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HomeMy WebLinkAboutBuilding Permit #320-2016 - 110 PEMBROOK ROAD 9/14/2016 s o 9 23 lis' NORTH q BUILDING PERMIT TOWN OF NORTH ANDOVER p APPLICATION FOR PLAN EXAMINATION J �' OR • 1. Date Received Permit No#: ass ACNu Date Issued: V I. MPORTANT: Applicant must complete all items on this page LOCATION Pr it PROPERTY OWNER Pr' t 100 Year StructureZes no MAP PARCEL: Q0e ZONING DISTRICT: Historic Districtyes . no Machine Shop yes. no TYPE OF IMPROVEMENT PROPOSED USE Resi ial Non- Residential ❑ New Building ne family ElA ition ❑Two or more family ❑ Industrial ❑ teration No. of units: ❑ Commercial El Others: Repair, replacement ElAssessory Bldg ❑ Demolition ❑ Other __ - -- Septic El'We ❑ FI`oodplain E!Wetlands Watershed'pistrict _O Water/Sewer . DESCRIP 40FWO TOB FO e tification e eype or Print Clearly OWNER: Name: Phone: Address: Contractor Name: Phone: Email: Address: .w. Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ "� Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access th gu anty fund l Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swiuuning Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dempster on Site ❑ TIME FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - 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/ Drivewav Permit DPW Town Engineer: Signature: Located 384 Osgood Street " FIRE DEPA►�ReTIVIENT Te rnp °nsite. eyes Lo ated at 124-Main S reet --' "xc st • J cr• 't7 s t :lr0.r t !� t .atmos it � .. s � r + t x Fe Depa m ntignature/date `. , ,yet , �[,�yt 'ate }-+q.+ s ,•-t �s.��d.aw.....ai,E:.�Le .. :� ..t.:l .,w.,� .... � �KOn� �,r` y ..ttry���� �,/� � f �o� ,}f'e-t ^z� <+a...'S fi r� ,•� ; ,�,s,... n fl��..�" � �F ' a tits '"w r7��?�'rd' C�S� �. r �: * �� k •� �� z„"� �,�.��, y g'. C®IVIM �� ✓w , .i� L9 r ��r+.�'F ,•t 4 r,`t ,�re;�.t . :,�''!� '�'!y�� «4 ��dty.w��� � .f a +''`� � 4�,�d•,+� 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 drops requires approval of Electrical Inspector yes No DANGER ZONE LITERATURE: Yes MGL Chapter 166 Section 21A—F and G min.$10o-$1000 fine N® NOTES and DATA— (For department use) i i ® Notified for pickup Call Email I 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 OTE: 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/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 IN OTE: 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 f Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: 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 ° Location Date . - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ " Foundation Permit Fee $ „� .., s°wK Other Permit Fee $ TMM TOTAL $ rF: Check#; r� Building Inspector 49 :. ; NORTH own o . � E ndover o -M :.. , �. No. � d ��a -Y C% h ver, Mass A ° > COC.4icto WICK S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THISCERTIFIES THAT .......... . 1.... � ..................&rkfb6W..............................:............................................ has permission to erect .......................... buildings on Foundation BUILDING INSPECTOR Rough to be occupied as ........... .. .... ,.P.............4..... � ....a 111111F .P............................................... Chimney provided that the person accepting this permit shall 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MO THS ELECTRICAL INSPECTOR . UNLESS CONSTRC S R 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. i The Commonwealth of Massqchuseffs z. ..' Department ofIndl tstrialAccideaats 1 Congress Street,Suite 100 Boston,MA 02114-2017 YYIYYY.F/Las .go Y/12Ga Workers'Compensation.Insurance Affidavit:Buiiders/Contractors/EIectricians/Plumbers. TO BE FILED WITH TM+G PERAUTT]NG AUTECORITY- Aplilicant Information Please Print I 'bl Name(Business/Organizaiion/Individual): Address: ty/MCiate/Zip: Phone Areyon an pioyer?Check the appropriate box: Type of project(required): 1. I am a employer with PO-1employees(full and/or part-time).* 7. 0 New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in &. []Remo deliAg any capacity.[No workers'comp.insurance required.] 9. [❑Demolition In I am a homeowner doing all work myself.[No workers'comp.insurance required]t 10E]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electric airs or additions proprietors with no employees. 12..[�Pl mg repairs or additions 5.❑I am a general contractor and I Have hired the sub-contractors listed on the attached sheet. 13. oof repairs These sub-contractors have employees and have workers'comp.insurauce.t 6.Q We area corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other 152,§1(4),and we have na employees.