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HomeMy WebLinkAboutBuilding Permit #1278-2016 - 16 ROYAL CREST DRIVE 6/8/2016 � eao�arp.' � BUILDING PERMIT O �o 10 2 , 646 O TOWN OF NORTH ANDOVER ® �.ti` Kt APPLICATION FOR PLAN EXAMINATION - A Permit No#: � "� ( Date Received �yS RarEo rep�g5 S CH5� . �iU i Date Issued: MPO R TAN T:Applicant must complete all items on this page LOCATION tONEFR v Print PROPERTY Print 100 Year Structure yes no 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 0 Industrial ❑Alteration No. of units: ommercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition _ ❑ Other b�SepticTiOfWell4�YFIYoodpla n D Wet1- "ds 77. i� 1Natershed ®.ism t .. 7211 DESCRIPTION OF WQRK TO BE PERFORMED: vl � GU I entification- Please Type or Print Clearly OWNER: Name: // // Phone: Address: c1 �o Ife / ✓b^• ,,a 4(.�Ao� Contractor Na Cc / Phone: 617 ' �- Email: 0 v CA kjofegL­aAv &n , cb Address: I)- ),9e, 2Supervisor's Construction License: S 06 5_)4J Exp. Date: Home Improvement License: Exp. Date:-/ 126 / ~f 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. Total Project Cost: $ !� U0V,f,Q FEE: $ Check No.: 6Receipt No.: �JDr1 Z- NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund : I Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped flans ❑ TYPE OF. SEWERAGE DISPOSAL Public Sewer ❑ Swilmning Pools ❑ . Tanning/Massage/Body Art ❑ well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Pennanent Durnpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF e U FORM PLANNING DEVELOPMENT Reviewed On Signature_ i COMMENT'S CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes rplanning Board Decision: Comments I -lonservation Decision: Comments i Water& Sewer Connection/Signature&Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street f-IRE D PSA �l6Vi BAIT Tem bum steron site, es. j {P �y�/ V p4 yc - -4x# L :. ��ys�' 1` # 1�,...�' p 1.e ,�, i J + sti... <.�i.`i3,'r >.2 �' Locatecl'at !,2 Main ' .* - d �, s =Fire�De�ament�i�raatu¢�/date, . �� �, _. - � •�: ,a ,, .: t_ 771. r i �,.'��, �}�. ; r's:M.. . r; r r �.,r .4..3na r,.k�»+.•-ti [ �, #L..�xta..' COMMENTS 1Xr t5 r� �4kA I i Dimension Number of vcories: 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 �I DANGER ZONE LITERATURE: Yes No NGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) I ® Notified for pickup Call Email = Date Time Contact Name Doc.Buildiug Permit Revised 2014 i Buildirng Department The follow! is a list of the required forms to he 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 Er?gineering Affidavits for Engineered products OTE-, All durrlpster 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/Cross Section/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 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 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 2012 IECC Energy code Engineering Affidavits for Engineered products ®TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit Irn 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 rrnust be submitted with the building application Doe:Building Permit Revised 2014 60 � 1 Location r a /7(07 A / f ' No. 7P !. 1c9 7 /d U.�.? cj/y Date ' f l J I • - TOWN OF NORTH ANDOVER r • -j Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ •' i Other Permit Fee $ TOTAL . $ Check#e 4519 30472 Building Inspector r�' NORT-� T®w �? . : , ,, Andover 0 No. rw- 1 2,61 "it ?,o h ver, Mass, �� � t�� cochu Ml WICK RwTED PP�,�'�y U BOARD OF HEALTH Food/Kitchen PERM -IT T LD Septic System. THIS CERTIFIES THAT .. o ... ..L..• ,,,,,,,,,,,,,,,,,,,,,,,,,,,,•,,,•,••••••••••••••••••••••••••••••• BUILDING INSPECTOR ............................... has permission to erect .......................... buildings on ... .. ...Ato!rmp%*:................................... Foundation Rough to be occupied as .../A ..�> c9.�s� ................................... 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 TION Rough Service . .... .. . . ....... ...... Fina BUILDING SPEC R 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. M e sill & 150 ito 9 bm 6f p a rt `e A all Oki 00 � _• pail GPnG wls3 '�f4S9� am rx l a p; all0. +k �� W N LU Uj PA The Commonwealth ofMassachasetts Department ofIndlustrial.Accidents 1 Congress Street,Suite 100 Boston,M4.021.14 2017 www.}Y ass.goVIdia Workers'Compensation Insurance Affidavit:Builders/Contractors/E lectricians/plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print LeOb NaMe(Business/Organization/Edividual): J, o. Addxess: dJ Pa City/State/Zip: y V�% Phone#: Areyou an employer?Clrecktlie appropriate box: Type of project()Vequired): 1.H1 am a employer with [](fuU and/or parti time)."` 7, Q New construction 2.Q I am a sole proprietor or partnership and have no employees working for me in 8. [Remo delilig any capacity.[No workers'comp,insurance required.] ❑Demolition 3.Q I am a homeowner doing all work myself-[No worlcers'comp.-insurance required.]t 9. 10 [1 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.