Loading...
HomeMy WebLinkAboutBuilding Permit #364 - 1160 GREAT POND ROAD 11/8/2007 Th BUILDING PERMIT o� NOROOR H TOWN OF NORTH ANDOVER 3? '` - *° oL APPLICATION FOR PLAN EXAMINATION ° ..� - 'A b Permit NO: Date Received ��SSACHUS��� Date Issued: .a'�� IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER � , . Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes (no Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: Identification Please Type or Print Clearly) OWNER: Name. Phone. Address: CONTRACTOR Name: Phone: Address:k51-60 Supervisor's Construction License: Exp. Date: Home Improvement License: 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: $ �`�ty °a FEE: $ Check No.: �0 3T — Receipt No.J_o 4-�- NOTE: Persons contracting istered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature pf contractor 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 ❑ 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 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 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 DATE REJECTED DATE APPROVED CONSERVATION COMMENTS DATE REJECTED DATE APPROVED HEALTH COMMtNTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water $ Sewer Connection/signature&Date Drivewav Permit Located at 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster on site- , yes no Located at 124 Main Street Fire Department signature/Mate 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.Building Permit Revised 2007 Location No. G Date 6 �oRT� TOWN OF NORTH ANDOVER Certificate of Occupancy $ < ' 6 O ;�s'•^°'E<� Building/Frame Permit Fee $ MUS Y Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 01 311 20778 Building Inspector VAORTH TO" of o w r` No. G -I o driver, Mass., I* ALL COC MIC NE WICK A. ORATED `S BOARD OF HEALTH PERMIT T DFood/Kitchen Septic System �` BUILDING INSPECTOR THIS CERTIFIES THAT. .�i ...... eAca.L........�Ste. ...................... ................... Foundation has permission to erect...................... ........... buildings o ...',..6.Q..... . � � • Rough ... .. . .. . . . . . . At to be occupied as:.. .46...... �. ........ Vii. .�.�i..?........... ........... ...................... ............. Chimney provided that the person accepting this permit shall in every respect conform to the terms of t e application on file in Final 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 6 Final PERMIT EXPIRES IN 6 MONTHS I� ELECTRICAL INSPECTOR UNLESS CONSTRUCTI TS Rough %wo.............. .............................. Service B TOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. SEE REVERSE SIPLJ Smoke Det. ,.10RTH Town of � G = - rw ft. o �odover Mass. • Q - LA 1 COCMICME W ICK RATED BOARD OF HEALTH Food/Kitchen . PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT. . . . ill ......vSC.oa.L........1Xe...... ........................ Foundation has permission to erect...................... buildings o ....0..6.0........ . . ...... . ........ • Rough t0 be occupied as... ....... �. ........ .�. :.�........... ........... ...................... ............. Chimney provided that the person accepting this permit shall in every respect conform to the terms of t e application on file in Final 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 I6 PERMIT EXPIRES IN 6 MONTHS Final ELECTRICAL INSPECTOR UNLESS CONSTRUCTI TS Rough ............... .............................. ... ............ ................ Service B TOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To BeDone FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. The Commonwealth of Massachusetts Department of Industrial Accidents c 1;, Office of Investigations 600 Washington Street ;li:ti i M pBoston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip "� � d\�`ES Phone Are you an employer?Check the appropriate box: Type of ' yp project�e ct(regwred): 1.