HomeMy WebLinkAboutBuilding Permit #764 - Stacy Drive 6/23/2008BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit N0: 7 Date Received
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DESCRIPTION OF wUKrc I U rst rKCrum'vir-u.
Identification Please Type or Print Clearly)
OWNER: Name: Prescaff Village- Associn+wn Phone:
ARCHITECT/ENGINEER Phone:
Address:
Reg. No
FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ 18 7 5 0. - FEE: $ '2,ZS'
Check No.: �1` _Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranVund
A
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
PLANNING &-DEVELOPMENT ❑
COMMENTS
DATE APPROVED
DATE REJECTED DATE APPROVED
CONSERVATION ❑ . ❑
COMMENTS
DATE REJECTED DATE APPROVED
HEALTH ❑ ❑
COMMENTS
d
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comments
Conservation Decision: Comments
Dimension
Number of Stories:
Total land area, sq. ft.:
Total square feet of floor area, based on Exterior dimensions.
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
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
o 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
o 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
❑ 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 DEPARTMENTMFORM07
Revised 2.2007
Location
No. 7 Date V✓1G Z.�-o�
HORTot TOWN OF NORTH ANDOVER
L
9
Certificate of Occupancy $
s�cNusE�� Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
21 11
-I Building Inspector
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�WooucER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFC'I~ . Tlt}t.
The Douglas Insurance Agency ; ONLY AND CONFERS NO RIGHTS UPON THE CEk• -'ICATE
Lynnfield Woods Office Park HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXT:AD OR
220 Broadway Suite #301 ALTER THE COVERAGE AFFORDED BY -THE POLICIES BELOW
Lynnfield, MA 01940 COMPANIES AFFORDING COVERAGE
COMPANY ► N — —�
A Commerce Insurance Co
wivAEO
COMPANY
Johnston Construction Co., Inc. • e- Zurich -American Insurance Co.
2 Reo Road
Peabody, MA 01940 COMPANY
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COMPANY
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COVERAGES ....: ..:, 1i4►gl •-:}�-�..,.:. '.. r�•i`� rN: ^ia'•''c-•• „r ;i: • ��.'� ... .•. •,b ,. _�.. - _
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.. S TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAiMED ABOVE FOR THE POLICY PE;;IG--
:: TEL NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHIC►• T-.•�
CATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL !►d 'E•pt►dc
:•SDN; AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
F TYPE OF INSURANCE POLICY "WRIERPOLICY EFFECTIVE POLICY EXPIRATION
_ DATE (MM/DD/YY) DATE (WWDO/M LIMITS
�EnERAL LIABILITY
X .0MMERCIAL GENERAL LIABRITY
_.A+MS MADE OCCUR
A -. EQ S a CONT PROI
-00wO8itt LIABELmr
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x
X _. •JWNE:) AjTOS
A .E:r4:E.AuTOS
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;ARAGE UASIUTti
Et:ESS UABAIn
AABRE . a'tORM
'-E A '..An UMBRELLA FORM
ftCORAERS COMPENSATION AND
ErtPLOTERS UABILTY
- YGENERAL AGGREGATE
s 300,000
PApDUCTSCOMP,OPAGG
s 300,000
PERSONAL 6 ADV INJURY
-
JN9125 8/20/0.? 812010 8 EACHoCCURRENCE _
'-s_300,000
=-'300, 000
FIRE DAMAGE (Any one tool
S 50,000
MED EXP IAn, one person'
5.,.000
COMBINED SINGLE LIMA
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OOMMT16128 1/1/07 1111Q8 BODILY 94JURY
(
-
1100,000
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BODILY INJURY-
(Poo 1041
'300,000
B •-E 2ROPRIETOR. - -6ZZUB-673X905-1-01
=A;*'dgS•EXECUrrvE INCL
'CRS ARE EXCI
PROPERTY DAMAGE
1100,000
AUTO ONLY . EA ACCIDENT
s ----
OTHER THAN AUTO oNL Y
-
-
EACH ACCIDENT
t
_—�— _ -- AGGREGATE
s
EACH OCCURRENCE
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AGGREGATE
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STANDBY LIARS
- -
9/20/06 9120/08 EACH�CCIDErt.
