HomeMy WebLinkAboutBuilding Permit #153 - 132 Waverly Road 8/25/2009 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued:
47
I P TANT.Applicant must complete all items on this page
LOCATION N
Print
PROPERTY OWNER
Print
MAP NO: PARCEL: ZONING DISTRICT: Historic District .- yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
New Building One family
Addition Two or more family Industrial
Alteration No. of units: Commercial
Repair, replacement Assessory Bldg Others:
Demolition Other
Septic Well Floodplain Wetlands Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: : Phone:
Address:
CONTRACTOR Name.
P oe -) '
Address: t`
63(yoa
Supervisor's Construction License: Exp. Date'
Home improvementLicense: Exp. 'Date.
ARCH ITECTIENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULFa9w
ERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost:DIFEE: $ �J -D O
Check No.: 2� Receipt No.:
NOTE: Persons contracting i re r d c ntractors do not have access to the uaranty f d
yignature of Agent/Owneri Signature of contractor
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
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
WatE & Sewer Connection/Signature &Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Ten Dumpster on site yes no
Located at 124 Main Street k
i
Fire Department signatureldate
COMMENTS
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
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 2008
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
❑ Fl.00r/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
❑ 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
hedecOne copsion y m the Board of cording
peals
that the appeal period is over. The applicant must then get this recorded at the Registry of and proof of re
must be submitted with the building application
Doc: Doc.Building Permit Revised 2008
E
Location ;2,
r
No. -s 3 Date ''� r Z",
�oRTh TOWN OF NORTH ANDOVER
� S
a y
+ ; . Certificate of Occupancy $
CNUs<� Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $ '
TOTAL $
Check #jq1.2 2
2256
t4uil ing Inspector
08/25/2009 13:45 FAX 6036448716
DAT:(MMmpIYYVY)
ACORQ CERTIFICATE OF LIABILITY INSURANCE j 08/2s/2009 _
PRC/DUG4;R (603)669-0704 FAX (603)669-6831 THIS CERTIFICATE IS ISSUED ASA MATTF,R OF INFORMATION
Znfantine Insurance, Inc, ONLY AND CONFERS NO RIGHTS UPON THE CFRTIFIC.ATE
HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTI NO OR
P.O. Box 5125 ALTER THE COVERAGE AFfOftDED BY THE POLICIES BELOW;,,,,,,,,,,,,,,,
Manchester, NH 0::108 n AIC n
INSURERS AFFORDING COVERAGE
Kathy Peppers -_.__..._................,........ ......._....
_..._.__..._...._................................ . __._.... ---._... -... I .4198
1nIaf�rr,A. Peerless Insurance . .. .,...._,_....___......_.....
IWAIRCD .._..__...._.�._....,.,,.
- _
Netherlands ins....urance 14171
_
Rescon Construction Services, LLC Iu•.mwl-I+c: Excelsior Insurance L104S
3 Commercial lane, Unit C ua ,ti`RT,
Londonderry, NH 03053
C VERAGEu ANCIING
THC g041CfFS pfIN 1R/NCE LISTED BELOW HAVE nCGN Ie5UEDTQ THE INSURED NAM@pAOOVLOfOLI(;Yy.(<C )
tJOlMITHCT
fir
Y R UIRE.MC=NT.1 F.T4M Ort pON0I'ION OF ANY CONTRACT OR O'rwj: f)OCl)ME,NT WITH RESPECT TO W FIICH THIS CERTIF�C AN CONDITfr.,W,;OP M C O
MAY PERTNra.THE IN:1Cn?nlvcri nFFDFH)EU 1;Y THE POLICIES DE5CR1HEb 1•+fRE1M 1;,,UC3JGC7 TO ALL THE TERM,,.EXCLUSIONS O
POLICIES.AOCREGATLF LIMIT,SNOWN MAY HAVE PFI-N REDLICED BY PAID CLAIMS .......
__............._.-._...................—,.............,,.... . , .....,...,_ _...::..
.._:_......:•.:. LILY I.PFCCTIVE I+U`I'Y E'K�I�N TI'N
IM•iR (?f.1.1 POLICY NUMLTKIR
lT1 rAn9 TYPE OPINSLtRANCE 6leAbUp011LX1 b1, .IMMIG 1L .__.._......-.......__
:_. ,,.r CCP9275777 01/01/2009 01/01/2010 r•.�r.:rlc;l'Gu1rI+I:n(:i•: 1,000,000
nr:Nr:11AL LlAmn t1v _•..•• ...... •••• •....
