Loading...
HomeMy WebLinkAboutBuilding Permit #265-12 - 158 MAIN STREET 9/27/2011 TOWN OF NORTH ANDOVER . APPLICATION FOR PLAN EXAMINATION permit NO: — 2- Date Received Date Issued: 2 l� �O`RTAI�IT:A Hcant must complete all items on this age LOCATION I 1 r 1 A CV P—T m—o Pr' PROPERTY OWNER 0- . 0 � m r0"USODA Print MAP NO: _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 'd Repair, replacement ❑Assessoxr Bldg X Others: ❑ Demolition _ .Other (-: Vq� - U F"V—k • DESCf f1 T1-10N OWORICTOEEPE� D: - 01. �11TE'R��R 1 R►1� •l� � � �N 1SOi�1S' \00J f� ��IwksN ('AWS �r�p►, �F C�� t�00e.S Identification ease Type or Print Clearly) OWNER: Name: I Phone: Address: s ' CONTRACTOR Name: -'Q 1� C k CO3o'm S Cc, Phone: Address: qIQ 1Vo(Lrt�6\na �T, �t31,��„r► \�� D�,O Supervisor's Construction License: Exp. Date: T (Aok3 Home Improvement License: 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. a " Total Project Cost: Check No.: ,3 2- Receipt No.: NOTE: Persons contracting with unregistered contractors do not have cess to the ar un - .Si nafure of�Agenf%Own. . - ------_,_9=�->--- -•-_-•--_•_-- •-- - - -- ----_ - = - Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Pians ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Swimming Pools ❑ Tanning/MassageBodyAxt ❑ 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 Signa ire COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decisionlreceiptsubmitted yes Planning Board'Decislon: Comments Conservation Decision: Comments Water& Sewer ConneCtlon/Signature&Date Driveway Permit = DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEP,A_RTNLNT -Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories: T offal square feet of floor area, based on Exterior dimensions. Total land area, sq. i.: ELECTRICAL: Movement of plater 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 I NOTES and DATA— For department use El Notified for pickup - Date DomBuilding Permit Revised 2008mi 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 ❑ 11'Vorkers Comb 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 of from Fire Department prior to issuance of Bldg Permit. Addition Or Decks o Building Permit Application - ❑ Certified Surveyed Plot Plan a Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses Ll Copy Of Contraci ❑ 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) i ❑ 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 Pian 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: Doc.BuildingPermit Revised 2008mi Location_�s� Gi�/ No. a�S- 12- Date �aRTM TOWN OF NORTH ANDOVER 0:+ �ao :•'��0 O �� L F 9 Certificate of Occupancy $ ,y b�+na'tea cHustt� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # Z` L 2 4 66 4 Building Inspector NORTH oAndover' .. Town t0 O �oi� ` o . dover, Mass., Z"? i LAKE A- COCHICHEwICK 7 ORATED PP�,��C� qS BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System I ` if BUIL D ING INSPECTOR ...•..•..THIS CERTIFIES ... Foundation has permission to erect..:..................................... buildings on ....e�5 ..�f�!: !.S "................................................. Rough • �F� /It /G� C'r .' � ,G: � Cc �/ / � Chimney to be occupied as.................. �1.�.......................:� ..�.�..�� .,,.b/.�.�E..c�l....r.%�r,�.b......M�. .f.. �c?.a"�s............. provided that the person accepting this permit shall in every respect conform to the terms'of he appl' ation on file in Final 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 S ARTS Rough Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIREE.DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. EverGreen Environmental Health&Safety,Inc Conducted by Associated General Contractors of Vermont Certificate of Attendance and Successful Completion g Renovator Initial-English Per 40 CFR 745.225 \ Mike Collins ))) P.O. Box 281 N.Salem, NH 03073 #. Certificate Number R-1-19630-10-00288 . :ltassat•6u�etts_ I� B�aar tl of del.11-tment or put ConsBuilclinti Ref#Ul;1ti()n�; rtrt Satoh truction S end S ; One_anq T Uperv- Licenset and;,,A, License: CS 61961-Farrii! Y Dwellings MICt•fgEL 6.'tcc lTRf4R COLLINS 429 N MAIN STYp °8px 281 N SALEM NH 03073 . "�qmi+siuRerwn«,:,�RW Expiration: 7/72013 Tr#: 231 !,/ .... . 0/ office of Consume*Affairs&$°sluess Illation R \ = HOME IMPROVEMENT CONTRA - i tioi%;<149502 TO 291367 1 EXpirati(in_;: 't(18R0 TyPez tndividial - t r:\ MICHAEL A ji1,CHA X429 NORTH Mp,INST Undersecretary 079 SALEM,NH 30 SEP-19-2011 MON 03;36 PM LAKESIDE INS. AGENCY FAX NO, 6034326076 P. 01/01 ,ACORQN CERTIFICATE OF LIABILITY( INSURANCE PATE(MM/DDIYYYY) i a9/i9/201,1 THIS CERTIFICATE IS ISSUED ASA 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 FIFTWEEN 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 SURROGATION 15 WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not coffer rights to the certificate holder In lieu of such endorsement(s). PRODUCER NAME: _ Lakeside Insurance Agency, Inc. PHONE 603.432.3666 Arc, e,�: „�_(AIC,No):603.432"6076 FiAX Three Wall Street -�IulA�l'. ADDRESS: _ Windham, NH 03087 INSURER(S)AFFORDING COVERAGE NAIC0 INSURERA: Western World INSURED Michael A. Collins Company INSURER B: Travelers IndeMni ty Co PO Box 281 INSURER C: North Salem, NH 03073•-0281 INSURER D: INSURER E: INSURER F: `y COVERAGES CERTIFICATE NUMBER: Michael A. Collins 2011 REVISION NUMBER: THIS IS To CERTIFY THAT THE POLICICS F INSURANCE LISTED B-L W HAVE BEEN ISSUED TO THE INSURIED 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 ISSUCD OR MAY PERTAIN,THE INSURANCE AFFORDED SY TI1E POLICIES DESCRIBED HEREIN Is SUBJECT TO ALL THE TCRMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TSR TYPE OF INSURANCE BR "- INSR WVID POLICY NUMBERMM/DD/YYYY MMIDDIYYYY LIMITS GENERAL LIABILITYNPP1304587 06/19/2011 06/19/2012 EACH OCCURRGNcr a 300,00( X COMMERCIAL GENERAL LIARILITYUE'T0-RENTED PREMISES(Ea accyrrence) 'S 50,00( CLAIMS-MARC OCCUR A MED EXP(Any one person) $ S,00( -- PERSONAL B ADV INJURY $• 300,00( GENERAL AGGREGATE $ 600,00( GGN'L AGGREGATE LIMIT APPLRS PER; PRODUCTS•COMPIOp AGG IR 600,00( POLICY jE LOC AUTOMOBILE LIABILITY Fa acclaent) $ ANY AUTO BODILY INJURY(Per perzcn) $ ALLOWNCp SCHEDULrQ AUTOS AUTOS BODILY INJURY(Per gccidont) $ HIREpAUTOS NON-O NFDAUTOS -p(� _(Per aPER ccident $ UMBRELLA LIA6OCCUR g EXCESS LIA6 HCLAIMS-MADE EACH OCCURRENCE AGGREGATE $ DEP RETENTION$ — WORKERS COMPENSATION iF AND EMPLOYERS'LIApILITY 1-18425517439 06/13/2011 06/13/2012 XDRY LIMITS ER ANY PROPRIETORIPARTNERIEXECUTI YIN 11�(L B OFFICCRIMEMBER EXCLUDED? NIA E.L.EACH ACCIDENT s 100,OOC (ManCatory In NH) If yos,oeeeribe under E.L.DISEASE-EA EMPLOYEE T 1aa,00C DESCRIPTION OF OPERATIONS below " E.L.DISEASE-POLICY LIMIT $ 500 00C DESCRIPTION OF OPERATIONS r LOCATIONS r VEHICLES (Attach ACORD 101,Add)tiopol Remark*Sahodulo,If mare apace Is required) slued as evidence of coverage on behalf of the Named Insured during the policy partied, CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRI13EII POLICIES BE CANCELLED B�EFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, St, Gregory's Armenian Church AUTHORIZED REPRESENTATIVE n ��,., 158 Main Street 7' _'�.e-G..c North Andover, MA 01845 Joseph Rossetti LYNN ACORD 25(2010/06) ®1988-2010 ACORD CORPORATION. Ail rights reserved The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 a� www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Pr><nt LeLy>ibly Name(Business/organization/Individual): Address: City/State/Zip: �hb��_Ve\ Phone#:_ Vff employer?Check the appropriate box: em to er with A3 4. g Type of project(required): p Y ❑ I am a general contractor and I r-bees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction sole proprietor or partner- listed on the attached shget. $ 7• Remodeling d have no employees These sub-contractors haveg for me in any capacity. workers'comp.insurance8' ❑Demolition rkers' comp.insurance 5. ❑ We ate a corporation and its9 ❑Building addition d.] officers have exercised their 10.❑Electrical repairs or additions 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 required.]t 12.❑Roof repairs insurance re ] employees.mployees. [No workers' comp.insurance required.] 13.❑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 are doing all work and then hire outside contractors must submit a new 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. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: C N Policy#or Self-ins.Lic. ` Expiration Date:_ Job Site Address: City/State/Zip: F Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). b^t 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. do hereby certify un der the pai a ena o erjury that the information provided above is true and correct. . Si nature: ✓ / _ i ,` Date: Phone#: t 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): I.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-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 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 C01-nx-nonweal`h oa Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MAA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia