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Home My WebLink AboutBuilding Permit #66 - 15 COLUMBIA ROAD 7/27/2012 AORTH BUILDING PERMIT ot,.r°;b TOWN OF NORTH ANDOVER .c_ 6 �` APPLICATION FOR PLAN EXAMINATION 1 a f � °.p L-1 Permit NO: Date Received �SSACHUS�� Date Issued: IMPORTANT:Applicant must complete all items on this page - Print ;_ PROPERTY�'01NNERt - I rnnt _ ' MAP'NO BARGEE:," 2-_ZON-ING�D.IS ,RIOT ' Histonc�District" yes' {f �--� . iJ L MachineShopVillage yesx 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 r Flootl lam Wetlands f Watershed�District _- Septica W_.ell I? _W,;Rer:/Sewed: DESCRIPTION OF WORK TO BE PREFORMED: •- I Identification Please Type or Print Clearly) OWNER: Name: � Phone: Address: AOR' �/. Name: ../ ro ACT sor's�Constructio4, L/ !ymprovement;License - ARCHITECT/ENGINEER Phone: Address: 1 ��l�M � Reg. No. FEE SCHEDULE:BULDING PERMIT;$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BAS ON$125.00 PER S.F. Total Project Cost: $ �,®�'�� FEE: $ Check No.: Receipt No.: U NOTE: Persons contracting with unregistered contractors do not have acces u an d ofcontrac Signature of Agent/ Owner Signature Location � co/0 ", No. 11016e Date . • 4 TOWN OF NORTH ANDOVER ,< Certificate of Occupancy $ Building/Frame Permit Fee $� Foundation Permit Fee $ Other Permit Fee TOTAL $ Check# 25546 Building Inspector 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 CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes b 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 y Ao •- +" # ,FZ 'f' f • 4 -?:e'P1 -+t-s yr +zt v_}' Located a � t 124 Main Street 3 i_ - FIre Depart111ente'siat gnure/dates aj. {�ti•tr , - .+.r •'.t. 'tom- . r �e .,. ,, ti}.q.;;.Y --• f ....•.; .. COIVIIVI.ENTS ""i. ., 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 _ 1 Doe.Building Permit Revised 2008 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 j 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 DEPARTMENTMFORM07 Revised 2.2008 OORTH Town of ndover o0 LAK _ No. r3h ver, Mass, • o� COC MIC N!WICK y1. A�RATEO P-*' aS V BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System • THIS CERTIFIES THAT ............................ BUILDING INSPECTOR has permission to erect buildings on Foundation JJ�� Rough to be occupied as ... ..0........ ......... ............. ............ ....... ...... !/ �.!�..� 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 Rough ELECTRICAL INSPECTOR UNLESS CONSTRUCTIffts S tf, Service ...............rz>........:................. ..................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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 L1017/27/2012 09:53 PALUMBO INSURANCE AGENCY 4 19786889542 NO.433 P001 " CERTIFICATE OF LIABILITY INSURANCE °/27/ATE °° 2 7/27/20].2 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 holdar 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 endorsament(5). PRODUCER CONT Kiz Cornetta N ME: RUB International ).Sew England LLC PHONE (,506)520-1755 FAX (50a1S20-455 fa,No- Na 195 Main Street Suite Two EODRE. kcornetta@williampalumbo.Cem INSURERS AFFORDING COVERAGE NAIC# Franklin MA 02038-0374 INSURFRA:Safet Insurance Company 9454 INSURED INSURERB:Hartford Ins Co 19682 Daniel bi ssault INSURER C; 990 Johnson Street INSURER D; INSURER P: North Adover MA 01845 INBUR)_RF: COVERAGES CERTIFICATE NUMBF-R•CL1272736701 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 ANb CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED 13Y PAID CLAIMS. SR TYPE OF INSURANCE POLICY NUMBER POU EFF rPOLICY EXP LIMITS LTR MIDDAIYM GENERAL LIABILITY EACH OCCURRENCE S .300,000 COMMERCIAL GENERAL LIABILITY MISES RENTED $ 100,000 A CLAIMS-MADE DOCCUR BMA0012372 9/15/2011 /15/2012 MED EW(Any one person) $ 10•,000 PERSONAL&ADV INJURY $ 300,000 GENERAL AGGREGATE Is 600,000 GEN'LAGGREGATEUMITAPPLIESPER; PRODUCTS-COMPIOPAGG $ 600,000. X POLICY PRO LOC $ INED E LIMIT AUTOMOBILE LIABILITY Ea accid9nil ANY AUTO BODILY INJURY(Per person) $ LL OWNED SCHEDULED AUTOSA BODILY INJURY(Persocidet!) S NUTOS ED ROPER DAMAGE $ HIRED AUTOS AUTOS Per soel $ UMBRELLA LIAR [j OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $. DED I RETENTION 13 WORKERS COMPENSATION WC STATU- DTH- AND EMPLOYERS'LIABILITY .ANY PROPRIETOWPARTNER/EXECUTIVE.ANY E.L.EACH ACCIDENT $ 100,000 OFFICERWEMBEREXCLUDED7' NIA %26/2013 /26/2013 (Nundatory in NH) BStEC$H1933 E.L.DISFASE-EAEMPIAYE $ 100 000 If yes,descrlbeunder EL.DISEASE-POLICY LIMIT a 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Addltfolal Remarks Schedule,IF mare space Is required) I CERTIFICATE HOLDER CANCELLATION (978)688-9542 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE F_XPIRATION DATE THEREOF, NOTICE 'WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Brian Leathe 1600. Osgood Street AUTHORIZEDREPRF-SENTATIVE N. Andover, MA 01845 HUB AGY/KCORRS i 01988-2010 ACORD CORPORATION- All rights reserved. ACORD 25(2010/05) 2Men9r. n, The ACORD name and logo are registered marks of ACORD Page No: of Pages. Residerhtiai•cotthmet> al David ion DeSig 19,MA Road Licensed&Insured saugttsnrio19Q6 Cell:781-405-4964 4& Pax.781-231-2133 PIWPOSALSUBMnTWT PHM �^� (17 MASK d - JIM MASK Ohl C"If.STATE AND ZIP CODE Joautzlmk qpm � 6ATE of Puns r Phtoroe WE HErAW SUBMrSPECSCMXh ANDES lMAIW POR: j we � Utit i � I f f ��>�p¢Q hvebYmhrttdstr��"eorrmh�etnncwnlancerhha6av®spedB�tleus.t��e i doltars i$ WO• Payment t6 be made as foilt 4z, ows� �1'1Y'� ,C� �,J i /. eJ 1.0®r.3 NF matervh is B to be as specified.An work m be oomWeted in a.vofkmaiAike - sooar6n6 m standard practices.AoV mneration m dorhatioa from above speofca' Authonzed - _- 1; iavaNixlg e'ga9 costs wM be e�rnted onlY up—v�-d—and coif ITe�an $tgllatltre s Nand O"Wand ebo*e ane esw ts,An as eeadn¢eat"pen'hikes.aoadenbc Mote=This pmgosai may be co,Coatoh Ower m carry fires tornado dna Mber reeeessa'Y 'm1C withdrawn us if not accepted within diiY$• amfrdyrCC J)f Oda l--the above prices.sped icatiOnsr ifrese ibdoyand are hereby�Pted. You are authorized Wk as spedfied.P"W"'bemade aso Armed above. �2 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): b,�,�1 rS�w4✓ Address: 710 d O 1✓6 6V11 City/State/Zip: IV. AA/ja-45?, M�I- Phone#: 7 8 z Are you,an employer?Check the appropriate box: Type of project(required): 1. am as employer with 4. ❑ I am a general contractor and I �* have hired the sub-contractors 6. E]New construction employees(full and/or part-time). 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. E]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.El Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL I L❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.] employees. [No workers' 131-1 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 a new affidavit indicating such. II' #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. j 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.Lie.#: fd� / Expiration Date:613ly Job Site Address: �� -& 2� City/State/Zip: /9,�_ fFi✓�f� 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. 1 do hereb certify u er to pa s and penalties erjury that the inform lion provided above i true an correct. Si nature: Date: t 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 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 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. #617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 5-26-05 www.mass.gov/dia oil, ctia e;:ul 1 s46 s C', '•r,r#'!'npFri#l:l4)t* IltJill?ti l ,; .t�f,LicensUPeeCS lSQr ` tn/:0Sy! " OAN, � OgO JpHN D vSSAULT AIV Sq ST' 'J DpVER MA 01 845 exp iratian ' �— 7'r*. r ;9 76/2012 IMP nsumer Affairs B sines Re HOME °� i �Re914tration.OVE ENT CONTPPR X1.49853 RRCTOR Ex-(ration 2/14%2014. TYAe. DU LILT CA'RP6NTRYh _-, DBq DANIEL p USSRULj 990 JOHNS ON STI3EETYjti NORTI f;gNDOVER Mq.01845 O I Undersecretary t 1