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Home My WebLink AboutBuilding Permit #522-15 - 100 ANDOVER BY-PASS 12/5/2014 it NORT►� BUILDING PERMIT 01* t%O TOWN OF NORTH ANDOVER 0�2 APPLICATION FOR PLAN EXAMINATION Permit No#. Date Received �qs q,TEo "try. Date Issued: djol SNCHUSE IMPORTANT:Applicant must complete all items on this page LOCATION r �N Jam, Print PROPERTY OWNER � �.1 /� /J v/ inn r7 C� Print 100 Year Structure yes no MAP02-5- PARCEL: 0 / / ZONING DISTRICT: Historic District yes no Machine Shop Village yes ria TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 0 One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: 0 Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑Wetlands 0 Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: i IJ Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Nameg;W al ,J Phone: Address-=_. .5 p�/o, / v.✓' S`i� /l'1A',7—i1,V1�^-' !� Supervisor's Construction License: Exp. Date: Rz-1 ro/� Home Improvement License: -1ir 7 7 5 Exp. Date: �,--/_� 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: $ o, FEE: $ Check No.: Receipt No.: �� NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund ;Signature of Agent/Owner ignature of contractor Locatio (/ N6 Dat ef // u TOWN OF NORTH ANDOVER . Certificate of Occupancy $_�� Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ b Check eu5 � tr Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYpF 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 PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS I CONSERVATION Reviewed on Signature i COMMENTS HEALTH Reviewed on Signature t COMMENTS i Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes i Planning Board Decision: Comments A Conservation Decision: Comments i Water& Sewer Connection/Signature&Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: 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 NOTES and DATA— (For department use) ❑ Notified for pickup Call Email Date Time Contact Name - Doc.Building Permit Revised 2014 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 Li Building Permit Application a Workers Comp Affidavit d Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract ❑ Floor Plan Or Proposed Interior Work I o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks Li Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) u 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) o Building Permit Application J o 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) o 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:Building Permit Revised 2014 i i u Massachusetts :Deeartinent of Public Safety Board of uildin -r i9 �,ations and:Standards C,nstrp,on Superl.isor. License: C"90120 GARY J LEIGHT9rl 35 PIEDMONT ST 0 METIIOEN MA 0184 t Commissioner Expira#ion 02/24/2016 t er A e°rCcrnsnmer NOME IMp gairs&B �es ice"c ration O�YE Gusfn Flrs RegnlatioQdeG«t 1 zprlaho' t4&77 RACrOR I NC-virq�Al of5/l 5 ry>7e: NOME, NiPR pVEME D$G -A G NTS�. y IGNtON 35`�IEDiyI ONT ST k1E3��iEN'MA 0184q .` - o� P 0 NORTH Town of A 6 h ver, Mass o� coc«��«ew�c« �'►. Ao Areo S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System tiTHIS CERTIFIES THAT ..........t Q !v!�..... .4.It............. .*.........., BUILDING INSPECTOR has permission to erect ........ buildings on .1.�. l....... !� - . ��. s�............. Foundation .................. .... .... ..�.�...!/.4 4.11......jl.:'l 5.�� :!`�_Y..�. o►�! Rough to be occupied as .. .... . . .... ...................................... Chimney provided that the person accepting this permit shall In every respect confor 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 IN 6 MONTHS ELECTRICAL INSPECTOR • UNLESS CONSTRUCTIO ARTS Rough Service ............... ... ... .............................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. 1 CERTIFICATE OF LIABILITY INSURANCE °A'E'NIM'°°m"' 6/23/14 HIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS r :'6ERT{FICATE 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. r IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to ? the terms i rms and conditions of the policy,certain policies may require an endorsement A statemerd on this certificate does not confer rights to the Certificate holder in lieu of such endorsernent(s). PRODUCER CONTACT NAME: Eric Jansen lHasbany Insurance Agency PHDNE (978) 685-3188 FAx N , (978) 685-9460 236 Pleasant Street ADAEss: eric@hasban .con Methuen, MA 01844 INSUIE S AFFORDING COVERAGE MAIC 9 INSURER A:Nautilus Insurance INSURED INSURERS:Travelers Gary Leighton INSURERC: DBA New Again Home Improvement INSURER D: 35 Piedmont St INSURER E: Methuen, MA 01844 INSURER F: COVERAGES CERTIFICATE NUMBER: RVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BF1,0W,HAVE BEEN I ' D'T"0'IHE INSLRED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION O ANY CONTRACT OR 01HER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY TFT POLI IES QES ISED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY RAVE BEEN REDUCED Y PAD NtS. INR TYPE OF INSURANCE 1M WVD ADDLSUBR POUCYA$l ..F��_.... .., LIMITS -- -- A GBNERALUASILITY NN062113' 0/ 10/4/15 E3kCHOCCiJRRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 100,000 CLAMS-MADE [i]OCCUR MED D(P(Arryone person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000-000 GENT AGGREGATE LMIT APPLIES PER PRODUCTS-COWIOPAGG $ 2 QQQ ;000 X POLICY Pk Ll RO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT a accidert $ ANY AUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED BODILY INJURY(per axident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS _ AUTOS ereccideM $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ tngRKERSCOMPENSATION6HUB-5BB2499-4-14 2/6/14 2/6/15 X WCSTATU- 0TH- AND EMPLOYERS'LUIBIUTY