❑ I am a employer with 4. am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 1 7. ❑ 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 10.❑ Electrical repairs or additions required.] officers have exercised their 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.Eg-OlBer S comp. insurance required.] Any applicant that checks boz#1 must also fill out the section below showing their workers'compensation pol icy information. fi 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. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date Sc_z" 'LOo%-, Job Site Address:yy�a '�-� Qo City/State/Zip: 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 hel certify un alties of perjury that the information provided above is true and correct. Si ature: Date: Phone#: 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 numbers)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 Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia WORKERS COMPENSATION AND EMPLOY(:RS LIABILITY EXTENSION OF INFORVATM PAGt POLICY POLICY k0. GSC 000143-7 P ITEflA i.CON IINdJED PACE NO. 1 M Es Tow $10001 E irnatad Itramal PY®n�me CLASSIFICATION OF OPERATIONS COME ��- to mDmmftn AN O -20 Intrastate Y.D. 089828 NO. Rem+�+"lon LOC. 1 FEIN., 04-2130844 rooks School 2160 Great Pond Road ortlh Andover, MA 01845 From 01/01/2007 To 01/01/2006 SCHOOL: PROFESSIONAL EMPLOYEES E 886t 68178, 332 0.64 39, 541 Clerical SCHOOL: ALL OTHER EMPLOYEES 9101 1,730,203 2.6 50,003 Employer's Liability fin 0001:9) 9801 0.01C 895 Limits 500/500/500 TOTAL UNMODIFIED PREMIUM 90, 439 crience Modification 989E 1.19 17, 183 Final TOTAL MODIFIED PREMIUM 107, 622 Deviation 9034 0.90 -10,762 STANDARD PREMIUM 96,860 Premium Discount 0063 0.0816C -7,904 II Risk Adjustment Program 027 1.25C 24,215 Expense Constant 090C 284 Terrorism Risk Insurance Act 974C 0.0 BTA Assessment 0.039 4,213.00 TOTAL ESTIMATED PREMIUM 113,455 TOTAL MA ASSESSMENTS 4,213.00 WC 00 00 CIA 08/22/2907 p8:24 97Q7256215 PAGE 02 LNIMPENDENT SCHOOLS COMPENSATION CORPORATION NCCICARMCODENO. WC 09 00 MA ,MG RS COMPENSATION SAND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE 1.The insured: Brooks School Policy No. WC 000143-7 Rernewal of: WC 000143-6 Waftaso; 1160 Great BaPondRoad Individual - Partnership North Andover, MA 01845 X Corporation or Federal Employers F.D.i 04-2130844 Internntrasitets Risk F.D./ 089828 Other I.D.0 Other wvrttplac"not shown above: See 'Schedule Z. po a b from 01/01/2007,tY:Ot eddrew. .m.to 0110112008meft 12;01 a.m.standard time at the In$~$ G. �-Tof MA poicya6e t!`I§wofkars c`:ompensawn`ow of the sats here: MA B.Embers I.laW ty Insurance:Part Two of the policy applies to work In each state distad to Item 3.A,The Umb of out Uabilly under Part Two are:Bodily i by Aoddent ; 5 0 o.00 d each accident Bodily b y by 0150459 i 5 0Q.00 0 policy Imit Bodly h#q by Disease i S n n f n n o each employee C.00 M.At Insurance-:Part Thtess of ft- p4- s ao ft rzme_'Lot Arm ft- -_4 REP-- ED BY ENi�tSEMENT WC 20 03 06 A D. This poky Includes these endorsements and scim"es: See Schedule 4.The premtum for the ply will be deterMInd by our Maneralls of€Fins.Ciaasll'Icatiorm Rates and Raft plans. All information ragulred below is subs to verillcatlon and change by audit. Code Total Estimated $100 of Estimated clessitteation No. Annual Remuneration Remuneration Annual Premium See 1tein 4. Extension WC 00 00 01A Total Estimated Annual Premium f 113,455 MI nlmum Premium S 263 (HR) 9101 Expanse Constant S 284 - DIA Assessment 0:040 4,213.00 Annuaa rqc srw.ars bv: s � : INDEPENDENT SCHOOLS COMPENSATION CORPORATION Dale:12/08/2006 BRENER & LORD Copt in?nVWwalCama a,Cmv n edonenaronka Original 08,122211-2007 08.