[No workers'comp.insurance required.] "Any applicant that checks box 41 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 andthea hire outside contractors must submit anew affidavit indicating such. ?Contractors tbat 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,Vioy nmst provide their workeis'comp.policy number.' lam an employer fleet ispNoviding workers' ompensatiora i2nsurance for my employees.' Below is the policy andjob site information. �—'�"' Insurance Company Name: Policy##or Self ins.Lie.4: Expiration Date: Job Site Address: City/State/Zip: t A$tacb a copy of the workers' compensation pohcy declaration p ge(showing flee policy num e a d ex zratxon 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. f do hereby certunder° a n dpe Ides ofperfuiy that the information provided above is true and correct signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or toren official. City or Town: PermitlLicense# 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 4: 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,asso ciation,corporation or other legal entity,ox 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 ofthe 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-theworkers'compensation affidavit completely,by checking the•boxes that apply to your situation and,if necessary,supply sub=contractors)name(s),address(es)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 LLC or LLP does have employees,a policy is required. B e advised that this affidavit may be submitted to the Department of I$dustrial Accidents fox 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 vrrite"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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.# 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia y. ACORO DATE(M omrYY) CERTIFICATE OF LIABILITY INSUFUNCE W61201THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLD R. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY:AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY TH UGIES BELOW. THIS CERTIFICATE OF INSURANCE DOES:.NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUT,'ORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the y(les1 llc must be endoised. If SUBROGATION IS WAIVED,sub)"�to the terms and conditions of the policy,certain policies may require an endorsement. A statemetit'on this certificate does not co fear r to the Certificate holder in lieu`of.such andorsemen s. PRODUCER I' Eaton&Berube Insurance Agency, NAME` s e c Inc. 9 � PHO y NE .. FAX 11 Concord St 2- ac Ne. M 30 E-MAIL Nashua NH 03064 :i ADD RP-"- n,iretlarrl(aeatonberube�com .fit x INSURERS AFFORDING COVERAGE INSURED INSURER A n AJCPR INSURER B-Rivecport Insurance AJC Properties LLC INSURER C:MMa IrISUOnGe CO dba AJC Roofing c/o Mark&Shirley Freeman INSURER D: ` 11 Daylily Drive INSURER E: 4, Nashua NH 03062 INSURER F: COVERAGES CERTIFICATE NUMBER. 14 28287359 REVISION -r;: I _ ,O NUMBER: THIS IS TO CERTIFY `- THAT POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POU.; PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT CET TO 1lUIi H THIS CERTIFICATE MAY _ BE ISSUED OR MAY PERTAIN, THE INSURANCE. BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE RMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS. �.i tNSRAM'SM ..LTR TYPE OF INSURANCEPOLICY NUMBER -MM/Dor Ey MM DCD EXP .. LIMITS A GENERAL LIABILITY AGLOO1113600 4/13/2015 4/13/2016 EACH OCCURRENCE 81,000 0 X COMMERCIAL GENERAL LIABILITY TO RENTED_ PREMISES oecu 8100 0001 CLAIMSA%OE a OCCUR MED EXP( one n) $10,0OOi,' X 500 PERSONAL&ADV INJURY $1.00b. 0 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $2;00000a=•, PRO- PRODUCTS-COMP/OP AGG $2,000:000 X POLICY LOC $ ryra C AUTOMOBILE LIABILITY KA0113773 6!24/2015 6/24/2016 Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED AUTOS AUTOS BODILY INJURY(Peraocident)IsNON-Ok p X HIREDAUTOS X TOS NEO AUTOS P eOPEDAMAGE $ 1 $ C . ' UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1I ' EXCESS UAB CLAIMS-MADE AGGREGATE 8 OED RETENTION$ B WORKERS COMPENSATION V%C288800204707 WC+STATU OTH $ x g a AND EMPLOYERS LIABILITY 8/2712015 6!27/2016 X ANYEB PROPRIETOR/PARTNERiEXECUTIVE Y/N OFFICER/MEMBER EXCLUDED? Y❑ N/A E.L.EACH ACCIDENT 5100 00{E_ (Mandatory in NH) Kes,describe under E.L.DISEASE.-EA EMPLOYE 5100000Et ¢ DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY UMI $500,000"" x 1, DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,AddManal Remarks Schaduto,If more space is required) ; a _ �, 4, ,> r d ft } CERTIFICATE HOLDER CANCELLATION It SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCEL LED. ORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELMM IN For Informational Purposes Only ACCORDANCE WITH THE POLICY PROVISIONS. ' do AJC Properties LLC 11 Daylily Drive ; Nashua NH 03062 AUTHORIZED REPRESENTATIVE si ©1988-2010 ACORD CORPORATION. All rights W rued. ACORD 25(2010/05) "The ACORD name and logo are registered marks of ACORD }8 Office OfConsumcrAffairs S Business Regulation R -" HOME IMPROVEMENT CONTRACTOR -*Registration: 153131 =.M Expiration: 10/30/2016 Type: = Ltd Liability Corpo• AJC PROPERTIES DR. MARK FREEMAN 11 DAYLILY DR. NASHUA,NH 03062 � a Undersecretan CS-096194 XARK FREFli4A . 11 DAYLfLy DRI.VR NashuaN-H43062 07/14/2016 r I I •k