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HomeMy WebLinkAboutBuilding Permit # 6/22/2016Permit No#: Date Issued: LOCATION UIL NG PE MIT T WN OF 0 TH A DOVER APPLICATION FOR PLAN EXAMINATION Date Received IMPORTANT: Applicant ust complete all items on this page PROPERTY OWNERAe MAP 62 PARCEL:Oia /4/1/1 (7(a 94.s Pr/int / 'n /2 7C4t( 2 r 04/7 ec,v Print 100 Year Struct re yes ZONING DISTRICT: Historic District yes (Fik) Machine Shop Village yes Q.) rEo 4CHU5 TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Building 0 Addition [Alteration 0 One family 0 Two or more family No. of units: 0 Industrial E l Commercial 0 Repair, replacement 0 Demolition * 0 Assessory Bldg 0 Others: 0 Other A / e Wetlands,,,,d66ziunEl, /7/r , d s'. 7 17vP,' e f el5f1C,el ifv e Y / / 1 ''' Watershed )01/6: / ° ewer , , , DESCRIPTION OF WORK TO BE PERFORMED: . 4le Afi C (0,71,(( Identification - Please Type or Print Clearly OWNER: Name:PR Re, si(),/c,‘4/3 /7'ict, jt7- Phone: 6/7 /PO Address: alc.54/N ,4-77(c), 74A 02,k,zr Contractor Name: Email: he,/ Address: Supervisor's Construction License: Home Improvement License: Exp. Date: Phone: Exp. Date: /2 - r ARCHITECT/ENGINEER kt,'..1" /fir Phone: <-07s Address: /417,/0,. D Reg. No. VS-3C) FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: S Check No.: NOT "". r ns contracting with unregistered ntractor iIL FEE: $ <2. 0(1.b1) Recei t or- 6-2 e access to the guaranty fund Plans Submitted-N Plans Waived _ Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer V Tanning/Massage/Body Swimming Pools ❑ Well — Art Tobacco Sales _ C Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Duinpster on Site C THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF m U FORM PLANNING & p'VELOPMENT Reviewed On COMMElyr \')i\ f'\ \r&r UJCt, Cat( Signature_►` CONSERVATION COMMENTS Reviewed on Signature HEALTH Reviewed on COMMENTS A-10� (7-‘ r(Lec +-co- ,J3 (Jr-S i'` l Q uvil y Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/signature & Date IDPW Town Engineer: Signature: Driveway Permit Located 384 Osgood Street 73 C O ® M. cn n c O CD Z CD ®' '0 '® ". ® ® 09 O C = CD CD moo o.; pa lmn o a o C', C, 0 CA VIOLATION of the Zoning or Building Regulations Voids this Permit. a_ 0 0 n <u' t a o} uolsslwiad seq 6/7/16 Town of North Andover 1600 Osgood Street Building 20, Suite 2035 North Andover, MA 01845 RE: Panera Bread 58 Peters Street North Andover, MA CORNERSTONE DESIGN/BUILD SERVICES, INC. LETTER OF INTENT Please be advised that the intent of the construction services shall be to complete a minor non-structural alterations to the beverage counter, P05 counter, and associated finishes with a proposed budget of: $72,862.00; as follows: Btillding t 47,677 Electrical $ 18,960 • Plumbing $ Mechanical $ -0- Fire Protection $ -0_ Fire Detection .,-0- The terms of this agreement will be submitted in the form of an MA Contract between the parties prior to the start of construction. Respectfully, ►�: .400t • Pres. Robert E. Sanford Jr. Lin President nstruction & Facilities Director Cornerstone Design/Build Services, Inc. Panera Bread / PR Restaurants Accept 163 Grand Army Highway — Swansea, MA 02777 508.679.2500 Phone 508.679.2600 Fax The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Cornerstone Design/Build Services, Inc. Address:163 Grand Army Highway City/State/Zip:Swansea, MA 02777 Phone #:508-679-2500 Are you an employer? Check the appropriate box: . 0✓ I am a employer with 22 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 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.] t These sub -contractors have employees and have workers' comp. insurance.t 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 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions I2.❑ 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. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: St. Paul/Travelers Policy # or Self -ins. Lic. #:DTAUB978K751-8-15 Job Site Address:Panera Bread - 58 Peters Street Expiration Date:7/19/2014 City/State/Zip:N. Andover, MA 01845 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. I do hereby certify un pa' s and aides of perjury that the information provided above is true and correct. Signature: I® Date: 6/7/16 Phone #:508-679-2500 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 #: AWR CERTIFICATE OF LIABILITY INSURANCE I DATE(MM/DD/YYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 6/7/2016 HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Newport Insurance Agency 460 East Main Road Middletown RI 02842 INSURED Cornerstone Design Build 163 GAR Hwy Swansea MA 02777 INSURER F : COVERAGES CERTIFICATE NUMBER MASTER 2015-2016 REVISION NUMBER: COE: Ann Rymszewicz PHONE (401) 619-1660 I FAX (A/C No Ext): (A/C, No): (401) 619-2689 ADE-DRESS:arymszewicz@newportinsuranceagency.com INSURER(S) AFFORDING COVERAGE INSURER A :St . Paul/Travelers Ins . Co . INSURER B : NAIC # TPC001 INSURER C: INSURER D : INSURER E : THIS IS TO CERTIFY THAT TH INDICATED. CERTIFICATE EXCLUSIONS INSR NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH REOSPECT R TOLICY WHICH PERIOD THIS MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE ADDL IYSD SUBR WVD POLICY NUMBER (MMJDDNYFYY) (MMIDD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY A EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 300, 000 DT—CO-978K7518—00E-15 7/19/2015 7/19/2016 MED EXP (Any one person) $ 10, 000 GEN'L AGGREGATE PERSONAL & ADV INJURY $ 1,000,000 P JECOT LOC PRODUCTS - COMP/OP AGG $ 3, 000, 000 OTHER: Employee Benefits $ 1,000,000 AUTOMOBILE X LIABILITY ANY COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 A AUTO ALL OWNED SCHEDULED BODILY INJURY (Per person) $ A AUTOS A AUTOS NON -OWNED BA_g78K7518-15 7/19/2015 7/19/2016 BODILY INJURY (Per accident) $ HIRED AUTOS AUTOS PROPERTY DAMAGE (Per accident) $ Underinsured motorist $ 1,000,000 X UMBRELLA LIAB EXCESS LIAB X O OCCUR EACH OCCURRENCE $ 5,000,000 A CLAIMS -MADE X AGGREGATE $ 5,000,000 DED RETENTION$ 10,000 DTSM—CUP-4217L829—TIL-15 7/19/2015 7/19/2016 $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/ N PER OTH- X STATUTE I ER A ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N N / A EL EACH ACCIDENT $ 1,000,000 (Mandatory in NH) It yes, describe under DTAUB978K751-8-15 7/19/2015 7/19/2016 E.L. DISEASE- EA EMPLOYEE $ 1,000,000 D DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1, 000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) f`_CRTICIf•ATC Linl non CANCELLATION TOWN OF NORTH ANDOVER 1600 OSGOOD ST BUILDING 20, SUITE 2035 NORTH ANDOVER, MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Ann Ryms z ewi c z /NEWAR1 ACORD 25 (2014/01) INS025 (2o14oi) © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 0 MAW 1111111110 { \[\jƒj ] ) .. \\ \\ }} \\ ?«.�:..