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HomeMy WebLinkAboutBuilding Permit #235-14 - 14 Longwood Avenue 9/13/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: .� Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION rint PROPERTY OWNER Print 100 Year Old Structure yeso .> MAP NO: PARCEL; iZONING DIS.TRLCT: IHistoric Districtyes no . _ _ _ _ Machine Shop Village _ yes- TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building Wbne family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic ❑Well ❑ Floodplain 14ands ❑ Watershed District, . [Ii.YWater/Sewer D SCRIP ION OF ORK TO BE PERFORMED: � � r Identification Please Type or P ' t Clearly) f OWNER: Name: /�ovtn,���t ,/ ,G (hone: 97�dn2/s-7s' Address: ®/-'o CONTRACTOR Name: Phone: Address:� p. � � r Supervisor's Construction'License: CS=- os2:�93 � Exp. Date:_111-311 --� Home Improvement-License; "__ Exp. Date: ARCH ITECT/ENGINEERT Q '2 el, Phone:y'7ff-;130- I Address:��� if� ��r✓� 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: $ FEE: $ zu� i Check No.: p Recei t No.: NOTE: Persons contracting with unregistered contractors do not have access to e guaranty fund Signature of Agent/Owner Signature.of contracto Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ tamped Pla ❑ Building Department The following is-a list of the required forms to be filled out for the appropriate permit to be obtained. Roofivg, 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 apo>-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 ❑ 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 PPR VED PLANNING & DEVELOPMENT ❑ �d l� COMMENTS ND ���N Aar '<aeaj- CONSERVATION Reviewed on e Signature COMMENTS 4 c�— Jh l HEALTH �e 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/signature&Datp � Drvewa Permit f DPS' Tow;: Engineer: Signature: /6 Located 384 Osgood Street FIRE DEPARTML-NIT - Temp Dumpster on sit yes no Located at 124 Mair, Street Fire Department signature/date COMMENTS_ Dimension Number of Stories: ' z Total square feet of floor area, based on Exterior dimensions.1 dD Total land area, sq. ft.: 1: JL 7/7 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 f 3 Doc.Building Permit Revised 2010 Location No. Date /3 . - TOWN OF NORTH ANDOVER" . Certificate of Occupancy $ Building/Frame Permit Fee $ � Foundation Permit Fee $ — ` Other Permit Fee $ TOTAL $ f i Check# / 2685 iLaA'i q Inspector i NORTH own o ? . : E : . Andover O - to &A- I No. �3S � 4 0 h ," ver, Mass, F// A_ COCNICNl WICK 7�A�R�lTED PP���S S V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT .. . . k.!! :: ts�•::?:.. ?�. ....: � .cr. .............................................. BUILDING INSPECTOR r Foundation has permission to erect .......................... buildings on ... ..................C�!' .. y .............................. Rough to be occupied as i3`'s'.f �7 d/L� /V i .......................................... Chimney .......................... .............. ... ............................ ............. provided that the person accepting this permit shall in every respect onform 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 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 ?�{ Massachusetts -Department of Public Safety �C Board of Building Regulations and Standards Construction Supeti isur License: CS-005693- � DAVIDA IGNDkED 65 EAST INDIA ROW#36H; ROSTON:-, 02110all � 1 Expiration Commissioner 01/13/2014 DATE .a►co v® CERTIFICATE OF LIABILITY INSURANCE 9/12(/2013 ) 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 UUNTACT NAME: M P ROBERTS INS AGCY INC PHONE g78 683-8073 F 978 1060 Osgood Street E ANo Ext: AIC No:� ) 683-3147 IL North Andover, MA 01845 ADDRESS:sandi@mprobertsinsurance.com INSURER(S) AFFORDING COVERAGE NAIC# INSURER A:ESSEX INSURANCE CO INSURED KINDRED HOMES INC INSURER B:MERCHANTS MUTUAL INSURANCE CO CORP. INSURER C:ASSOCIATED EMPLOYERS INS CO P.O. BOX 483 INSURER D: NORTH ANDOVER, MA 01845 INSURER E 978-688-6558 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 TYPE OF INSURANCE ADDL SUBR POLICY FF POLICY EXP LIMITS INSD WVD POLICY NUMBER MM/DDfYYYY MM/DD/YYYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 110001000 CLAIMS-MADE FKOCCUR PREMISES Ea occurrence $ 50,000 MED EXP(Any one person) $ 0 A 3DM5468 7/22/137/22/14 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY❑PRO JECT F-1LOC PRODUCTS-COMP/OP AGG $ EXCLUDED OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMI I Ea accident $ 1,000,000 ANYAUTO MCA7014524 03/08/13 03/08/14 BODILY INJURY(Per person) $ ALL OWNEDSCHEDULED B AUTOS X AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident UMBRELLA LAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WAND EMPLOYERS'LIABILITY ORKERS COMPENSATION X STATUTE ER IH ANY PROPRIETOR/PARTNER/EXECUTIVE YIN WCC500-5008521-2013A 08/1/1308/1/14 E.L.EACH ACCIDENT $ 500,000 C OFFICER/MEMBER EXCLUDED? N/A F7(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE$ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS!LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE NORTH ANDOVER MA 01845 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-20 3 ACCRD CORPORATION. All rights reserved. ACORD25(2013104) The ACORD name and logo are registered marks of ACORD The Commonwealth ofMassachusetts Department of Industrigl Accidents Office oflnvestigations 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leaibiy Name(Business/Organization/Individual): • sG Address: - City/State/Zip:Z , 4�� ,141W jq�,l 6 Phone#: 9»—�5`% 7l Are y an employer?Check the appropriate box: Type of project(required): 1. T am a employer with / 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have Hired the sub-contractors 2.❑ T am a sole proprietor or partner- listed on the attached sheet.? �• EJ Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9• ❑Building addition . We are a [No workers 5 ❑ comp.insurance corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ T am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions self. m o workers'comp. c. 152,§1(4),and we have no y [N p 12.01toofrepairs insurance required.]i employees.[No workers' comp.insurance required.] ad Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they ai:e doing all work and then hire outside contractors must submit anew 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 thepolicy and job site information. Insurance Company Name:. Policy#or S elf-ins.Lic.4: Expiration Date: Job Site Address: / !—Orr!i/G�G°G City/State/Zip:/Y. I4ri 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 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 maybe forwarded to the Office of Investigations of the DTA for insurance coverage verification. I do Hereby cer u er the and, na i of rju at the information provided above is true and correct. signature: �> Date; / / LIP— Phone#: c7 [Official useonly. Do notwrite in this area,to be completed by city or town official.ity or Town: Permit/License# ssuing Authority(circle one): 1.Board of Health 2.Building Department 3.CitylTown Clerk 4.Electrical Inspector 5.PIumbing 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 employeils 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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapterhave 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 confumation 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 D epartrrierit lias provided a spaco 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 whichwill 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: Tho GoMYAQRweaWth ofM-assachvstitts Department offadustdat.Aceldents office oifhayestigations. 600 Washington Street Boston?SIA.02111 `ol,#617-72.74900 e7.t406 ox 1-877.;MASSAFF Fax 4 6J.7�7�7 Revised 5-26-05 7749