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Home My WebLink AboutBuilding Permit #237-14 - 133 MAIN STREET 9/16/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: I Date Received Date Issued: I t ��l IMPORTANT: Applicant must complete all items on this page LOCATION -1 2 Print / PROPERTY OWNER 1?�� C" t FY► �r � Print 100 Year Old Structureyes MAP NO: 0�0 PARCEL: ZONING DISTRICT: Historic District esDn 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 ES CRIPTION OF WORK TO BE PERFORMED: ( r ,tS Identif ion Please Type or Print Clearly) OWNER: Name: Phone: Address: CONTRACTOR Name: =+' (1N '� = � Phone: �� ✓ j < <� / J Address: Supervisor's Construction License: iExp. Date: l �> Home Improvement License: ,�� /g 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. C, Total Project Cost: $ �`� FEE: $ Check No.: Receipt No.: Z_i(P NOTE: Persons co tracting with u gistered contractors do not have access to t/ aranty fund Signature of Agent/Own Signature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPEOY 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 es -Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW'To` ;2 Engineer: Signature: Located 384 Osgood Street FIRE-DEPARTMENT - Temp Dumpster on site yes no Located-at 124 Mair Street Fire Department signature/date ° I � 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 2010 I Building Department The following iso list of the required forms to be filled out for the appropriate permit to be obtained. RoofU,g, 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 apm-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 Location No. .Z ��—I Date I� I w . - TOWN OF NORTH ANDOVER n Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# � r Building Inspector The Commonwealth of Massachusetts " Department of lndustrialAccWnts Office of Investigations 600 Washington Street Boston,MA.02111 www.mass govIdia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legib Name(Business/Organization/Individual): lJ ��' ( P (A 4C Address: �- ( /1 / City/State/Zip: � `'`P �� Yv,d Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.�a employer with— ' 4. ElI 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. �• E]Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition workers'coin insurance. ' working forme in any capacity. P 9. ❑Building addition . We are a corporation and its [No workers 5 comp.insurance ❑ � 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.Eoof repairs insurance required.] employees.[No workers' q � 13.❑Other comp.insurance required.] 'Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they 97re doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. f Insurance Company Name:- I �� Policy#or S elf-ins.Lic.#: ►V G 0^ �� l J 7 Expiration Date: Job Site Address: ►� �� f City/State/Zip: �� fi� Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL o. 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 certiry under the s andpenalties ofperjury that the information provided above is true and correct - Simature: Date: Phone#: Y S 689q-7q 7 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 - - C'�nfiarf PPrcnn� Phone#: Inform- ation 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." er. - p Y 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 ofits 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-contractors)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 maybe 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(ifnecessary)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 CoxrmonweaXthofMa:.ssa..rhvsPtts Departmezit of Industrial.Accidents Office ofInyestigatious 604 Washington Street Boston}MA 021.X 1. Tel,#617-727-4900 oxt406 or 1-877,MASSAFE Revised 5-26-05 Fax#617-727,7749 µORTH Town of E ndover 0 . 3 No. 22 h , ver, Mass, (a LAII COC MIC,41WICK y1' S U BOARD OF HEALTH Food/Kitchen PERMIT D Septic System • THIS CERTIFIES THAT19L ..1.0*%"^........ BUILDING INSPECTOR Foundation has permission to erect .......................... buil ings on ..........1.3.'3....:....al�(t0.11. ' Rough to be occupied as ...... ..... .�...... ........ .. !4 ........�. .... .�. ..... "..... Chimney provided that the person accepting his permit sha in every respect conform to the terms of th 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-I MONT ELECTRICAL INSPECTOR UNLESS CONSTRIJ ST. TS 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. SEE REVERSE SIDE ,nr L.Ca 1821 DA,, :. :' c.,-ULEZIAN 42— r;,*:T ST N Mt),.)VER, MA 01845 OP ID:SHHE ACORO DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 05/01/13 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 Phone:978-688-6921 NAME:NTACT Macdonald&Pangione Insurance Fax:978-688-5350 PHONE FAX P.O.Box 428 A/c No Ertl: A/C No): 104 Main Street E-MAIL North Andover,MA 01845 ADDRESS: PR Donald Schemack PRODUCER DGCON-1 .� CUSTOMER IDA: _ INSURERS AFFORDING COVERAGE . NAIC A_ INSURED D G Contracting, Inc ID 646648 I INSURER A:Travelers Prop&Casualty CL 25674 428 Pleasant St INSURER B:Safety Insurance Company 39454 North Andover, MA 01845 INSURER C:Chards INSURER 0: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 POLICY EFF POLICY EXP R TYPE OF INSURANCE POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS GENERAL LIABILITY l EACH OCCURRENCE $ 1,000,000. A R]COMMERCIAL GENERAL LIABILITY 1-680-1563R18-1-ACJ-12 05/17/13 I 05/17/14UAMAUt:10 KENT ED PREMISES Ea occurrence $ 300,00 CLAIMS-MADE n OCCUR MED EXP(Any one person) $ 5100 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEML AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 POLICY X PRO , LOC I $JECT AUTOMOBILE LIABILITY I - - COMBINED SINGLE LIMIT $ 1,000,00 - ! (Ea accident) ANY AUTO j BODILY INJURY(Per person) $ I ALL OWNED AUTOS j BODILY INJURY(Per accident) $ B X SCHEDULED AUTOS 13116538 07/12/12 ! 07/12/13 B X HIREDAUTOS I j PROPERTY DAMAGE $ (Per accident) B X I NON-OWNEDAUTOS $ ! $ UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1,000,00 X EXCESS UAB CLAIMS-MADE AGGREGATE $ 1,000,00 A -- CUP-009C153321 I 02/22/13 05/17/13 DEDUCTIBLE I ! $ i RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY X T R C ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N IWC009874107 03/31/13 ! 03/31/14 E L.EACH ACCIDENT $ 1,000,00 OFFICERIMEMBER EXCLUDED? Y N I A (Mandatory in NH) I E L.DISEASE-EA EMPLOYEE $ 1,000,00 It yes,describe under i DESCRIPTION OF OPERATIONS below E L.DISEASE-POLICY LIMIT $ 1,000,00 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,it more space Is required) Re: Clubhouse project. Certificate holder is an additional insured as required by contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ( ACCORDANCE WITH TKIEZOLICY PROVISIONS. AUTHORIZED REPRESENTA ,,,�_Dw Donald Schemack �'I`� ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD