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HomeMy WebLinkAboutBuilding Permit #451-13 - 108 MAIN STREET 12/5/2012 TOWN OF NORTH ANDOVER /APPLICATION FOR PLAN EXAMINATION Permit N0: - (-7 Date Received Date Issued: �� 5 IMPORTANT:Applicant must complete all items on this page LOCATION 109 IVIG ( kv PROPERTY OWNER `f-TJ f3a Print n� Print 100 Year Old Structure yesno MAP NO: PARCEL:tM' ZONING DISTRICT: Historic District ye, no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: Commercial 4Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic 0 Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: f" lm( ro�s� 0 u-e� Gv► c� s�I� Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: CONTRACTOR Name: Phone: Address: QQ- Its,jury A A �- Supervisor's Construction License:CS OS17 3 Exp. Date: Home Improvement License: 1146 q q3 Exp. Date: b- s 13L- ARCH Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.,$112.00 PER$1000.00 OF THE TOTAL ESTIMATED COSTBASED ON$125.00 PER S.F. Total Project Cost: $ �a00 FEE: $_ Check No.: / -Z Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractorA4 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ 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 Nater & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Os ood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Departinedt 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 U Notified for pickup - Date E I Doe.Building Permit Revised 2010 I 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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ 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/Crossection/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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application Li 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 o Mass check Energy p p 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: Doc.Building Permit Revised 2012 Location /0 �p No. LI S—� — Date /2 l/2 a • • 4 TOWN OF NORTH ANDOVER • Certificate of Occupancy $ Building/Frame Permit Fee $ �b Foundation Permit Fee $ ' ' Other Permit Fee $ TOTAL $ Check# �� 26016 G60 ing Inspector NORTH -own of ? E : ., 6Andover O - 0 law 13 C' ver, Mass, 5� . COCHIC"tWICK y1' �d p�RAt, S U BOARD OF HEALTH PERM .IT T LD Food/Kitchen Septic System THIS CERTIFIES THAT ............ .. ... 4. ,/. . `4. .4................................................................ BUILDING INSPECTOR Foundation has has permission to erect.......................... buildings on .................................. Rough R to be occupied as ............ :.... .:SL!.. ... !. .............. Chimney provided that the person accepting this permit shall In every r4spect conform to t e 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 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 ........ .. ...................... Final BUILDING IN ECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises - Do Not Remove Final E No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE 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 s -r Name (Business/Organization/Individual): Address: 14,E 7,re%I+_(L 1i City/State/Zip: Sn (t S DoN OL 4f,)­Phone#: cY '7� ��(',3-8�7 ? 7 Are you an employer?Check the appropriate box: Type of project(required): 1.A I am a employer with ,, 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.F1 am a sole proprietor or partner- listed on the attached sheet. E]Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]i employees. [No workers' 13.❑ Other comp.insurance required.] kny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy and job site formation. tsurance Company Name: (M If C4 :)licy#or Self-ins.Lie.#: Expiration Date: ►b Site Address: � o M61 l, (,-4• N Pm CS(_.Q r City/State/Zip: 0 (g ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). tilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a is 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 up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of vestigations of the DIA for insurance coverage verification. 3o hereby c rtify antler the pains and penalties of perjury that the information provided above is trite and correct. nature: Date: V —36 ( c;L tone#: 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#: �f �dri" t�i� us'�� g(u4eel7a Office o o3�sumer airs mess e u ahon HOME'fMPROVEMENT CONTRACTOR Registration: „j40493 Type: Expiration: ,_10/22!2013 Individual M EL WOLPERf-' MICHAEL WOLPERT:-`;:.., 1 45 FOREST ROAD SALISBURY,MA 01952, Undersecretary - _ Massachusetts-Department of Public Safety Board of Building Regulations and Standards Construction Supers isor License: CS-081738 *�\��T I S p1I WCHAEL W6&ERT 45 FOREST F6 rl SALISBUR)qJA i01952, 5 I-:,r Expiration j commissioner 12/27/2013 i j' i f ,l 45 Forest Rd Estimate Salisbury MA 01952 978-463-8177 Date Estimate# 12/3/2012 643 Name/Address Al Management Brian Wolpert 27 Nason Rd Hampton Falls N.H.03844 Job Address Description Total 108 Main St N Andover Frame over existing skylights,install 30 year asphalt shingles 2,000.00 Install suspended ceiling in vestibule area See attached plans $500.00 to start balance due upon completion I agree to the above terms Total $2,000.00 AC,Jl�its DATE{MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 10/3012012 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Salisbury Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 10A Elm St. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Salisbury,MA 01952 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Northland Ins Co H&M Industries, Inc INSURER B' A.I.M Mutual Ins CO 45 Forest Road INSURER C Salisbury, MA 01952 INSURER INSURER E: COVERAGES 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERT3FiCATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALLTHE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ;ElPOLICY EXPI RATION LTR PMO TYPE OF INSURANCE POLICY NUMBER DATE IMMlDO/YY DATE IMMIDLUW) LIMITS A GENERAL LIABILITY WS133608 06/0412012 06/0412013 EACH OCCURRENCE $ 1,000,000 J COMMERCIAL GENERAL LIABILITYMAGE 0 RENTEC ip0,000 PREM]SES Ea occurence $ CLAIMS MADE W OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY 3 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMNOPAGG $ 2,000,000 POLICY nPROJECT n LOC AUTOMOBILE LIABILITY I COMB NED SINGLE LIMIT ANY AUTO (Ea accident) $ i ALL OWNEDAUTOS ! BODILY INJURY SCHEDULED AUTOS (Per person) S HIREDAUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) FPRCPERTY DAMAGE g accident) GARAGE LIABILITY AUTO ONLY-EAACCIDENT $ ANYAUTO OTHERTHAN EAACC $ AUTO ONLY. AGG $ EXCESSIUMBRIELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMSNADE AGGREGATE $ I $ DEDUCTIBLE S RETENTION $ $ B, WEORKFRSCOMPENSATIONAND AWC 7013121012012 06/03/2012 06/03/2013 TORYLIMITS J ER EMPLOYERS'SJABRnY ANYPROP RIETORIPARTNEwEXECUTIVE E.L EACH ACCIDENT S 1,000,000 OFFICERIMEMBER EXCLUDED? EL DISEASE•EA E311ROYEE b 1,000,040 If yes,describe under SPECIAL PROVISIONS below E.LDISEASE-POLICYLIMIT $ 1,000,000 OTHER Carpentry-dwelling,contractors,contractor-sub work,excavation CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF TH EABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Town Of North Andover 1600 Osgood St. DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN i Building 20 Suite 236 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL North Andover, Mass. 01845 IMPOSE OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPR N TIVES. AUTHC494REPRESENTATIVE I ACORD 25(2001108) 0 ACORD CORPORATION 1986 Z d e9l•:60 ZI- t0 0e4 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 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 employer." MGL chapter 152, §25C(6)also states that"every state or local licensing 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,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for 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 sure 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 number 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 for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/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 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 should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-7274900 ext 406 or 1-877-MASSAFE -vised 5-26-05 Fax# 617-727-7749 1 1 a �,� 1 �� ��c t� 1 STRUCTURAL CALCULATIONS NEW FRAMING OVER EXISTING ROOF SKYLIGHT TDBANK 108 Main Street North Andover, MA 01845 Prepared for: H&M Industries, Inc. Mr. Michael Wolpert, Contractor 45 Forest Rd., Salisbury, MA 01952 By: PRM Engineering, LLC Structural Consulting Engineers Newburyport, MA 01950 PRM Job #: J12-73 �P„SH OF moo= P D 0 "59 U 0 0 S R U Lmi 0 42 54Q Cl) 01STS\-” FSSIto) E!VA\ 1A / � � � , Pedro R Munoz,Ph.D., P.E. MA PE License#: 42854,Expires 6/30/2014 Date Signed: 12/1/2012 December 1, 2012 ©Cogyriahts by Pedro R.Munoz of PRM Enaineerina LLC- 2012—All Rights Reserved The original and copies of this set of calculations or any parts thereof are the property of PRM Engineering,LLC. Reproduction in any form of this set of calculations or any parts thereof is strictly prohibited except by written permission of PRM Engineering,LLC. PRM Engineering,LLC—6 Woodman Way, Suite# 116,Newburyport, MA 01950 Tel: (978) 465-7105; Fax: 978 465-7002; E-mail: Prmen2(&att.net;Website: www.nrmen2.net �1 1 PRM ENGINEERING, LLC JOB Structural Consulting Engineers SHEET NO. K- OF Newburyport, MA 01950 TEL (978) 465-7105 FAX (978) 465-7002 CALCULATED BYDATE f '" Email: prmeng@att.net 1 CHECKED BY DATE SCALE I ' 2 3 4 5 6 7 8 2 3 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 1 8 1 2 3 . .. 3 h N'o ; Coy o s �I ,�►} ; - cc.. - ,► G. ..t' . � r4.1U�-p ty { /i_y (A��:� . . ...... 6 314- n ... ...i..... i /'�.( .. .. 2 m ..... ... ... ..... ....... r .. 'Tb Cav,4 'F ' Rt b e SF-& �y 2 N. ln—T........................:.......... _ F7M-T. .... qN� 2�_ 2 10 x as 2 7 6 r " T Rf%it,� 5 TO 3 C �5 " 5 /4 wv5s 4 ......... :... NtiJEC� °N�j�►1 ..�) . . 5 _. n o _ ... 6 10 D n m PRODUCT 207 II I li r JOB C PRM ENGINEERING, LLC �� �- Structural Consulting Engineers Newburyport, MA 01950 SHEET NO. OF TEL (978) 465-7105 FAX (978) 465-7002 CALCULATED BY DATE Email: prmeng@att.net CHECKED BY f�=� DATE SCALE \ S7 SA M �� �- � 8 - 177 -"/ -(-1 -Dv �J�F-T5 -fie , SET C) 6 LKye JOFi -� � x - - - - TT i 73 ► if 13 o /20 E s . 2 � � � Y �� tb _. . . - i I /VV\ a I;zz ' � odisc --- - T? -.5- _ - t r t 13 a a ----- I x i i