[l Electrical repairs or additions proprietors with no employees. 12.[J Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.1 �—y�, 6. F1 We are a corporation and ifs of5cers have exercised their right of'exemption per MGL c. 14'. Othar O/ 152,§1(4),and we have no,employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also 01 out the section below showing their workers'compensation policy information. Homeowners who submit phis affidavit indicating they are doing all work and then hire outside contractors laust submit a new affidavit indicating such. TContractors jhat check this box must•attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. lain an employer drat ispr'ovzd!hg wor&,s9 compensation insurance for my employees.'Below is thepolley and job site information. Insurance Company Name: Poli cy#or Self=ins,Lic.#: ( ALI )2. I Expiration Date: Jv Job Site Address: / ((ter 1( ��i — �a�7_� 0 City/State/Zip: Attach a copy of the worldre compepn ation 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 WORD 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 verification. I do hereby certnder hepai, s _ndpenaldes ofperjury that the information provided above is true and correct. Signature: U Date: 6 Phone#- 6 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.Plectrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information 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 truatde of an individual,partnership,association or other legal entity,employing emplol yees. 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 p erformance of public work until acceptable evidence of compliance with the,iinsurance - 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=contractoz(s)name(s),address(es)aad•phone number(s)along with their certificate(s)of insurance. LimitedUability 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 fez•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,riot the Department of Industrial Accidents. Should you have any questions regarding the law or if yo'u'are required to obtain.a Workers' compensation policy,please call theDepartment.at the number listed below. Self-insured companies should'enter'their' self insuraace 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 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-201.7 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia A�® CERTIFICATE OF LIABILITY INSURANCE 4�4i o ' 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(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 certifi to holder in lieu of such endorsement(s). PRODUCER CONJean Sullivan, CIC, AIS Burgin, Platner, Hurley Insurance Agency, LLC PHOS (617)472-3000 FAX Nok(617)472-1248 14 Franklin St. E-MAIL . •as@b hins.com INSURERS AFFORDING COVERAGE NAIC S Quincy MA 02169 INSURER AJIanover Insurance Company 2292 INSURED INSURER B.Safety Indemnity Insurance Co 33618 B & M Restoration & Contracting, Inc. INsuRERc-Acadia Insurance Company 218 Paris St INSURER D: INSURER E: East Poston MA 02128 INSURER F: COVE GES CERTIFICATE NUMBER taster Cert 2016-17 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 i D POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER IF-2MM (MWDDNYYYI LIMITS GENERAL LIABILITY Y N EACH OCCURRENCE $ 2,000,000 DAIVOLGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES Ea ocwrrence $ 1500,000 A 7-1 CLAIMS4MADE Ex—]OCCUR ZHUS997647 /17/2016 /17/2017 MED EXP(Amy one n) $ 10,0001 PERSONAL&ADV INJURY $ 2,000,0001 GENERAL AGGREGATE $ 4,000,006 GEN'L AGGREGATE LIMIT APPLIES PER: t PRODUCTS-COMP/OP AGG $ 4,000,000 JECT B POLICY PRO- LOC I $ AUTOMOBILE LIABILITY y y EaMBINEO SINGLE LIMIT 1,000,000, B ANY AUTO BODILY INJURY(Per person) $ ALL OWNED $ SCHEDULED 208157 1/6/2015 11/6/2016 BODILY INJURY(Per accident) $ AUTOS AUTOS NPROPERTY DAMAGE $ % HIRED AUTOS $ AUTOS O AWNED Pg ant PIP-Basic $ 8,000 R UMBRELLA UAB g OCCUR Y N EACH OCCURRENCE $ 5,000,000 A EXCESS UAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED. x RETENTIONS 9055121 /17/2016 /17/2017 $ C WO KERS COMPENSATION N B WC STATU- (N- AND EMPLOYERS'LIABILITY Y/N Y LIMITS ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N/A -20-20-003740-03 /10/2015 /10/2016 (Myandato.In NH) EL DISEASE-EA EMPLOYE $ 1,000,000 If DESCRIPTION describe OFOPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,H more space is required) Contract # 18122-422094-CPe-00002; Property Name- Royal Crest Estates(North Andover); AIMCO North Andover LLC is additional insured per written contract CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN AIMCO North Andover LLC ACCORDANCE WITH THE POLICY PROVISIONS. 50 Royal Crest Drive North Andover, MA 01845 AUTHORrLED REPRESENTATIVE Massachusetts De Board of Buildin Partment of Public Safety 9 Regulations and Standards ` Licerose: CS-065281 Construction'Supervisor ` ��. i s �➢ PAUL BRUNO 109 CHESTNUT STREET r . LYNNFIELD MAY0194; � J 6 4 .)i"145\h Commissioner.. Expiration: -- -- — - 09/28/2017 i .r