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HomeMy WebLinkAboutBuilding Permit #1024-2016 - 105 HILLSIDE ROAD 3/30/2016 BUILDING PERMIT O NORTH,SLED ib (. TOWN OF NORTH ANDOVER 3� yr,'• .`__, 46 °L APPLICATION FOR PLAN EXAMINATION ~ Permit No#: lel Date Received � N 1. ��A0RATE0 .Pay,�GJ gSSACH�1`��� Date Issued: I ORTANT: Applicant must complete all items on this page 06A Of , _ P��nt: 100 Year w>t re es �©a MPTP - tPAR:CEL ®,NJ:NG ®ISS€TRI, T� _ H,isto4ic{D,tstr.ct eye :; +n;®p - - _ . f M+ach+ne Sh®pi_Ilge TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building A5Qne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑_Other �O�Septic F®�e�� �, ®�Flo dplain�"Y�Wet;lands; � k�0 1%Uaters�hetl �Distrr �:� . . I DESCRIPTION OF W RK TQAg PERFORMED: Ident.fic tion;.,,Please T e or Print Clearly Y OWNER: Name: Phone:�� (� Address: �Contractorl= me� _ h � Peron-k — - [Email� _ f :tlrress�:,.• s . ,. 7 S,upenis®�-s"Con=trur t®;n LicmnSe Expo;I®tea e P y i r 'Leg cce #Fi,ome I,mp,roveme t, ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT:$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ R,q H -:5,- FEE: $ � Check No.: 122 Receipt No.: � NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 1 i 'rat�ure of A entlOwner Si nature.of contractoe 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 PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS I j CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on -Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes tC/ Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit j `• ill DPW Town Engineer: Signature: j Loc 84 S r Located 3 Osgood Street FIRE DEPARTMENT Temp 'D"urnUP pste�on sites yesa atm © ,_ Located t 124 IVlai�n Steet��,�° ` A _ Depart�n�si,gnatu a/darfite n u 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- p $ $1000 fine I NOTES and DATA— (For department use) I ❑ Notified for pickup Call Email a 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 ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products VOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks I ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ 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) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products DOTE: 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 COTE: 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 Locatiori !D �- ..� - No. t Date) a =# i • TOWN OF NORTH ANDOVER. Certificate of Occupancy $ Building/Frame Permit,Fee $ Foundation Permit Fee $ Other Permit Fee TOTAL ,� $ Z Check# 301 f Building Inspector i tAORTIy Town of 0 No. ?0 A9 h ver Mass oCOC > > Aff 7,95 RwrEo 'IP¢��5 - U BOARD OF HEALTH Food/Kitchen PER. I * . . JL? D Septic System THIS CERTIFIES THAT � ...... ..L ao1R ................ . BUILDING INSPECTOR ........ ....... .... ..... .•.i. ` ...... ...... Foundation has permission to erect ......... ........ buildings on .�.� �l .. . . W..... ~ Rough 4 to be occupied as .� . . . . .... . .. Chimney .... .. . . . . .. . .... .. ..... .. .. provided that the person accepting this permit shall in every respec conform to the terms of the pp ication 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 �erina.� . Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. - Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION ST S Rough ............. Service ...................... ...... ... 46i .......... Final LDING 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. 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MAR L� i-:._ 0, . 4 4 � Beres AdrddbactlRh�e6 W 0 Room llsfp m xviam�B�OhUtW.�am4a1A0�1 .. bV�AV, FABS - Pie : CK&M Elm DoaaW �� 02 04=6 40= 00003 1053rOsd 10680 de Road am Galwallmabw , -- Nae*Andovat MA Ql84S NO&Amkv@;MA OINS JOBEm dacombodnadb�ratyaatea�aBe�Omeeda�aefm�ec7�elmeaaahsooll9Qmdbaiaoaoattoyoa TdddbwMk wadjacildno �rea0 �pnS 'PILLm' and 4PAT Wt, hcLv,&iaQk ou (tui on &mrvd wakr he= a&(O-c r iv9 pM r * e" LwYk . Robre4q',veA !I -Prom Rls� f rn��n . ,Weel -Me.. toork ors. ala-Lej I to UTA* 42^U CudmwTd* amaea� wwaoram�.eaeo�earaoaaa�e�s ►asuoEaasav IMMY-ThNO&48MW Qhs $gam mil OVA" A asamta4aa�aet�os® ��e�e�a� awes e0 daa ®®egg,�e....�°° s The Commonwealth of Massachusetts Print Form = � Department of Industrial Accidents s Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers Compensation Insurance Affidavit: Builders/ Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Builders Services Group d/b/a Quality Insulation Address: 110 Perimeter Rd City/State/Zip: Nashua NH 03063 Phone #:603-324-1974 Are you an employer? Check the appropriate box: Type of project(required): 1. ✓❑ I am a employer with 100 4. ❑ I am a general contractor and 1 employees (full and/or part-time). �. have hired the sub-contractors 6. ❑ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. E] Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in an capacity. employees and have workers' L y p y• 9. EJ Building addition [No workers' cornp. insurance comp. insurance.