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Home My WebLink AboutBuilding Permit #554 - 72 Elm Street 2/20/2007 ■ TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 01 No 0 T6�tio ! 16 F A P * e Permit NO: ��7 Date Received �9S Date Issued: �Ole s ACHUs IMPORTANT:Applicant must complete all items on this page LOCATION ,/Print PROPERTY.OWNER �i��/y.1/ f,?1i*�T -- Print MAP NO.: �I PARCEL: 01 ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential ❑New Building ❑ One family ❑ Addition ❑Two or more family ❑Industrial ❑Alteration No. of units: ?'Repair, replacement ❑Assessory Bldg ❑ Commercial ❑ Demolition ❑Moving(relocation) ❑ Other ❑ Others: ❑Foundation only DESC= WORKTOBE PREFORMED Identification Please Type or Print Clearly) OWNER: Name: ��C/ /�°j /`� i 0&1G 4Phone: Address: ` 4A) <S7 a0aeK CONTRACTOR Name: ^`f IP15;��S ll O S6^/- Phone: Address: .53' _<:�,-7— /� .©G�'�i 1,%t�L Supervisor's Construction License: Q Exp. Date: 6-/ V' 10aC" 0,p Home Improvement License: ` Exp. Date: ARCHITECT/ENGINEER Name: Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PIT:$12.00 _�J1L90.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost :$ � FEE:$ 3S`— Check No.: /�0� Receipt No.: / Page 1 of 4 Location 7J No. Date ��d NpRTM TOWN OF NORTH ANDOVER 9 • ; , Certificate of Occupancy $ cMu CHU Building/Frame Permit Fee $ s� s Foundation Permit Fee $ Other Permit Fee $ TOTAL $ ti Check # Q 19994 �' Building Inspector ■ TYPE OF SEWERAGE DISPOSAL Public Sewer 11Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well F1Tobacco Sales ❑ Food Packaging/Sales Permanent Dumpster on Site ❑ Private(septic tank,etc. ❑ Electric Meter location to project NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ 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 APPROVED HEALTH ❑ ❑ COMMENTS FIRE DEPARTMENT - Temp Dumpster on site yes no Fire Department signature/date COMMENTS Zoning Board of Appeals: Variance,Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water&Sewer connection/Si2nature&Date Driveway Permit Building Setback (ft.) Front Yard Side Yard Rear Yard Required Provided Required Provides Required Provided Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: NOTES and DATA— For department use) I b Page 3 of 4 Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM05 Created JMC.Jan.2006 r 1 I 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 o Floor Plan Or Proposed Interior Work i Addition Or Decks o Building Permit Application ❑ Surveyed Plot Plan ❑ Workers Comp Affidavit 0 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) New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ _Photo of H.I.C. And C.S.L. Licenses o 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 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:BPFORM05 Page 4 of 4 1 xAORTH Town of 4 L Andover No. -0 Orf - * Q , ' A E dover, Mass., COCMIC ME ICK y�' ADRATED PPS` �5 S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT.......... ....1..../... ..�.......Q�.II�..�i .. ........ 0.... . .. ..... :v/G&'(................... Foundation has permission to erect........................................ buildings on .. �� ..... ........................... Rough to be occupied as1Chimney provided that the person acre E&i.p.-ermit shall in every respe conform to the terms of the application on file in Final this office, and to the.provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU .. STARTS Rough ..................... Service . . ..... .. .. . .. ....... .. TOR Final Occupancy Permit Required to Ocmpy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE smoke Det: Phe Contmomvealth of A9assaclucsetts Department of Industrial Accidents Office of Investigations 600 I-Vashingtorr Street Bostolt, MA 021.1.1 ^N �•'�� rvrvlv.mass.gov/din Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/i'lucltibers Applicaut Information Please Print Legibly Natlle (13usinesslOrgaruzation/individual): ZS/ Address: �� - e / -!�:% City/State/Zip: 40 WPMC/'` /V#Phone 11:_97k 6 Are you an employer? Check the appropriate bo • Type of project(required): l.❑ I am a'employer with 4. 011 am a general contractor and 1 6. ❑ New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached:hcct. 1 Zemodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. g. ❑ Building additiolt [No workers' comp. insurance 5. ❑ We are a corporation and its requited.] officers have exercised their 10F] Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑ Roof rcpaits insurance required.] t employees. [No workers' 13.❑ Other comp, insurance required.] 