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HomeMy WebLinkAboutBuilding Permit # 12/21/2016 10RT BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION ~ Permit No#: € Date Received Rs gCHUS t Date Issued: - t IMPORTANT:Applicant must complete all items on this page IwOGATION PROPERTY Q'JVNER �. ZONING DISTRICT HtSttarrc ®strct i Yyes no MAP PARCEL .:, _. n Machine shop Village _ yds o TYPE OF IMPROVEMENT PROPOSED USE Residential Non Residential ❑ New Building ❑ One family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration: No. of units: ,Commercial p,Repair, replacement ❑Assessory Bldg ❑ Others. ❑ Demolition ❑ Other - - ❑ Septic O llllell ❑ Food - i ❑Wetlands Q Watershed I]istricf l VUai:_erlSewe'r DESCRIPTION OF rWORK TO 13E PERFORMED: L 41 Identification-- Please Type or Print Clearly' OWNER: Name: y E Phonel Address: 'I° I Ci, -, Cdntracf r' Name' �.� Phone:. � ' Address 6.73 . 1-�w,+- RikI . _2J Supervisor's Constr btiori Lacer se:. 5 Rxp. Date Home Improvement License: __ Exp. Date = ARCHITECTIENGJNEER Phone: Address: Reg. No. F.5E SCHEDULE.BULDINE;PERMIT-$12.o0 PFR$1000,00 OF THE TOTAL ESTIMATED COST BASED ON$125 00 PER S.F Total Project Cost: $ FEE- $ Check No.: '� Receipt No,: 1 . NOTE: Persons contrae ing with unregistered contractors do not have.access to the guaranty fund °°5i��i.a:ti.Ei-c>if_A�en�IQwper _-- mature dt coritrac�or� f NORTH To wn of , � _ Andover 0 �; ., 0 No. 4 hver Klass � o .. . 7 9YE coc"'C"9WICK 1' A0"OATFa ,.ea���5 S V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT .. . alv.g. j.... BUILDING INSPECTOR .. ,. 3 .. .,.. ......0. ....... Foundation has permission to erect .......................... buildings an .... ., ........ � ........,• Rough to be occupied as ....... .........P 5 :.0. .......... Chimney provided1hat the person accep ing this permit shalt in every respect conform to the terms of the application 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 I NSPECTO R UNLESS CONSTRUCTION4,s'-I- Rough Service ... ..... ..... ,. .. ...... •• Final BUILDING INSPECTOR GAS INSPECTOR Occupancy PermitRequired to Occupy 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. u` f �c,v 0 EXECl.3"I'1VE OFFICES 875 EAST STREET TEWKSBURY, MASSACHUSETTS 01876-1495 978--851-8000 December 16, 2016 Attention: Building Inspector Town of North Andover 120 Main Street North Andover, MA 01845 Re: Market Basket 350 Winthrop Avenue North Andover, MA To Whom It May Concern: On behalf of Market Basket, I, Brian Metivier, authorize Seppala Construction to remove and replace existing precast stairs, at the above location, for the estimated sum of Three Thousand Six Hundred Dollars($3,600.00). If you have any questions, please feel free to contact our office. Yours truly, Brian Metivier Enclosures i i I The Commonwealth of Massachusetts g Department ofln&fstrialAccirlents I Congress Stree4 Suite 100 Boston, MA 02114-2017 ' www.mass.govldia NA-lurkers'Compensation Insurance Affidavit: Btiilders/Contractors/Electridans/Plumbers, TO BE FILED WITH THE PERIVIITTINGAUTHORITY. Applicant Information Please Print Legibis Name (Business/organization/Individual): Seppala Construction Co., Inc. Address: 153 Hunt Hill Road City/State/Zip: Rindge, NH 03461 Phone #: 603-899-3011 Are you an employer?Check the appropriate box: Type of project(required): 1.5fl am a employer with 16 employees(full and/or part-time).' 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in g, ❑Remodeling any capacity.(No workers'comp. insurance required.] 9. El Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]f 10E]Building addition 4.❑I am a homeowner-and will be hiring contractors to conduct all work on"property. I will ensure that all contractors either have wolces' compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13. Roof repairs These sub-contractors have employees and have workers' comp.insurance. 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Qther Exterior.Stair Replacement 152,§1(4),and we have no employees. [Noworkers'oomp.insurance required.] JL *Any applieantthat checks box#1 must also rill cut the section below showing thea workers'compensation policy information. t homeowners who submit this affidavit indicating they are doing all worts and then hire outside contractors must submit anew 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 apt employer flirt is providing workers'compensation insu a ncefor my employees. Below is the policy tutdjob site information. Insurance Company Name: Ohio Security Insurance Co. Policy#or Self-ins.Lic.#: XWS (17)57 00 26 30 Expiration Date: 01/01/17 Job Site Address: Market Basket#12 350 Winthrop Avenue City/State/Zip:North 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 MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby con* ander theeppains wtdpeiudlies ofperjwy that flee ircformcVonprovided above istrtae andeorreet Lip-nature: C/ Date: December 15, 2016 ' Phone#: @6-899-'1'0 11 i Official use only. Do not write in this areg to be completer)by city or town o„(vial City or Town: Permit/License# Issuing Authority(circle one): f. Board of Health 2.Building Department 3. City/Town Cleric 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: I i 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 dwellinghouse 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 ora 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 contractfor 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 sm•e 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 nurnber 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 foryou to fill out in the event the office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permitllicense number which will be used as a reference number. In addition,an applicant that must submit multiplepermit/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 notrelated to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 p Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE 9 Fax# 617-727-7749 Revised 02-23-15 www.mass.gavldia DATE(MMIDDIYYYY) Acorn ® CERTIFICATE OF LIABILITY INSURANCE lllk� 1 12/19/2016 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(les) 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 C NTACT �7ennifer Galante FIAT/Cross Insurance PHONEFAX (603)645-4331 arc 1�z. tj: (603)669-3218__ AfC Na: _ 1100 Elm Street AOVRE alante@crossa enc com ADDRESS:]�3 5 y INSURER@)AFFORDING COVERAGE NAIC q Manchester NH 03101 INSURER American Fire & Casualty 24066 INSURED INSURER B:Ohio Security Ins Co 24082 Seppala Construction Co. , Inc. INSURERC,.Ohio _Casualty Insurance Company 24074 153 Hunt Hill Road INSURER D: INSURER E: Rindge NH 03461 INSURER F: COVERAGES CERTIFICATE NUMBER:16-17 All lines 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. ILTR NSR TypE OF INSURANCE ADDL 5UBR POLICY NUMBER 1NM1DDYfYEYYY POLICY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGETO RENTED 300 000 A CLAIMS-MADE X OCCUR PREMISES Ea occetrence $ , X BKA55358735 1/1/2016 1/1/2017 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE"LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 L_'j JPRO- POLICY L_x J LOG E PRODUCTS-COMPlOP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident) X ANY AUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED AUTOS AUTOS BAW55358735 1/1/2016 1/1/2017 BODILY INJURY(Peraccdent) $ I NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS (Peraccidenl) $ Medical a mants $ 2,000 X UMBR;LIAH AB X OCCUR EACH OCCURRENCE $ 10,000,000 C EXCESCLAIMS-MADEAGGREGATE $ 10,000,000 OED ETENTION 10,000 X VSO55358735 1/1/2016 1/1/2017 $ WORKERS COMPENSATION XWS55358735 X PER OTIi- AND EMPLOYERS'LIABILITY _ ,STATUTE_ _ER_ ANY PROPRIETORIPARTNERIEXECUTIVE YIN NIA (3a.) Na MA V! NY SC ME E.L.EACH ACCIDENT $ 1,000 000 tl OFFICERIMEMBER EXCLUOEO? N❑ B (Mandatory In NH) All officers included 1/1/2016 1/1/2017 E.L.DISEASE-EA EMPLOYE $ 1,000,000 d If yes,describe under B DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 1,000,000 u B DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Various Work Market Basket #12 North Andover, MA. Market Basket #12 and Delta MB LLC are included as ° additional insureds with respects to General Liability and Umbrella when required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Market Basket #12 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 331 Fletcher Street ACCORDANCE WITH THE POLICY PROVISIONS. Lowell, MA 01854 AUTHORIZED REPRESENTATIVE U Harrison, V.P./JSC ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD ,: INS025 onidnn ACO DATE IMMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 12/19/2016 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 lleu of such endorsement(s). PRODUCER CO TACT NE. Jennifer Galante ' AM .._. PHONE (603)669-3218. AX (803)645-4331 TAI/Cross Insurance {AfC�No Ex))W_ AIC No _ m E-MAIL alante@crossa enc Com 1100 Elm Street _AODRIESS:Jg_. _.._,. y' -.....-.....-_ INSURER(5 Al FFORDING COVERAGE _ _ NAIC 1) Manchester NH 03101 INSURER A:American Eire & Casualty 24066 INSURED INSURERB:OhiO Security Ins Co 24082 Seppala Construction Co. , Inc. INSVRERC:Ohio Casualty Insurance Company ._ 24074 153 Hunt Hill Road INSURERD INSURER E: Rindge ATH 03461 INSURER F: COVERAGES CERTIFICATE NUMBER:16-17 All lines 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. TYPE OF INSURANCE ADDL SUBR POLICY NUMBER MM)IDNYYY MO DBmYY LIMITS LTR X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 5 1,000,000 DAMAGETORENTE-0 A CLAIMS-MADE ❑X OCCUR PREMISES fEa oceurrence S 300,000 BKA55358735 1/1/2016 1/1/2011 MEDEXP(Anyonepersan) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO- PRODUCTS-COMPIOPAGG $ 2,000,000 POLICY I JECT �LOC OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT g 1,000,000 _,(Ea accident} _ _.. X�ANY AUTO BODILY€NJURY(Per person) S ALL OWNED SCHEDULEDBAW55358735 1/1/2416 1/1/2017 BODILYINJURY(Peraccldenq S AUTOS AUTOS NON-OWNED PROPERTY DAMAGE S X HIRED AUTOSX AUTOS Per ao„ciden❑ Medical Rayments, S 2,000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE S 10, 00,000 C EXCESS LIAB CLAIMS-MADE AGGREGATE S 10 _000 000 DED X RETENTION 10 DOD Uso55358735 1/1/2016 1/1/2017 S WORKERS COMPENSATION X I XWS55358735 STATUTE _ EORH AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXECUTWE YIN NIA (3a.) IVH i4A VT NY SC ME E.L.EACH ACCIDENT S 1,000,0 0 OFFICERIMEMBER EXCLUDED? B (Mandatory in NH) All officers included 1/1/2016 1/1/2017 E.L.DISEASE-EA EMPLOYE S .,1,000,000 It yes,describe under E,L,DISEASE-POLICY LIMIT 5 11000,000 DESCRIPTION OF OPERATIONS below u DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (ACORD 101,Additionat Remarks Schedule,maybe attached if more space Is required) u RE. Permit - Market Basket #12, N. Andover, MA I s: CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE The Commonwealth Of Massachusetts THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Department Of Industrial Accidents ACCORDANCE WITH THE POLICY PROVISIONS. 1 Congress Street Suite 100 AUTHORIZED REPRESENTATIVE Boston, MA 021142017 f J Harrison, V.I?./JSC fes"^""`~• ij 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025owam