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HomeMy WebLinkAboutBuilding Permit #1287-2016 - 148 MAIN STREET 6/9/2016 V1oRTH �( BUILDING PERMIT o�tLE° 16 6 y TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Q * i Date Received 04 ® •/ Permit No#: � gSSiCHUs�t Date Issued:09 40 IMPORTANT: Applicant must complete all items on this page LOCATION SuT",r©N ?oN-Di CQV-L'yDM ]V)L)M Print PROPERTY OWNER Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes 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: 188 ❑ Commercial XRepair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: ICS �EMoLtc ►a NVO R pycr'� VENTtt-ft-ri,ow F9019 Low aP, tie DI/rr .1- L! M,Ns NO/V�vaa�Tio.yi .��5CO�t/,vEcT�t�A�!QF LT i21) -7A,,U,C l�CPLACr 7,0 0or0a 1*0A.-r ?R1FVJDusyvys£D.A s140A�Lea 4ayr2 "E LQeD Identification- Please Type or Print Clearly OWNER: Name: St,- -moo Etc N-o (1oN-zd.%PSsac. Phone: Address: `V-2 IV ff iA) 6L 47-& RyZ;DvcR NA DI P'4-t) t.tl ott,x ol�t . Contractor Name: AFWes ✓. riyi.L.A Phone: Email QM- Address: M•Address: 132 C ItigsTJWVT -s-r DIk4,y. Supervisor's Construction License:-0,6 )05199 Exp. Date: `�/z �ZO/b Home Improvement License: 10582 Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT:($112.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt No.: ©42� NOTE: Persons coiltracting with unregist red contractors do not have acce o tl e guara f Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swiunming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Pennanent Durnpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On (�13� Signature_ COMMENTS r� ZCONSERVATION Reviewed on Si naturZIPe COMMENTS 6 �O�-� �:� ; ��,.� oo" a' HEALTH Reviewed on Z. 1G Si nature COMMENTS A-4 Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes `r Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Lo ated 384 Osgood Street FIRE DEPARTMENT Tem Qumpstergon } Looatetlat1�2,4iMamistreet. '.Fire tDepar�tments,ignature/dafe;_. , • � . _-- ___m___.___.�rl .m. _.. �. . f CQMMENIRS. PC kMR4.,,rA7 �7 c 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.$10o-$100o fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email IDate Time Contact Name Doc.Building Pennit 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 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 OTE: 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 4, Copy Of Contract 4. Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) :rE Mass check Energy Compliance Report (If Applicable) Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Building Permit Application 4 Certified Proposed Plot Plan 4, Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit 4, Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ,4. Copy of Contract ,;6 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: 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 f� a ..:r,,c Location f�' G- !"%f9/ft/ 5�. ` �yYl�✓ _c `% - i, fJ/r No./ Z-�'� 1-G �JO Datea,,' • - TOWN OF NORTH ANDOVER 9d s' Certificate of Occupancy $ Building/Frame Permit Fee $ 4 Foundation Permit Fee $� Other Permit Fee $k TOTAL $ Check# t i r J " Building Inspector r V Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost 4,000.00 m $ - $ 48.00 Plumbing Fee $ 6.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 6.00 Total fees collected $ 160.00 148 Main Street 1287-2016 on 6/9/2016 eliminate air filter tank NORTH wn of 32 ndover No. * t - 1 C, h ver, Mass oRk'. I > COC NIc"awI�/[ 1' 7,95 R^reo U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System ti THIS CERTIFIES THAT ..�N!V� I/• ..................................................................... BUILDING INSPECTOR . .................. .... has permission to erect .......................... buildings on &f.&tf ..5 ` ........................................ Foundation 9AC,�pRough to be occupied aa.... . .. .f.��� .. • '/ 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 CONS ION S Rough Service .. ...... .. .. .... .... ........... Final BUIL G 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 Dr Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. The Commonwealth of Massochrtsetts Department of Industria AccUents I Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/IJJ lee'tricians/Plumbers. TO BE I+'ILED WITH THE]PERMITTING AUTHORITY. Applicant Information Please Print LedblV NaMe(susiuess/Organization&dividual): .Address: City/State/Zip: Phone#: Are you an employer?Check the appropriaie box: 'Type of project()required): l.❑I am a employer with employees(full and/or part time).* 7. []New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remo delirig any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.F1 I am a homeowner doing all work myself.