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HomeMy WebLinkAboutBuilding Permit #417-14 - 1160 GREAT POND ROAD 11/6/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: r ' IMPORTANT:Applicant must complete all items on this page LQCATfON�)I b0 GA-a- /Q,► !?ODI : '} ?DL- - :. _ PROPERTY OWNER' 3�O�s ���UL -- -- � - _ Print 100 Y at©IdStructure. yes vno: MAF,NO - PARCE,=)�—ZONIN5, 40,ISTRICT:. {Historic.District yes noh `� . - �Machirie,Shop Village yes �_,n J TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family El Industrial El Alteration No. of units: El Commercial ❑ Repair, replacement ❑Assessory Bldg 8'Others;--, El Demolition 11 Other El Septic. Well ❑'FloodpVr lain p Wetlands° ❑:wWatershed District DESCRIPTION OF WORK TO BE PERFORMED: Or) a lea u f 11 I N 113 6y-f- LN/''// i n s hAll a l�l�ihd dile L�tt/YI�4/U >9�T civ � B,�a�,cs s��a� Identification Please Type or Print Clearly) OWNER: Name: 0P-00M 5r._tf0e6 5—wn Ja srt Jr� Phone:97.9-YM 59� Address: �/�00 �ai�a�� �av /10, /r/- - _ _ CONTRACTOR' 'Name:C r15. iA a _ e� ��� l?hone -'- a , ez D /v1 Witte �-c�u I d Cl �,�n Address_ Supervisor's.Gonstructlon License , z _� Exp ate: . _ _ Home l=mproyement'License _ -- - - Exp: Date' .._ - �. q Michael &Ou l Phone: 644 > Address: /F Cl/h?3),i PrlVe. 110111s,A 111 e3GY,9 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: $ �i �� FEE: $ c- Check No.: -72-93 Receipt No. NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Si nature eof Agerit/Nvher' Signature. coritracfor . . .. 9 - -^ _ .�. .. . .. F-1r��_--_ I n I_:..__0 n l+....1:2:...J I")L.� /71.... I C4-r "� A Done II Building Department •The fol',3wing 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 ❑ 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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cans if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apw-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.tted with the building application Doc: Doc.Bui?ding Permit Revised 2012 Plans Submitted ❑ PlansWaived ❑ Certified Plot Plan ❑ Stamped Plans ❑ -TY—PE OF°:SEWERAGE:DiSPOSAL' Public Sewer ❑ Tanning/MassageBodyArt ❑. . ..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: DATF-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 es -Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature & Date Driveway Permit DPW To-wo Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMf_-`NT =Temp Dumpster on site yes no Located'at 124 Main Street.- Fire'Departinerit signatureldate` 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 - Date Doc.Buildivg Permit Revised 2010 Location 0 No. Date © - TOWN OF NORTH ANDOVER ' e e ` t Certificate of Occupancy $ Building/Frame Permit Fee r Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# 2 7082Building Inspector NORTH \Andover 0 No. 4n. 14 - 4. h ver, Mass C6IAM. �S" COC"Ic"IWIC" �1 �•9 A°R�rEo �Pa,��(5 S U BOARD OF HEALTH Food/Kitchen PER IT T LD Septic System THIS CERTIFIES THAT00 A. 64"Jo. ............. ,,,,,,,,,,,,,,, BUILDING INSPECTOR 4has permission to erect ............ buildings on .. . Foundation Rough to be occupied as ............... .Vf.... ... .........T ............................................... Chimney provided that the person accep ingthis 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MDNTkIS ELECTRICAL INSPECTOR UNLESS CONST ION RTS Rough Service .. .. ........ ................... .................. Fina BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Reguired to Occupy Buildinz 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. SEE REVERSE SIDE r- 1 NORTH E : ve-o No. 4n. 14 - � Z h ver, Mass O� LAN( COC NIC N(Wt[. y1. S t! BOARD OF HEALTH Food/Kitchen PER1T T LD Septic System .,.,, , ,,,. . .. ............... BUILDING INSPECTOR THIS CERTIFIES THAT ............ 0ID A. 6 0. ................................. . �,�. ..�........... has permission to erect .......................... buildings on ..u.6o..... ...jowd..... . Foundation Rough to be occupied as ............... .Vf...�,... .........T ............................................... 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6MONTbiS ELECTRICAL INSPECTOR UNLESS CONST ION RTS Rough Service .. .. ........ ................... .................. Final BUILDING INSPECTOR GAS INSPECTOR' Occupancy Permit Required to Occupy Buildinz 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. 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 /- DC3f} Name(Business/Organization/Individual):aY/S�AI'I ���l -f GHQ�N SCi^V/le,T�'J�• �f,l r2/577A�/ Address: f8 Cl in-61 N^I V& R6=tv7A t' City/State/Zip: Ha S , A,117 6-301 Phone#: 6D '893—X32 6 Are you an employer?Check the appropriate box: Type of project(required): re 1. ll .'I am a employer with !