Y/N APROPRIETOR/PARTNERIEXECUTIVE NY E.L.EACH ACCIDENT $ 10O 1000 OFFICE RMEMBER EXCLUDED? N I A (Mandalory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 if yYes describeunder DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY UMFT $ 500,000 ASCRIPTION OF OPERATIONS r LOCATIONS/VEHICLES (Attach ACORD 101,Additional Renarks Schadule,H nrors space Is regd red) I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ERIC JANSEN ©1 10 ACORD CORPORATION. All rights reserved. ACOP are registers arks of ACORD Phone: Fax: E-Mail: The commonwealth of 4,8sachu efts , Department of Indust�itcrAccrdins Office of Invesfigations 600 Washington Street woston,MA 02111 www massgoir/dia Worker' Compensatzonbsi rance Afar.davit:Builders/Contractors/EX ec ne PsIPlumbers bl. leaserintLe .Applicant Jhformatxon Naino(13usiness/Organization&dividual):^ A Aft `�L y A.ddxess: � S` City/StatelZip: •s,a`TL� InAQ/f Phone#: Are you an employer?check the appropriate bog: Type of project(required): I am a ein to p yerwith 4. ❑ 1 am a general contractor and I 6. New construction _ employees(fu11andlorpart-time)•* have hired the sub-contractors 7. ❑Remodeling 2,El am a sole proprietor orpartner- listed on the attached sheet. These sub-contractors have S. [(Demolition. ship an.d7iave no employees workers'comp. ' working forme in auy capacity. p 9. ❑Building addition [No workers'comp.j asurance 5. ❑We are a corporation and its 10.0 Electrical repairs or additions xequired.] officers have exercised their right of exemption Par MGL 11.❑Plumbing repairs or additions 3.[] I am a homeowner doing all work g § � )p P 12,[]Roof xepairs myself.[No workers'comp. c.152 1(4),anal we have no insurancerequired.]i employees.woworkers, 13,14 Other/' �iotPl tC�l oV comp.insurance required.] Mny applicant that checks box#il mustdso fill outthe sectionbel6w showing their workers'compensation policy information. 'Homeowners who submit flus affidavit indicating they tie doing aUworlc and then hire outside contractors must submit a new affidavit indicating such. ?Contractors that checkthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. X erre an employer that is providing workers'compensation insurance for my ernployees: .8elow is the policy and joh site information. Insurance Company Name: Policy#or Self-ins.Lic.##: 'K�-f l//��'9 o�� "� ! ExpirationDate: S C /State/2i .��//✓ VV3 Job Site Addxess: �� S( i S� � tY p' .�Y� --- A.ttacli a copy of the workers'eompensationlpoicy declaration page(showing the policy number and expiration date). Failure to secure coverage as required-ander 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 lml?'Isomnent,as well'as civil:penaSties in the foam 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 maybe forwarded to the Office-of Investigations of the DIA for insurance coverage verification. X[lO 1Z2Ye�y Certify unc�eY trZepains" penartie Of peYjrtYy that fhe informadon providled ahove is true and correct: - Si ature Ds Phone#- Official use onry. .Do not write in this area,to he completer)by city or town official. City or Town' permit/License V Issuing Authority(circle One): • 1.Board of Health :.Building Department 3.City/Town Clerk d.Electrical Inspector 5.Plumbing Inspector 6.Other Phone M. Contact Person: 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 tho service of another under any contract of hire, express or implied,oral ox written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two ormore of the foregoing engaged in a joint enterprise,and including the legalrepresentatives 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 notmore than three apartments and who resides therein.,or the occupant of tho 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 employes." MGL chapter 152,§25C(6)also states that"every state or local lie-ening 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,MOL chapter 152,§25C(7)states"Neither the commonwealth nor any of its p olitical sub divisions shall enter into any contract for the p erformance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contractiug authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),addresses)and phone number(s)along with their certificates)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 LL C or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Tudustrial Accidents fox confirmation of insurance covexage. Also be sure to sign and date the affidavit: the affidavit should be,retamedto the city or town thatthe application for thepermit 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 besue thatthe affidavit iscomplete and printed legibly. no Deparimenthas 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 Of in the permit/Iicense number which will be used as a reference number. Th addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating curxent policy infomnation(if necessary)and under"Job Site Address"the applicant shouldwrite"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 afff davit is on file for fature permits or licenses. Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a license ox 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 sh9uld you have any questions, please do not hesitate to give us a call. The Department's address,telephone anal fax number: Tho Com-monNm.alth ofMlouaehusotfs Depaxtae,7at df dusWal.Aceldonts Off toe offAvestiga lorts• d WaaugWa StxQj�,t Boston,MA 021.11 TO,4 617-72.7-49. oA 406 ox 1-877-MASSM Revised 5-26-05 ``all`#617-727-7749 '�W.1?aaSs,�4��dia I' i t 1 i J �I Massachusetts DFpartment of Public"Safety Board of puildjng'Reg11tions and Standards Con§[ruction Supehjsor License: CS-090120 ``.;" rs0. GARY J LEIGHT971T 35 PIEDMONT ST ° I METfIUEN172 Mp 8184 Expiration CQmmissioneira 02/24/2016 a II , I • I i 1 I i •