400,000
DISEASE POLICYLIMI1
500,000
-- DISEASE - EACH EMPLOYEE —'1lLO�
000- -
:•cSC21p,1On Of OPERAT►ON&LOCATIONSNEMICLEWSPIECIAL ITEMS --- - - -
Construction work at various locations
CERTIFICATE HOLDER
Town of North Andover
North Andover, MA 01845
ACORD 25-S (3/93)
- - - -•— - —. —__- CANCELLATION
SNOULD ANY OF THE ABOVE DESCRIBED POUCIES 8E CANCELLED 8EFORE TNF
EXPIRATION DATE THEREOF, THE ISSUING COMPANY YYILL ENDEAVOR IO um,.
DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO TIrE LEFT
• BUT F 'NTE TO MAIL SUCH NOTICE SMALL IMPOSE NO OBLIGATION OR LIABILITI
i OF UPON THE `►-...� fT5 OR REPRESEMATIVES
AUTMO ATIYE __.
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Ai tL.i.f E D n i. �i /
_4 www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): :;ahi stop C6ns4rucfion
Address: 1 Rea R d
City/State/Zip: Peabody, MA oI,ico Phone #:
Are you an employer? Check the appropriate box:
. ❑ 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, § 1(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. F1 Electrical repairs or additions
I 1.❑ Plumbing repairs or additions
12.0 Roof repairs
13.❑ Other
*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 their workers' comp. policy information.
1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: ('bmmPrce Thsurance
Policy # or Self -ins. Lic. #: 6 7 7 u 3- c 1 3 X90 T- I- o I Expiration Date: 9- 20-03
Job Site Address: 5 TA C v % R i v e City/State/Zip: Nit, Ar, do ve r, MA
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.
Signature: A,,H%W e, Qoiti�Ce tax_ Date: 7-23-69
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 #:
The Commonwealth of Massachusetts
^;
Department of Industrial Accidents
o, y5 t. r .
IFS.."
Office of Investigations
1 11 I t! I -
;, lilt,;
600 Washington Street
O flit
w : ;
Boston, MA 02111
_4 www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): :;ahi stop C6ns4rucfion
Address: 1 Rea R d
City/State/Zip: Peabody, MA oI,ico Phone #:
Are you an employer? Check the appropriate box:
. ❑ 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, § 1(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. F1 Electrical repairs or additions
I 1.❑ Plumbing repairs or additions
12.0 Roof repairs
13.❑ Other
*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 their workers' comp. policy information.
1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: ('bmmPrce Thsurance
Policy # or Self -ins. Lic. #: 6 7 7 u 3- c 1 3 X90 T- I- o I Expiration Date: 9- 20-03
Job Site Address: 5 TA C v % R i v e City/State/Zip: Nit, Ar, do ve r, MA
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.
Signature: A,,H%W e, Qoiti�Ce tax_ Date: 7-23-69
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 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. # 617-7274900 ext 406 or 1-877-MASSAFE
Revised 5-26-05
Fax # 617-727-7749
www.mass.gov/dia
�, • ✓fie �Da��vs�umusea(� a�"< lla�a�uselta
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
= Registration: 123124
y Expiration: 12/122008 Tr# 125437
Type.. Private Corporation
JOHNSTON CONST CO, INC. .
DAVID JOHNSTON-
2
OHNSTON_2 REO RD �-d-
PEABODY, MA 01960 Adndnistrator
License ofregistration valid for individul use only
before the.expiration date. If found return to:
Board of Building Regulations and Standards
One Ashburton Place Rm.1301
Boston, Ma 02108
Not valid witho signature
JOHNSTON CONSTRUCTION CO., INC.
Two Reo Road
W. Peabody, Massachusetts 01960
(978) 535-3228
www.johnstonconstructioninc.com
May 6, 2008
Great North Property Management
c/o Prescott Village Association
95 Brewery Lane
Suite 210
Portsmouth, NH 03801
Description of work: Building New Desks
New decks installed on Units; 10, 11, 12 & 13..
Decks to be framed with pressure treated wood.
Install Trex decking for the surface of the deck.
Install new pressure treat wood railings.
Remove all rubbish from the premise; Allowance:
Labor & Material :.................................................$18,750.00
Total: ............................................................................... $18,750.00
�Qd,�-:57�23-or\2vk
�'� A NO"
Johnston Cons ction Co., Inc. Date omer Signature Date