andover MA 01846
MA Lic. 0 16141 MA Re.q. 131960
Job Name
Job Location A�
Job #
C7 ^15, Date Mw 1 Date of Plafrs
Fax 9 Architect
d estimates for:
A - rd�� 4?
d9
;01
0
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."P A'. /'�2 9�4- "69 "A
Kj
—77 -- — - ---------- ---
rWe propose hereby to furnish material and labor — complete in accordance with.We abov . e specifications for the sum of:
Dollars
with payments to be made as follows: an W�
...........
Any alteration or deviation from above specifications Involving extra costs will be Respectfully
executed only upon written order, and will become an extra charge over and
submitted
above the estimate. All agreements contingent upon strikes, accidents, or delays
beyond our control. Note —this proposarmay be withdrawn by u§'If not accepted within .2d clays�.
acceptanct of Propossal.
The above prices, specifications and conditions are satisfactory and are
Signatur
hereby accepted. You are authorized to do the work as specified.
Payments will be made as outlined above.
bate of 4 Acc * eptance Aj 2_'6� Signatur\
M NQ381 9 MADE
0/1. i'llamaclu"Jea
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 131950
Expiration: 10/13/2006
Type: Individual
NORMAN L. BLAD
NORMAN BLAD
40FERNVIEW AVE #10
N. ANDOVER, MA 01845 Administrator
t
h
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 016141
Birthdate: 03/15/1947
Expires: 03/15/2006 Tr. no: '2169.0
Restricted: 00
NORMAN L BLAD.
40 FERNVIEW AVE #10
N ANDOVER,
MA 01845
Commissioner
0/1. i'llamaclu"Jea
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 131950
Expiration: 10/13/2006
Type: Individual
NORMAN L. BLAD
NORMAN BLAD
40FERNVIEW AVE #10
N. ANDOVER, MA 01845 Administrator
t
h
NORFOLK AND DEDHAM MUTUAL FIRE INSURANCE COMPANY
S14ALL CONTRACTORS POLICY
RENEWAL CERTIFICATE
.1-olicy # R0412920
Named
BLAD NORMAN & DAVID N
Insured *40 FE'RNVIEW AVE #10
. N ANDOVER MA 01845
FORM OF BUSINESS:
Agent INTERNET INSURANCE AGENCY, INC
Phone (978) 685-7690
-Agent # 20"155
Policy Period: ONE YEAR from 0/04/05 to 02/04/06
This declarations page together with the policT jacket, the policy form.and any endorsements, completes this policy.
Coverage begins at 12:01 A.M. Standard ime at the covered premises.
..................................... . .. . . ......................
Basic Annual Endorsements State Taxes Total Annual Add'I/Re - t :. u �; r :. n
Prprnhirn P PM11im Fpp--, Prprnhim Prprn 0 11M
$1,488
. ..... . $1,488
Bid /Location
AciXess If Differenti
Mortgagee Information
Business Description -
[CARPENTRY
POLICY DEDUCTIBLE
BUSINESS PERSONAL PROPERTY
Limit
T 0 T A L P R E M I U M P E R 8 U I L D I N Q
$250
$10,000
Included
1
$ 11, 489. 00
EXCEPT FOR FIRE LEGAL LIABILITY, EACH PAID CLAIM FOR THE THE FOLLOWING COVERAGES REDUCES THE AMOUNT OF
INSURANCE WE PROVIDE DURING THE APPLICABLE ANNUAL PERIOD. PLEASE REFER TO PARAGRAPH D.4 OF THE BUSINESS
LIABILITY COVERAGE FORM.
LIAB & MED EXP (OCCURRENCE/GEN AGG/PROD COMP OPS AGG)
MEDICAL EXPENSES $300/ $600/ $600 Included
TENANT FIRE LEGAL LIABILITY $5 1 ne I uded
$50 Included
SEE ATTACHED PAGE
BOP -2 I
(REV.01/94) Twe of Pavment: DIRECT RTI1 in
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Bus i ness/organ ization/I nd iv idlial): A 41 A Al
Address:- �� )"'ExA�, V/ "IF aAt ,
City/State/Zip:.&A�A:o PC- t?,MA 0/9e/fhone
Are you an employer? Check the appropriate box:
1. El I am a employer with 4. El I arn a general contractor and I
�ernployees (full and/or part-tii-ne).*
2. 1 arn a sole proprietor or partner-
ship and have no employees
working for ine in any capacity.
[No workers' comp. insurance
required.]
3. 0 1 am a homeowner doing all work
myself [No workers' cornp.
insurance required.] t
have hired the sub -contractors
I isted on the attached sheet.
These sub -contractors have
workers' cornp. insurance.
We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. F-1 New construction
7. E] Remodeling
8. 0 Demolition
9. E] Building addition
I O.E] Electrical repairs or additions
I I.E] Plumbing repairs or additions
122"koof repairs
13T� 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.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurancefor my eniplayees. Below is the policy andjob site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #:
Job Site Address:
Expiration Date:
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 staternent may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify !p4g the pains andpenalties ofjerjW that the information provided above is true and correct.