�:P,�7 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El 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.]t employees. [No workers' 13.0-6ther comp.insurance required.] *Any applicant that checks box#1 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 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. I Insurance Company Name: Policy#or Self-ins.Lic.#: WC 1-_D 31 O q gI 7D Expiration Date: Job Site Address: SO Glral— P/'d 12d, City/State/Zip:_l V,-And6yy;, /V/4 C,57187.- 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 hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Si nature: Date: �d ZV-12— Phone #: Z" 3'S3Z� 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#: 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 Tei.#617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax##617-727-7749 www.mass.gov/dia ACC)RO CERTIFICATE OF LIABILITY INSURANCE9A (MMIDD i4i201 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 lieu of such endorsement(s). PRODUCER CONTACT NAME: Tracy Picardi Tebbetts Insurance Agency PHONE (603)465-3333 FAQ 0.(603)465-6800 P.O. Box 848E-MAIL .tract'@tebbettsins.com 3 Market Place INSURERS AFFORDING COVERAGE NAIC A Hollis NH 03049 INSURERA:Citizens Insurance Company of 31534 INSURED INSURERB:Hanover Insurance Company 2292 Christian Delivery & Chair Service Inc. INSURER CNCCI 15172 dba Christian Party Rental INSURER D: 18 Clinton Drive INSURER E: Hollis NH 03049 INSURER F: COVERAGES CERTIFICATE NUMBER aster 13-14 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. INSR ADDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MMIDD MMIOD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE X COMMERCIAL GENERAL LIABILITY PREMISES a occurrence $ 100,000 A CLAIMS-MADE OCCUR BV0644363 /1/2013 9/1/2014 MED FRCP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 X POLICY PlFrT RO LOC $ AUTOMOBILE LIABILITY Ea as INEideD SINGLE LIMIT 1,000,000 A X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED &BV0716909 /1/2013 /1/2014 BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOSNON-OWNED PROPERTY DAMAGE $ AUTOS Per accident Uninsured motorist combined $ 11000,000 X UMBRELLA UAB OCCUR EACH OCCURRENCE $ 4,000,000 BI EXCESS UAB MS-MADE AGGREGATE $ 4,000,000 DED I X I RETENTION$ UHV0844365 9/1/2013 /1/2014 $ C WORKERS COMPENSATION X WC STATU- I X OTH- AND EMPLOYERS'LIABILITY Y/N ER ANY PROPRIETOR/PARTNER/EXECUTIVE❑ E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? NIA (Mandatory In NH) CID31098170 /1/2013 /1/2014 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS i LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Evidence of Insurance ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Seth Tebbetts/TPICrJ� ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 rgn+nns)m Tho annon name nnel Innn aro ronictororl mnrlra of annRn Certt"ficate of jf1ame Re!61'otanre REOh5RMD AZTEC TENTS eats bused or �" � 26M COLUMBIA ST """"'�"d0iae° TORRANCE'CA 90503 0212008 cwt cows F41s01 (809P231166r Thisisbow ytlraftrisnwbrldsdawfbedbelowhare0havebowfamerebroledtruled(ararsidrarae*rranlYarrrulrMj. FOR ' CHRISTIAN PARTYRENTAL IS CUNTON DRIVE HOLDS,NH 03049 CwUftalfon Is hereby made that(check"a"or IV) (a) The articles described belowt is certificate love been treaded with a flame retardant chemical approved and registered by the State Rre Marshal and that the applicstionof said chemical was done in confor- ❑ mance with the laws of the Shits of California and the Rules and Regulations of the State Fire Marshal. Name of chemical usedChem.Reg.No...,....._._»......... Meathod of application.e.._...»...»».»».»...»».»»._»..».»».»».......»..»....»»»»...»...»» (b) The articles described below hereof are nude from a flame-resistant fabric or material registered and approved be the Slate Firs Marshal for such use;Fabric has been tasted and passes NFpAT01•96. Trade name of flanwmsist d fabric or material used_t.er.+deaer� .Reg.No. The Flame Retardant Process Used.. l fir .......Be Removed by Washing 60 David Bradley Chuck Miller-President NW6edAWCdW0 CUSTOMER ORDER NO. R168629 ITEMS MANUFACTURED: 2-2620 F+e 0w1 Top UW with Double Valence 2-20x40F*dW Top UW whh Double Valance 3-40x40 2pc.JumboThac Top UW JP C Q-4WO JumboThac Middle Top UW 1-10Ibr30 Series 2000Middle UW 2-2ftW Series 1500 10c.Top UW 2-20x30 Series IMO tpC6 Top UW 2-2040 Serf"15001pc.Top UW PDQ' created with pdfFactoiy trial version www.odffactory.com 10/24/13 Google Maps To see all the details that are visible on the Gooslescreen, use the"Print" link next to the map. .y IN Awr 3 - 3 " t, r sl�` M1 � Lfi Shr .J J 9 -��1 h��✓ E _ t � w , ., ..ti. •�-. `t ery�02013 Google,Map data®2013 Google- https://maps.g oog Ie.com/maps?ie=UTF-8&q=Brooks+School&fb=1&gI=us&hq=brooks+school+1160+8 reat+pond+road&cid=0,0,13231616318272897240&ei=... 1/2