'I;A.unaf0 F rT)FFNTF4) <. 50 000
J( t:(:•Mrnf•R!ay.ufrH°•An1 1!AfA;.'YY )c:•
Fn'd7Gr7i(^i:'Uf7
V11",P1,01 tnnv Mm aor:.r.•1 3 5,000
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2.000,00
}lig _
AurtTMOD!LE LJ.:DIL11Y BA�927917 01/01/2009 01/01/2010 it(+.Ir+rC!':JI•tr:l.t urAfr
_. Ilia r•x.'Cemj 1,000,000
ANY AIJQJ
At ritVtirli AU i OF 1•,Irri.)Il.!'!+J.r'sRY
Ivr.nr.•%rml
X NINF•I)l,Ili:i:R T;011(Y I"1;1;7+
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A1.IT0 C,rn.Y.Pn Aiaa';i:Fr S
GARAGE LIADILITY -
A•7r null) CT rI IAh( fn AiA' :
AUTO ONLY Arty
FXCFTSAJMRRFI,I,AI•IA(,1ILITV CU8Z44Z9 01/01/2009 01/01/2010 r.K1•It,-l:lmlTCNcr. S 1,000,000_
_ nr;,(,1r,unit 1_,0_0.0_,000
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nF NX,Thai f ......
-ter. ' 10,00
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WC:8379426 01/01/2009 01/01/2010 X °'Jt•`Inilt
WORHCR6 COMPQNUMON AND _.___C('d:Y_1111..4 _. ..1 ra. --•--..-._.........__......
EMPLOYERS'LIAnILIT-1 STATES INCLUDED:NH, LL ::ACII ACr I(:LW 5 500.000
C .i,Y Par,,t'Rll'1 QIZ/1"AI;rK,•.f7,!i(F:I"1171'!;, --_.._................. _._....._...-..
,t Flrl HAY1PMIt:K 1 X,a uI N-rY) I:M ERS/OFFICERS:EXCLUDED a t !)c•W •r t,Fr ail r:•YI`1 500,000
«) -.•)wanNm v 1+,, FROM COVERAGE F tx::,a r:M:-,;��r::r 1.1411x S — 500,000
()iV•1FlN —
Ok'(:NIPTWN OF OP(ihAT10�S I LOCA'f1ON5,V•NN:LCLJ CXCIU$IC)NTi ADDC DY ENDM5E-.*MCNT I SP,(IAI.PH0VI%tf)NS
eference: David & Mary Mo.'-"ton 132 Waverfy Street NorN, Andover, MA
liorkers, Compensation: other States Insurance: All states except ND, OH, WA. & WY.
lass is included in the broad form all states coverage
Cancellation exception: N14 Law requires 10 days notice for cancellation for non-payment of premium.
CERTIFICATE HOLDER -ANCELLkTION
.N0VLU ANY OF 1'H('.ADOv(;L)C,'b(.rtlNtD Pp(u;lt;r1E(:ANGt LLG9 UEI qHL I Hh
CXPIRA'IIUN bA1G 1FICNrOr,11+'1'ISSUING WtWAL'H WILL t:NUCAVOR YO MAIL
Town of North Andover 30'^' Oert>WRITTEN NOTICE TO Tilt GCRT+I-fCA'IC 110LOCR NAMEP'?TIIC I.CrT,
Building Dept.
Uu1 fA,LURC TO MAIL SUCN NOTICE GNALL IMROIK NOOOLIGAiNN Of L1ADtlITY
Gerry Br'QYIn
1600 OSQOOd Street Or ANY KIND UPON TN WRER.ITL:AGI T.'.-OI R4I)FIC,l•Nrp7rvf,t.
North OsgoAndood
Street
O1R4S AUTIfORIZZEDREPRE N t� r..._
PA A i J A&JV
FORATK)N 1988
ACORD 26(2001108( FAX: (978)688-9542 OACORD
Ota/'15/'Luny 1's:45 inn bVdb440i ro
IMPORTANT
It the cartifiCA10 1141001'is an ADDITIONAL INSURED,the policy(ies)must be HndorsPtl A st3tertir'nt
on this cenificats goes not confer rights to thr_certificate holder in lieu of such ondorsernf nt(;s).