-'24 a. -J'�-'�L5 ilJJ 2:S.... ..�.� ..... • Poky Etftmment '; CHE®UEE OF ENDORSEMENYS 20WC-1 (12/91), 20WC-2 (5/96) , 20WC-3(12/91) , 2014C-4 (5/86), WC 00 01 06(4/92) , WC 20 03 06A(4/05) em any 5: vfa� a @P— .. --f Ea DRACOM ar. d_- ;�•M ragama `3s-' t Mw Infortnalon below is regtdM when mis arwormnem Is Issued subsequema to pnperetlen of the poft4 Enftwnmm Effmoa 01/01/2007 Pocky No. WC 000143-7 int No. msL"d Brooks School + g C-0--m--do—And-- aY INDEPENDENT SCHOOLS COMPENSATION CORPORATION- 08 22P200? U6:26 (3787-25562-150 6s T_ �s PAGE Qct " "11;� S COMPENSATION AND ENKOMS UA13U 1 1 FNSURArjCE POUC 7 Af r W 01 04 A (Ed.4-fly} LIDN-1—.: E AND HARM WMUM' COMPENSATION ACT COVERAGE ENDORSEMENT This dog.:sa azrs_a_ es shy in the Schadsi�, The to ' LOngshom and Harbor Workers' COmpensadon Act in a state Page, ► to that worts as though that state Were listed in Item 3.A. of the inkrrnation -- -- Cmr*�wo is replaced by the fottstrMW C- Wadws Compensation Low Workers Ctsnpensation law m6ans tits workers or wwkmen's compensation lase and OCCupatlorml disease low Of each stat® ar territory named in hent 3,A. of the Information Page and the Longshore and liarbor Warks' Cft tattpen88dot Act(33 USC Sections 01-95ti).It includes any amendments to those laws that are in effect ging Ncy Period. it does not include arty anter federal workers or workmen's Compensation law, other Beal OWUP disease law or tm provisions of any law that provide nonoccupational disability benefits. Part TWO(EmPtaym liability Insurance}, C. Excivai ms.,exclusion 9,does not apttty to work subject to he Longshore and harbor orkers'Compensation Act. Or lila ittorta�M Y= ap'Y a - 8460 t`% ",a 30fe "ase ACs, lie outer Continental Shelf Larofs Act, pproprigted Fund instruntentelfts Act. Schadule Longshore and Harbor Workers` Comoensattorf Ad COvmtle ParesntM The rates for classificationsria followed " " f r worts with numbers roll o6 os'+ed by the Ist� F are rates o not ordinarily sttbjeCt to the Longshom and Harbor Warkm.' CMpensation Ad. If this policy covers work tinder such clessNtcations, and It ttla work is subject to the Longshote and Harbor Workers'Compensetlon Act, those non-u'classification renes will to ihcreased by the Longshore and Harbor Wariters'Compensation Act Coverage Percentage shower in etre Schedule. Ti emiarea mafT-ft Me p0q w ren t is aftoved and is eaeewe on Ow date issued uniess at rise *Mod (The kdbrmatbn below is required only wlfon this sndwaearent is tswsd subusqumd to pmpsraftn of the potlay l PoficyEffecoveDate: 01/01/2007 b=01/01/2008 PrerrdumS h-sur 5-rook-'s Scilccl ORA; CasrissllismiCade: INDEPENDENT SCHOOLS COMPENSATION CORPORATION _ Go 6i A `'`- CounteWgned by Ed.4-92) - . Page B of 8 PURCHASE ORDER Brooks School 1160 Great Pond Rd * North Andover, MA 01845 * 978-686-6101 P.O. Number: 0004874 X. To: ATHLETICA Ship To: 1160 Great Pond Rd ATTN: SCOTT LEBEDZ North Andover, MA 01845 15300 25TH AVENUE MINNEAPOLIS, MN 55447 Requested By: J. TROVAGE Tel#: Fax #: P.O. DATE DELIV DATE SHIP VIA F.O.B. TERMS 10/30/06 REQ#38030 Net 30 QTY PRODUCT I CRYSTAPLEX SERIES 6 ALUMINUM DAHER SYSTE $131,470.000 $131,470.00 (QUOTE#CP0504-124-6ASU-Q-MA-4) 1 INSTALLATION CHARGE $5,500.000 $5,500.00 K ***25%DOWNPAYMENT REQUIRED*** ***$32,867.50-DASHER*** *** $1,375.00-INSTALLATION*** 1 COACHES WALKWAY BEHIND BENCH $1,444.00C $1,444.00 GL#53108031 Ik Purchase Order Total: $138,414.00 va�� Vendor Copy-WHITE . v,, Requester Copy-BLUE Business Office Copy-GOLDENROD Authorized Signature 2nd Business Office Copy-GREEN The P.O.Number listed above must appear on all invoices,shipping papers and packages.