+ required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12 ❑ Roof repairs insurance required.] T c. 152, §1(4), and we have no employees. [No workers' 13. ✓❑ Other Weatherization comp. insurance required.] *Any applicant that checks box#1 must also till out the section below showing their workers'compensation policy inforniation. 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 state whether or not those entities have employees. Ifthe sub-contractors have employees,they must provide their workers'comp.policy number. I am an emplover that is providing workers'compensation insurance.for my employees. Below is the policy and job site information. Insurance Company Name. ACE American Insurance Company Policy # or Self-ins. Lic. 4:WLRC 48151553 Expiration Date:6/30/2016 ,+, Job Site Address: L4r4(f �P� City/State/Zip: IV outer 1 01 p'1"!� 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 herebv certify under the pains and penalties ofperjury information that the inrmation provided above is true and correct. Signature- � . . ....: . . __ _ Dater 3 _ 2!�2zl(e Phone 4:603-324-1974 Oficial use only. Do not write in this area, to be completed by city or town of riciaL 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#: 6 CERTIFICATE OF LIABILITY INSURANCE DA 62 ro0 5YYY) 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 BEMIEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER- IMPORTANT: OLDER IMPORTANT:If the certificate holder is an ADDITIONAL INSURED, the policy(ies)must be endorsed. (f 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). 15 PRODUCER CONTACT N Aon Risk Services Central, Inc. NAME: Southfield MI office PHONE (866) 283-7122 FAX (800) 363-0105 m 3000,Town Center (Svc.No.E"). lac.N. ): E-MAIL D SUlte 3000 ADDRESS: _ Southfield MI 4807S USA INSURER(S)AFFORDING COVERAGE NAIC» INSURED INSURER Old Republic Insurance Company 24147 26T.0eJi m Corp. INSURER B: ACE American Insurance Company 22667 60 Jimmy ann Drive Daytona Beach FL 32114 USA INSURER c. ACE Fire UnderwriTers insurance Co. 2070' INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 570058348882 REVISION NUMBER: THIS iS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIO INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THISD 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. Limits shown are as requested S ' TYPE OF INSURANCE S OL CY c LTR INSD V✓VD POLICY NUMBERM,DD1YY, I(tOC cXdMIDDNYYYI UM17S A X COMMERCIAL GENERAL LIA.BWTY MWZY304834 Ubi 3 _01S1061J012D1b1 EACH OCCURRENCE 5?,000,000 CLAIMS-MADE X❑OCCUR. DAMAGE O RENTED 12,000,000 PREMISES Ea occu rtencel MED EXP(Any one person) 325,CDO PERSONAL d ADV INJURY 52,000,000 roe GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE 14,OOO,000 4 X POLICY ❑PRO- ❑ JECT LOC PRODUCTS.COMP/OP AGG 1-0,000,000 m O HEP.: o 0 A AUTOMOBILE LIABILITY MWI B 304833 06/30/2015 06/30/2016 COMBINED SINGLE LIMIT (Ea-midenn 55.000,000 ANY AUTO BODILY INJURY(Per person) I O Z ALL O'✓✓NED SCT DULcO BODILY INJURY(Per acudent) O AUTOS ALT _ NON-OWNED PP.OPE RTY DAtdA.GE X HIRED AUTOS X O AUTOS L d UTEBRELLA LIAR OCCUR EACH OCCURRENCE C.7 EXCESS LIAB CLAIMS-MADE AGGREGATE IDE D PETENTION B WORKERS COMPENSATION AND WLRC48151553 06/30jZO1S 06/i0/7016 X PER OTH- EMPLOYEP.S'LIABILITY YIN All Other States STPTU'E ER C ANY PROPRIETOR I PARTNER,I EXECUTIUc 2 11,000,000 OFFIC ER/MEMBER EXCLUDED' N/A SCFC4815190 - 06/30/2015 06/30/.016 `L EACH ACCIDENT (Mandatory in NI-0 WI only If yes,dcscnbe under y E L DISEASE-EA EMPLOYEE S1,000,000 DESCRIPTION OF OPERATIONS below E L.DISEASE-POLICY LIMIT 11,000,000- I E SCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional P.emarks Schedule,may be anached B more space is required) vidence of Coverage A. P,,.J =R7IFICATE HOLDER .=J CANCELLATION - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFOREI EXPIRATION DATE THEREOF, NOTICE ✓TILL BE DELIVERED IN ACCORDANCE VTI7POLICY PROVISIONS.Builder Services Group, Inc.A TopBulId Company AUTHORIZED REPRESENTATIVE 260 3immy Ann Drive Daytona Beach FL 32114 USA ©1988-2014 ACORD CORPORATION.All rights reserved. %CORD 25(2014/01) The ACORD name and logo are registered marks of ACORD T--:; -s unull Business Reau Registration.: 179141 Type: Supplement Card BUILDER SERVICES GROUP, INC. Expiration: 6/25I2016 RICHARD SCHWART7 110 PERIMETER RD NASHUA, NH 03063 t rilate:>,d�r�ss an<i return card. .'1I?ri;reasan fur c1r?n e. f Address Rcnvexal F-im aloymeni Lust( and f)3'fire of Consumer.Affair, Business Re;;ulmion Lieense or r egisir-anon valid for individul use ard-, 77 Ot IMPROVEMENT CONTRACTOR the expiration nate. 1f found return to: } CMace of Consumer MfAirs?nil Business Re,ulatir;ra Ne istration: ?c1 _ 41 Type "laza i3:L 1,iU Expiration: 6f,512016 Supplement 3rd Boston.MA 0213G UILDER SEPVICE:GROUP, NC. ICHARD SCHIPJARTZ A,YT0N'A cEA,CH', EL 2'14 : nLPr?Ci r:iilrt Not ti'2i1d_N'iliat7L'[SIgnatCrC I f Y, [WALARtl SC:tiWARTZ 19SUIIJNFtt[.5� `,I RA: lvfmttchcter NCI (Blo) C19l2fi1201 fi • 1c 5tfirftact To: C: SLAC -IftsUlaficrrt Corttr,tunr ifurk�&1 pUSSEss a Current edition of the trfa set_k,usc ttt 't[:N Clllib lil(j Code is cause 161 revocation of this licenstr.