'Any applicant that checks box Hl must also fill out the section below showing their wrnkers'compensalion policy information: t homeowners who summit this affidavit indicating they ate doing all work and then hire outside contractors must sulnnit a new affidavit indicating such. 1Contractom that check this box must attached an additional sheet showing the name orthe sub-contractors and their workers'conn).policy irrronrlation. 1 ant all employer that is providing workers'contpensation insurance for my employees. Below is the policy acrd job site information. s Insurance Company Name: Policy/t or Self-ins. Lie. #: ®��( �� (.�D Expiration Date: fr // 7 uh Job Site Address: City/State/Zip: �w&elluw 41111 n/j-� 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 ora fine,up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the fora)of a STOP WORK ORDER and a fine of up to$250.00 a day agaurst the violator. Be advised that a copy of this statement may be forwarded to die Office of Investigations of the DIA for insurance coverage verification. I do hereby ceilify under lite pains and penalties o perjury that the information provided above is true and correct. e� 0 Si�rlature: �/ -- ---D_rte_ � Phone#: Z? Ojj'icial use only. Do not write in this arca,to be completed by city or toren official. ^ City of-'row": Perntit/License# Issuing Authority(circle one): 1. Board of health 2.Building Department 3.Cityrrown Clerk 4_ Electrical Inspector 5. Plumbing inspector G. Other Contact Person: Phone v: 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 hiie, 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, constriction 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 nurnber(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 perm Vlicense 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 lie 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 opffation_and n}d 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 Tei. # 617-727-4900 ext 406 or 1-877-NtASSAFE Revised 5-26-05' Fax # 617-727-7749 www.mass.gov/dia CERTIFICATE OF INSURANCE ISSUE DATE(MM/DD/YY) 11/08/2006 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE Samuel J Durso Insurance DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE Agency Inc. POLICIES BELOW. 198 Mass Ave Suite 101B COMPANIES AFFORDING COVERAGE North Andover, MA 01845 INSURED Arthur Walsh COMPANY A.I.M. Mutual Insurance Co dba A. J. Walsh&Sons LETTER A 55 Pleasant Street North Andover, MA 01845 COVERAGES THIS IS TO CERTIFY THAT 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 CONTRACTOR OTHER DOCUMENT WITH RESPECTTO 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_ LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATIO LIMITS LTR DATE(MM/DD/YY) DATE(MM/DD/YY) GENERAL LIABILITY GENERAL AGGREGATE $ COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG. $ LAIMS MADE�CCUR PERSONAL&ADV.INJURY $ OWNER'S&CONTRACTOR'S PROT. EACH OCCURRENCE $ FIRE DAMAGE(Any one fire) $ MED.EXPENSE(Any one Person) $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ GARAGE LIABILITY - PROPERTY DAMAGE $ EXCESS LIABILITY EACH OCCURRENCE $ MBRELLA FORM AGGREGATE $ HER THAN UMBRELLA FORM WORKER'S COMPENSATION ANDWSTATU- OTH- .EMPLOYERS'LIABILITY X TORY LIMITS ER' 7014648012006 11/14/2006 11/14/2007 E ACCIDENT $ A THE PROPRIETOR/ INCL EL DISEASE—POLICY LIMIT $ SOO OOO PARTNERSIEXECUTIVE OFFICERS ARE: X EXCL EL DISEASE—EA EMPLOYEE $ 100,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Town of North Andover EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 15 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE UTA ------ B�,yrd of 13uilding g�ufa tifo�nHOME IMPRovwMENros(an`d�S�tLa�n d" ds Registration, ChlrRACToR Expi103358kion: ' 7R1,008 Type- Private CorAora,," SONSAC tittirur vvalsh.Jr }S Pleasant St N Andover MA 0 184 5 r)ePoty Administrator OzmO { a Tf. 55 PLEWW ST k+ NIA MA 01, Pae# of pages CS # 022680 978-6887737 HIC# 103358 A. J. Walsh & Sons or 55 Pleasant Street 1-866-AJWALSH North Andover, MA 01845 Proposal Submitte, Job Name Job# Address Job Location/ Date Date of Plans p_Wehereb4ysub Fax# Architect mit specifi tions and estimates for: ---________ _� �_�+=,�/ — �-l� � •-�?i1 r�v_��t'��' moi! ___ We propose hereby to furnish material and labor—complete in accordance with the above specificatti for the sum__f: $ �4` Dollars with payments to be made as follows: 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 above the estimate.All agreements contingent upon strikes,accidents,or delays submitted beyond our control. Note—this proposal may be withdrawn by us if nota pted within days. 2cceptance of roog The above prices,specifications and conditions are satisfactory and are Signature hereby accepted.You are authorized to do the work as specified. Payments will be made as outlined aboo e.la":7 �—_Date of Acceptance 'dSignature c -