S_
Phone4: 17 r2 Or- / f 7 - � A 4�1�
Of
.ficial use only. Do not write in this area, it) 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 inc I uding the legal representatives of a deceased employer, or tile
receiver or trustee of an ind iv idual, partnersh ip, association or other legal entity, ern ploy ing employees. Howeverthe
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 oil 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
requirernents 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 (LLQ 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 tile city or town that the application for the pen -nit 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 pen-nit/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 cornmercial 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 I ike 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
NORTH ANDOVER BUILDING DEPARTMENT
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordan�e with thLp provision of MGL c 40 S 54, a condition of Building Permit
at: /, r
5 V, I �/� W. is that the debris resulting from this work shall be
disposed of in a prop'erly 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
I OA.
The debris will be disposed of in:
Fire Department Sign off-
Dumpster Permit
& 01
(Location of Facility) )Yc) R 0 1,,IP114
Signature of Permit Applicant
Date
0
Location /, S- 57- 6VA u -e LL r PaP
No. /,p Y -(o Date
40R'rol TOWN OF NORTH ANDOVER
Certificate of Occupancy $
CHU Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
17 *..1'- 6 3
At,( ce-<� -
Building Inspector
TON" OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPA15 RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
777
BUILDING PERMIT NUMBER: DATE ISSUED:
Z4 LW
SIGNATURE:
Building Commissioner/IRECEtor of Buildings Date
SECTION 1- SITE INFORMATION
1. 1 Property Address:
1.2 Assessors Map and Parcel Number:
(6 - 66 C' <S'
A,-yt-�, A -It
Map Number Parcel Number
1.3 Zoning Information:
1.4 Property Dimensions:
R - � R F
S- &C't -
Zoning District Proposed Use
Lot Area (sf) Frontage (ft)
1.6 BUIELDING SETBACKS (ft)
Front Yard Side Yard
Rear Yard
Required Provide Required Provided
Required Provided
- 36 1 JV6 _e±n 2� 1-4-, Ak
'361 1 A! (S
1.7 Water ly M.G.I-C.40. Si 54) 1.5. Flood Zone Information:
�" Zone Outside Flood
1.9 Se 7W Disposal System:
Public Private 0 Zone R
mun�cipal On Site Disposal Sys
SECTION 2 - PROPERTY OWNERSEEIP/AUTHORIZED AGENT
es NO V
2.1 Owner of Record
L'4�� E, 6 -Q��
Namc(lPrint) U Address for Service:
r— e-
-A2
Si(nt# e Telephone
2.�7ner of Record:
rqame Print Address for Service:
S ature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable 0
(-�zs 14 6 5—(-,- K.
Licensed Construction Supervisor:
License Number
/ 6 A N R J
Address
Al. Az"dA-i-x- /4(/(
W6 9/
Expiration Date
Sign1ature Telephone
L
3.2 Registered Home Improvement Contractor
-1�o-t Applicable El
^6 a-3 7
Company Name
Registration Number
9/7
Expiaton Oate
Address
&ta,J-- Y9 7
Signature Telephone
Ma
X
z
0
M
1(�,
0
z
M
90
0
M
z
Q
SECTION 4 - WORKERS CONWENSATION (NLG.L C 152 § 25c(6) i
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes ....... 0 No ....... 0
SECTION 5 Description of Proposed Work (check an applUic b:le��
New Construction 11 1 Existing Building 0 1 Repair(s) Pr I Alterations(s) 0 1 Addition 0
Accessory Bldg. 0 1 Demolition 11 1 Other 11 Specify
Brief Description of Proposed Work:
I
I SECTION 6 - ESTIMATED CONSTRUCTION COSTS I -
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
OITICIAL USE ONLY
1. Building
Z
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
-3 Plumbing
Building Permit fee (a) x (b)
Mechanical (HVAC)
6
-4
-5 Fire Protection
4 ()
6 Total (1+2+3+4+5)
Check Number
SECTION 7a OWNER AUTHORILATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BURDING PERMIT
'e V as Owner/Augiarind=Awnt of subject property
Hereby authorize to act on
elialf, in al?
I ' to w k authorized by this building permit appli
s "relaLve or cation.
"'4,'Zo , . - . C J /v
Kg6aure of Owner Date
WTION 7b OWNER/AUTHORIZED AGENT DECLARATION
1, c (I � V (,.-.s Z'::�( lao4mm/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
Date
NO. OF, STORIES SIZE
BASENENT OR SLAB
SIZE OF FLOOR TUVIBERS I IT -Y' 2 NJ) 3 RD
SPAN
_DIWNSIONS OF SELLS
DEVIENSIONS OF POSTS ------
_DMENSIONS OF GIRDERS
-HEIGHT OF FOUNDATION THICKNESS
-SIZE OF FOOTING X t a,
MATERIAL OF CHDANEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
!0
, .4 W . -
G REGULATIONS
BOARD OF BUILDIN
License: CONSTRUCTION SUPERVISOR
Nurnb*'� 041071
Q
11.0/1612005 Tr.no: 5738
ko�,tric d.
CHARLES H FOSTER',--,
16A MARGATE
N ANDOVER, MA Of845 Administrator
077 &
Board of IN j1di . It
,qQN RAC.TOP
on: 1-023,
on:
%,�*pq 7/7/20,04
JY06: Individual
CHARLES H. Fb,�TER
arles'
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