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HomeMy WebLinkAboutBuilding Permit # 12/7/2016 BUILDING IT . TNORTH APPLICATION FOR PLAN EXAMINATION � Late Received 1;� � � Permit N ��� � � d Date Issued: 14- , -1 PORTANT: A llcant must coo lets al] items on this 2ae LAO 1 , PER. ng#;!; I t rl Di tr Llno ahre,Shd ill TYPE OF IMPROVEMENT PROPOSED USE Residential Nora- Residential New Building ❑ One family Vddition ❑ T c or more family ❑ Industrial lteration o. of units: v6ommerci i ❑ Repair, replacement ❑Assessnry Bldg ❑ Others: ❑ Demolition ❑ Other ❑ e � © SII Ipltn OW etlar ❑ rshc Dir. Identification Please Type or Print Clearly) OWNER: Name: /11 ,� �� Phone: SPI 7 7 76 ---(�0' 7 7 Address: , � g- c �. CTO. ' W1` Ph � t? � f �' i . € r ctio 0 ame,lrr� rovemen : er ate ARCH ITE T/EN INEER Phone: Address: Reg. No. FEE SCHEDULE:SULDING PERMIT $1.Z. PER$1000.00 OF THETOTAL ESTIMATED COSTSASED® $125.(0 PER S. Total Project Cost: �G� ;� FEE: Check No.:_ - — � m � Receipt No.: NOTE; Persons contracting with unregistered contractors do not have access the guara lyra d rgrl tare; f A t/O b a re of c� tr #ear. Plaits Submitted ❑ Plans Waived 0 Certified Plot Plan ❑ Stamped Plans ❑ FPublic8ewor SEWERAGE DISPOSAL ❑ Tanning/Massage/Body Art ❑ SvF'iimuing fools❑ Tobacco Sales ❑ Eood Packa&g/Salesptic tank, etc. ❑ permanent Dubnpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF a U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ 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 Water & Sewer Connection/Si nature& Date DrivewaV Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT -' Temp Dumpster on site yes no Located:-at 124.Main Street Hire Department signatureldate COMMENT , limension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, roast or service drop.,requires approval of Electrical Inspector fires No ®ANGER ZONE LITERATURE: fres No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA-- (For department use) bl L 1 o - L3 Notified for pickup Call Email ate Time Contact Name u Doo.Building Permit Revised 2014 3 7 'Town of � qI1�RTt� - ' : �' , Andover 0 �o tnl[E h ver, Klass, - 7 • 0 / CONIC riE WIC.[ � ATE0 U BOARD OF HEALTH Food/Kitchen PERM T T LD Septic System THIS CERTIFIES THAT ........ ��........... .��.�.... ..����� .. ..���..�..���� BUILDING INSPECTOR has permission to erect .......................... buRldings on .... ..... ! Lk c........ Foundation to b p ... .tob...�40 t..... ...�. .0. E..�... y Rough e occupied as ... ... ,... i�/. .IA. chimney provided that the person accepting this permits halFin eve respect conform to the terms of the application� p pp Final on file in 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 PERMIT EXPIRES 16 MONTHS ELECTRICAL INSPECTOR . UNLESS CONSTRUCTIO TS Rough Service ............ "BUILDING INSPECTOR.. Final GAS INSPECTOR Occupancy Permit Required t® Occupy Buildiu Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final. No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. MDM Contract Owner: Stop and Shop Companies 1.385 Hancock st. Quincy, MA 02169 Contractor: MDM Construction 41 Brigantine Cir. Norwell, MA 02061 RE: Liquor Store @ Stop and Shop N. Andover Scoe o Work p * Install all shelving as per plan. * Install 2 Hill refrigerated self contained cases as per plan. * Install new walls as per plan (8-6" high). No ceiling, open at top. * Install new counter and displays as per plan. * Install front and rear security gates as per plan. 'rotai Project Cost: $24,700 Exclusions: Any costs associated with change in above scope. Any unforeseen construction issues associated with this project. Any Fire alarm or Security alarm work. Please sign and return to: MDM Construction, 41 Brigantine Cir., Norwell, MA 02061 Owner:z-, Date: 1"7 The Commonwealth of Massachusetts r Department oflndustrialAceidents X Congress Street, Suite 100 Boston,MA 02114-2017 wivmmass.gov/dia Wericers'Compensation Insurance Affldavit:Builders/Conti-actorst.Electricians/Plumbers. TO BE FILED WITH TRH vERMIi ilia AUTHORITY, A Wicautinformation Please Print Legibi Nairn (Business/Organization/Individual): ro iI�k ,IJ C « Address:_.___.._._ _ t i City/State/Zip: _ _-_ _ Mni Phone#: , Are you an employer?Check the appropriate box: Type of project(r'equir'ed): I.Q I am a employer with employees(full and/or part-time).* 7. 0 New construction 2,Q 1 am a sole proprietor or partnership and have no employees working for me in 8, F; I emodeling any capacity.[No workers'comp.insurance required.] 3.Q I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. El Demolition 4.[JI am a homeowner and will be hiring contractors to conduct all work on my property. I will. 10 F1 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repair's or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5. tam a general contractor and I have hired the sub-contractors listed an the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insruanceJ 6.[:]We are a corporation and its officers have exercised their right of'oxemption per M(irL C. 1.4. father 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *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. 