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HomeMy WebLinkAboutBuilding Permit #405-15 - 133 MAIN STREET 10/29/2014 L BUILDING PERMITGNO oT e,"tio TOWN OF NORTH ANDOVER 0� h, - - 6 °� APPLICATION FOR PLAN EXAMINATION _ h i n O Permit No#: l Date ReceivedSsgrcD Or �h Date Issued: l o b"t IMPORTANT: Applicant must complete all items on this page LOCATION )_25V �2 VI Iii e7 + - I Print PROPERTY OWNER Y A, ,:5 rint 100 Year Structure e MAP _PARCEL: ZONING DISTRICT:`Historic District yes 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 ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: f v r/40 da'--b" z u mfr j L/v a l l qhI�y�f. did 61 ;poi lc�(VV � Identification- Please Type or Print Clearly OWNER: Name: 1 '7 � Phone: Address: Contractor Name4y� I �1 Phone: Address: Supervisor's Construction License: C ` / 1 Exp. Date: Home Improvement License: __ Exp. Date: ARCHITECT/ENGINEER `N tJ����'I1�/1� 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: $ iU� aD FEE: $ Check No.: CPReceipt No.: NOTE: Persons contracting with unregistered contractors do not have access tothe uaranty fund Signature of Agent/Owner Signature of contractor 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 PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on � Si nature COMMENTS HEALTH Reviewed on Siqnature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes I Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department 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) ❑ Notified for pickup Call Email 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 o Workers Comp Affidavit a Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract o Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks a Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o 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) o Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o 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 Doe:Building Permit Revised 2014 Location i M u' " f:41� No. �u"JAI Date b �G l� . - TOWN OF NORTH ANDOVER ov • s�"�°'646., . Certificate of Occupancy. $ Building/Frame Permit Fee $42Q-- Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# / r I- L 1 a1 `6136ilding Inspector tkORTH Town of 2 E ndover O 1, / No. �� Y 9 h ver, Mass,&&6 A 261q O �wNE 1• COC NIC N A°R,TEo ►�l WICN4�' 5 S U BOARD OF HEALTH Food/Kitchen PERMIT T L D Septic System 1110 11 111''0 l� /� ���. BUILDING INSPECTOR THIS CERTIFIES THAT ................ ... .. ... .. ...... .............. ... �........................... • Foundation has permission to erect .......................... buildings on .1.?,�,�.......... .�t.�... .. ............................ Rough to be occupied as ... ... ...�....�`...�� ��® �� ....... .� A .................................... 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 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough Service .......... ......... .......................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildin,:; 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. M The Commonwealth of Massachusetts - Department of IndustriqlAccidints Office of Investigations V. 600 Washington Street Boston,MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectriciansfPlumbers Applicant Information Please Print LeObly Name(Business/Organization/Individual): CCI) ►ao 1,W(� Address: 0_1 (t �I� _ ; City/State/Zip: velY- Phone Are ,you an employer?Check/the appropriate box: Type of project(required): 1.L1 am a employer with V 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ Tam a sole proprietor or partner- listed on the attached sheet. em ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g_ ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.F1 Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.El Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roofrepairs insurance required.]i employees.[No workers' 13.❑Other 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 anew 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. I am an employer that is providing Torkers'compensation insurance for my employees. Below is the policy and job site information. 11 Insurance Company Name:. a Y `�r e, Policy#or Self-ins.Lie.#: QJ 6, 6 9 Expiration Date: l 5 Job Site Address:— T Vylym _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 hereby certio under t sins andpenalties ofperjury that the information provided above is true and correct. Simature: Date: Phone#: F qlS 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.EIectrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: �1 OP CERTIFICATE OF LIABILITY INSURANCE I DATE09/25/1 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. 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(les) 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). CONTACT PRODUCER Phone:978-688-6921 NAME; Hannah Courtemanche,AAI,CIES Macdonald&Pangione InsuranceFax: 978-688-5350 PHOAIC No ENE 978-688-6921 AAIC No): 978-688-5350 P.O.Box 428 xt 104 Main Street ADDRESS:hannah@mpins.net North Andover,MA 01845 PRODUCER Donald Schemack CUSTOMER ID#:DGCON-1 INSURER(S)AFFORDING COVERAGE NAIC# INSURED D G Contracting, Inc ID 646648 INSURER A:Travelers Prop&Casualty CL 25674 428 Pleasant St INSURERB:Safety Insurance Company 39454 North Andover,MA 01845 INSURER C:ChartlS INSURER D INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: --THISIS T0_CER_T1.EY THAT THS_URARCE1QW-HAVE BEENIS_SUED TCZTJiE_INSURED NAMED ABOVE FOR THE POLICY PERIOOp 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 TYPE OF INSURANCE DD SUBIR POLICY NUMBER MM/DDY EFF MM/DDPOLICY EXP LTLIMITS R GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 AMAGE TO REN A X COMMERCIAL GENERAL LIABILITY 1-680-1553R18-1-ACJ-12 05/17/14 05/17/15 PREMISES Ea occurrence) $ 300,00 CLAIMS-MADE Fx_]OCCUR MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GEN ERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 PX PRO LOC $ OLICY AUTOMOBILE LIABILITY CO BINEDt)accident) LIMIT(Ea $ 1,000,00 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ B X SCHEDULED AUTOS 3116538 07/12/14 07/12/15 PROPERTY DAMAGE X HIRED AUTOS (Per accident) $ X NON-OWNED AUTOS $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,00 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,00 A CUP-0090153321 05/17/14 05/17/15 DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY X TORY LIMITS ER Y/N C ANY PROPRIETOR/PARTNER/EXECUTIVE C009874107 03/31/14 03/31/15 E.L.EACH ACCIDENT $ 1,000,00 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Massachusetts Port Authority is added as additional insured for this project CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Massachusetts Port Authori THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ty ACCORDANCE WITH THE POLICY PROVISIONS. One Harborside Drive,Ste 209S East Boston, MA 02128 AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD CS-001821 �+ DAVID P GULEZIAN 428 PLEASANT STS • N ANDOVER MA 01945 10/02/2015 I