If Sl,ff3POGATION IS WAIVED, ',Utgerl to the lawns and conditions of jhf,;policy,certain policies mey
roquire an endorf.E,!rvwnt A statement on this cenifirato doin not confer rights to the certifirale
hold•ar in lieu of orldorsement(s).
DISCLAIMER
The-,e-l:ficate of 6lguaince oil the reverse side of this form doe;!:not Constitute a contra((hetwoon
the,!%,-a ing fnsurcrts),authorizoid represent hive or producer, and The.certificate holdar, nor does it
lfflrr'1?INe?ly or nec.¢(lively amend, ewx no w:altar the coverage 3fforclecf ay the poliCIES h5tOd thereon
ACORD 25(100110$)
1.ce L-OmPAanweaft of Massachusetts
�lt O'Damnerrt Of Industrial Accidents
�' Office of Inrestigatio)u .
. .� 600 N
,
lashing tan Street
-� B&SIon, MA 02111
n�ww_rnassgrry/dia •
Workers' Compensation IaskMee Affidavit R.wwd rs/Coutractors/nectriciarts a
A 'cant Inf�►rrga ion /Piambers
Piease Print Leeibi
aMe(Bus'ness/0rgaoiza60Mndividual);
Address: a
Ci
Are you 8a eo3pioyerl Cheek.the appmpriate-bozo
1.Q I'am a employer with 4. Type of PrqJect(r ui
Q J am a gemeraJ coniractar and I (requi*:
2.Qemployes(full and/or part-time).* have hired the mub- 6 ❑New construcct on .
I am.asole �
P�pn ar P �- Iisttd on the attached sheet t 7. []Remodeiiag
ship and have no employees . '1'h `
workingfor mem aci su&conftators have
. �S'capacity. work � 8• Q Demolition•
o workers co � comp.insurance.
mP. iastuant;e.. 5. 9• Q BUIlding addition
Wo Bre g CBrporaftt)ti and 1t5
3.Qrequired.] ofn"cers have exercised their 10.0_Ela.-trical
I am a homeowner doing all work right of repans or additions
myseI£[No-workers'cxtrrtp. exairtption pw MOI: 11.Q Piumbing L52, §1(4),and-we have no TeP or addi£ions
insurance• Roof
ngnu�tL]Vit' .entployeCs.[No work=? 12.I] r'epair's
*Amy ePP[;cm+ttic COmP• insurancemquired.] I3.(�.O}}ter
d>xics bo>'#l mutt also fi[1 ottt the section below abu
Home--*wbo n6mtt this of ridavh indicating they are an wtag thoirworicatb ooripensation poiMY infnmutioa
Coatracmrs that check.this box must dvmg "''o 'end fhon hie outside eomraetots nnist •
ea sdd.�fioasl sheetshown•the nems ofthe cu submtt anew affidavit Wicdiat such'
b-contn;ctois and
I�;art eioyer titaif���vtaairarg:►oar� '"�" o worI� fm=,OIL.
irtform�o.L �rrsarmrce for my.enrploves: B�1ne��.*.�.e �:..
Po'y� jac sir
Inswuncc Company Name:
Pofiay#or Serf-ins. Lie.#:
Expiration Date;
Job Site Addr mss
AtEaah a copy of the workers'.compensation ii d CrtylStatrJLp:
Farms m se Po c3 emEaration page showiaa
eta a Coverage as requited under Section 25A of ( the policy number and expimfioa ofate}
fine up to S`I,5oo.f)o and/or one-year iYrrprisonm 1vIOL c. 15Z can Iead to the imposition of cs�tinal
Of up Go$250.00 a � as weal 8s civil penalties in the form of a STOP W MiraDRK ORDER Peres of a
investi against-the violator. Be advised that a copy.of this sta=ant may be forwarded to the Of m f a fine
gallons of the DIA for insurance coverage venin-cion,
I do hereby cwg8 the
of perpuY hkf&the irufarnwVoa yrvvided ova
Ar e and coned
Date: g
Phone 9: _7 �
offIcial use on*. Do nal wale is this
4 In be compte—r-Md by at or town efif cial
City or Town:
Issuin„g Permit/Licence#
Authority(circle one):
1. Board of Beattb Z Smiling Department 3.City/Town Clerk 4. Electrical Inspector S..PIum6irra Itis
6 Other
pastor
Contact Person:
e
Phon #;
Information & lid In's' tructions-
Mas=husetts
General Laws chapter l S2 requires all emp 3 oyers to provide workers' compensation for thou employers.
Pursuant to this statutZ,an employee is defined as"..:every person in the service of another under any contract of birp
ssc ,1A
=Treor implied,oral or written:"
An emptayer is defined as"an individual partnership,asst:i6a6M corporation or other legal entity,or arty two(r more
of the'formping engaged in a joint enterprise,and includi"g the legal rcpresentataves of a dec=ad employer,or the
receiver ortnutx•of an individual,partnership,associetiazn or other legal-entity,employing ernployem'Howe=the
owner-of a dwelling house having not more than thrx apa_rtinerrts and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance,construction orrcpw
wdre on such dwellinghouse
or on the grounds or building appurtm=thereto shall not b=m=of sucb employment be deemed to be an employe."
MGL chapter 152,§25C(6)also states that"every state as-local licensing agency Shan withhold the issuance,or
reeewal of a license or permit to operate a business or tta construct baiidigs in the commonwealth for any
applicant who has not produced acceptable evideam of compliance with tiie.insnrance coverage required."
Additionak,MOL chapter 157,,§25C(7)states-Neither tile commonwealth nor any of its polificel submvisions shall
enter into any eottraat for the peribrimince,of public work until-acceptabk evidence of compliance with the ins==
requirements.of this chapter have been prwm tad to the contracting authority."
Apple®fits
Please fill out the workers'compensation•affidavit completely,by checking the boxes that apply to your situaiaon and,if
necessary, supply sub-contractor(s)name(sl addreas(es):and phone number(s)along with their cm-rificate(s)of
insurance. Limited,Liability Companies(LLC)or Limited Umbility Partnerships(LLP)with no employers otherthan the
members or.partrmas,arc not required,to car*workers'ccsrnpmu;ation insmarrcx. Van LLC or LLP dots.have
lb ees a policy is wired. Be advised that this afn
'gyp Y Po c5' Teq davit m be submitted to the artraettt of
may Dep Industrial
Acciderits for confarmation of insraance oDvarne. Also•be sure to
sign and date the affidavit The affidavit should
b i ret=ed to the city or town that the application for the permit or licxnse is being requested,not'the Departmemt of
Industrial Accidents. Should you have arty.questions.repo-cling the law or if you are required to obtain a workers'
compensation policy,please-cd the Department at the member.fisted below, Self insured con. antes should entatheir
salf°ixssrusnce lice;isc MUM=on tire'appropiiata i=
City or Town Officials
Please be sure that the afadavit is complee and printed legibly. The Departnmmnt has provided a spat at the bottom
of the affidavit fear you to fifl out in the event the.Office of Investigations}mar to contact you regarding the applicant.
Please be surz to fin in the permit/license number which W-till be used as a mferencc number. in addition,an applicant
that must submit multiple patmit/iicense applications in any givem year,need only submit one affidavit indicating-current
policy inform son(if necessary)and under"Job Site Adds-em"the applicarrt should write"all locations in (city or
town), A copy of-the affidavit that has be sn.officisily stamped or marked by1he city or town may be provided to the
appiicznt as prx+of that a band efFidavit is on n"ie for fuz pernrits or licenses. A neve atfidavitmust be filled out each
year.Wheal a home awri.-r or citizen is' obtaining a lic:-use. or permit not related to any business or commercial venture
(i.e a dog license or permit to bum leaves etc.)said person is NOT-required to-campictt this affidavit
Tic 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.
7-Im Department's address,tel.,-phone and fax munber.
The Commonwmadth of Massac3�tisetts
Department of lmdusb7al Accidents
Office-of rmVesk-scions
600 Washington Streit
Boston, MA 02111
TeL#617-727-4900 iza 4.06 or 1-977-MASSA:FE
Fax 4 61 7-727-774
Bruised 5-26-{15 Www.>aass.govidia p '
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