[No workers'comp..insurance required.]t 4.FJI am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 E]Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ 13.F1 Roof repairs These sub-contractors have employees and have workers'comp.insruance.� 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 152,§1(4),and we have no,employees.[No workers'comp.insurance required.] .. . r:. . . *Any applicant that checks box#1 must also flu out the section below showing their workers'compensation policy information. t Homeowners who submif#his affidavit indicating they are doing all work and then hire outside contractors must sgbmit a new affidavit indicating such. tContractors that check this box must-attached.an additional sheet showing the name of the sub-contractors and state whether or not those entities have "employees. lfthe sub-contractors Piave employees,they must provide their wmkeks'comp.policy number. I am' an employer that is providing workers'compensation insurance for my employees.'.below is the policy and yob site information. n q Insurance Company Name: 'v\ TA N S Policy#or Self-ins,Lic.#: �(�— ' '�� ZJ 1�'� ��� A" Expiration Date: 10 is 6 Job Site Address: «8 14APr1 tJ ST" City/State/Zip: J N"(1-f A�,,f�K /'U4 01 Yj Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verific tion. I do hereby ce tify nder thepains and enal 'e ofpei;ury that the information provided above is true and correct. Si nature: Date: 6Ct16 Phone#• 609 $b } Official use only. Do not write in this area,to he 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.Flectrical Inspector 5.PIumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workei ,mpensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of liire, 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 lias 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=contractoi(s)name(s),address(es)and-phone number(s)along with their certificates)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 foi•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 Accidenis. 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-iiisured 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"fob Site Address"the applicant should write"all locations in (city or town)."A copy ofthe 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.#617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia DENNI.5 OP ID:JG '4�orzo¢ CERTIFICATE OF LIABILITY INSURANCE DATE 6 16 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 endorsemengs). PRODUCER CONTACT Segreve&Hall InSUr.AssoC.Inc NAME: 305 North Main St. PHONE Ext): ac No Andover,MA 01810 EMAIL Eric Page ADDRESS: INSURERS AFFORDING COVERAGE NAIC# INSURER A:Commerce Insurance CO. 34754 INSURED Dennis V.Molla INSURER BALM. Mutual Ins.Co. 33758 dba DM Painting&Carpentry 132 Chestnut St. INSURER C: No.Reading,MA 01864 INSURER D: 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 TYPE OF INSURANCE POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DDNYYY MMIDDIYYYY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY DAMAGE TO E 100,000 PREMISES a occurrence $ CLAIMS-MADE D OCCUR MED EXP(Any one person) $ 5,000 BGKVSV 10/18/2015 10/18/2016 PERSONAL 8 ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 POLICY PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT a accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS PERACCIDEN LLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X VJC STATU- OTH- AND EMPLOYERS!LIABILITY TO I B ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N N/A CC-500-5013988-2014A 10/28/2015 10/28/2016 E.L.EACH ACCIDENT $ 100,00 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Project address: Sutton Pond Condominiums, 148 Main Street, North Andover, 01845. CERTIFICATE HOLDER CANCELLATION NORTHAN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Building Department Main Street AUTHORIZED REPRESENTATIVE North Andover,MA 01845 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD tf Massachusetts -De Board Of Building Partment of Aublic Safety Construction Regulations and Standards Supervisor I License: LS_105898 DENNIS V MOLD}` - i 132 Chestnut St North Reading MA 01864{ —��✓!,� a t i ti�y Commissioner Expiration 09/02/2016 �fe�poozvn7a�zcuecz��o�G�t�czlla�ur�elr1� Office of Consumer Affairs&Business Regulation OME IMPROVEMENT CONTRACTOR _ — s Registration: 170582 Type: - Expiration: 11/10/2017 DBA DM PAINTING&CARPENTRY DENNIS MOLLA 132 CHESTNUT ST _ NORTH READING, MA 01864 Undersecretary .r A f' f, i9l Illlltl 1 i t • , I� �1 11,E Iafill iiill iiia; it i � � _ ,.� t. : 1 1 1 1 � I�t11i1ii�iilil i�tiiii 1. ttil k 19 t i tyl Ft , Ffillf 1 1 t tit � 111 , � � tl r w _ r yam„ 77it Ar Mg- AN un z a :�:'m". ��. #` S y�. ��peyrl�bll���MW�I I ��III�I V;" r ` �•,- ��r Y a s g �i.�.i, ggaapps� J 1 � y � r rr k� I sn I . f �'I�I I .VIIEII u'r�ffi t _ D s U-rl VjC, 7114-7701V B x pj�;j z 8' r , XON o R :Z X l o jye r ?p 167 Xcetf 3• .1Q�i STS 16" 0 /U CawT R FD✓VJ/1•f�dN /s.�.