1-arrr au employer drat is pr'ovidirrg iporlcers'coniperrsation irrsurarece for'Frey eneployees. Below is the policy and job site infor-rnatiou. Insurance Company Name. f Policy#or Self-ins.Lic,it: (" 1 () 20 t T� -10 AExpiration Tate: 0 Job Site Address: a -. � ro City/State/Zip: 0 ; Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date), Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine tip to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORD ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the IIIA for insurance coverage verification. hereby fy �� t s acid perraltles of pei jury that the information provitled above is true and correct. tl ra rrlrn Silnature'. cern . rrruler �.. Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Pernrit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: AC40R[3 UhK 11F1[;A I C Uh LIAUILI I Y 1N5UKAN[:t 11r2612016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 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 02136-001 NA14'IEACT Branch 2136--1 - q Starkweather&Shepley Ins Brkg Inc AM1811,Ext): {901)935-3640 We.No.: (401)431-9323 PO Box 649 ADDRESS: spanciera@starshep.aom Providence,RI 02901-0649 - -- INSURER(S)AFFORDING COVERAGE NAIC# J(SURERA: A.I.M. Mutual Insurance Company INSURED INSURER.B NDM Construction Management Inc INSURER C 91 Brigantine Circle INSURER D: Norwell, MA 02061 �w INSURER E INRI In WR F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER, 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO 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, IN5R TYPE OF INSURANCE AINSRN POLICY NUMBERLTR MMfI)DIYEYY MMI OLIC YEXY LIMITS ^T GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ _PREMISES Ea occurrence CLAIMS-MADE OCCUR MED EXP(Any one person) $ _ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ EN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG $ OLICY —]LOG AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident - ANY AUTO BODILY INJURY(Per person) $ _.. ALL OVMED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) $ _ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS MADE AGGREGATE $ DED RETENTION $ _ $ TORY LIMITS ER T A P � ICIPL�� fE7CEGUTIVEYIN E.L.EACH ACCIDENT $ 1_000 000.00 A o Ic €)? [N] NIA VWC-100-6020269-2016A 811612016 8116/2017 (Myandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 0 OkSCRIPTION OF OPERATIONS below _ W E.L.DISEASE-POLICY LIMIT $ 11,000,000.00. DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,it more space Is required) CERTIFICATE HOLDER CANCELLATION Town of North Andover 120 Main Street SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE North Andover,MA 01846 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 0 1 988-201 0 ACORD CORPORATION.All rights reserved. ACORD 25(20101051 The ACORD name and luno are renistered marks of ACORD Client#: 100370 MDMCONST DATE(MM/DDIYYYY) ACORD., CERTIFICATE OF LIABILITY INSURANCE 11/23/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 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 NAME Lauren Luke Starlcweather&Shepley(WW) PH° 7$1 320-9660 FAX 401-431-9635 { /C __ A/C No Insurance Corp.of MA E-MAIL Nuke@starshep.com PO BOX 5549 INSURERS)AFFORDING COVERAGE NAIC 0 Providence, RI 02901-0549 INSURER A:Kinsale Insurance Company 38920 INSURED INSURER B,Plymouth Rock Assurance Co 14737 MDM Construction Management Inc, INSURERC; 41 Brigantine Circle INSURER D: T, _ Norwell, MA 02061 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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 HEOUIREMFNT, TERM OR CONDITIONOF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO 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, INSR ADDL UBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MMIDD/YYY MWDDIYYYY A X COMMERCIAL GENERAL LIABILITY 01000369140 03/21/2016 03/21/2017 EACH OCCURRENCE $11000,000 71 CLAIMS-MADE �OCCUR PRE L a DAM6iCIEj� E"FN'TED occurrence} $100'000- X 100 000X Bl/PD Ded:2,500 MED EXP(Anyone person) $ _ PERSONAL&ADV INJURY $1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s2,01[110,000 PRO PRODUCTS-COMPIOPAGG $2,000,000 POLICY 1-1JECT LOC OTHER: $ COMBINED SINGLE LIMIT B AUTOMOBILE LIABILITY PRC00001004734 4/29/'2016 04/29/201 Ea accident) 1,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $ UT AOS AUTOS PROPERTY DAMAGE NON-OWNED X HIRED AUTOS Per accident X AUTOS $ A UMBRELLA LIAB OCCUR 01000369090 3/21/2016 03121/2017 EACH OCCURRENCE $5,000,000 X1 EXCESS LIAR X CLAIMS-MADE AGGREGATE s5,000,000 DED RETENTION$ $ WORKERS COMPENSATION PER ETH- AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNI=R/EXECUTtVE YIN E.L.EACH ACCIDENT $ OFFICEWMEMBEREXCLUDED? NIA (Mandatary In NH) E.L.D€SEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-PflLICY LIMIT $ 9 BDESCRIPTION OF OPERATIONS/LOCATIONS 1 VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is reclu€red) p Proof of Insurance. CERTIFICATE HOLDER CANCELLATION Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover,MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION.All rights reserved. j, ACORD 25(2014/01) 1 of 1 The ACORD name and logo are registered marks of ACORD � y Q mss hus s oepa4me2 a Pub% safety \\ Board of Buildmg keeg 9 sans and Standards G nse CS-087596 © : ® MARK FMcGuNC HE Y ® 41 BRIGANTINE CIRCLE � �. RWE LMA 2#1 ° . . co%maven» oaG,a