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HomeMy WebLinkAboutBuilding Permit #0812-2017 - 162 AMBERVILLE ROAD 3/1/2017 NORT" Q BUILDING PERMIT TOWN OF NORTH ANDOVER o �w APPLICATION FOR PLAN EXAMINATION ' _ 2^?6/� Date Received �,4" awK Permit No#: °"Argo LIS Date Issued: BHORTANT:Applicant must complete all items on this page `La+^S; hd •..F".h'sC-r�'��.�.....,.�,:� '.1 F f' -.. 1 6Ya. i 1 ,--.a-- _sL..., t t �' �.a o-.. ! � Off t♦p 3 • y�' }} �i, P Intl. fy P�ROPER;TY - 1, Structure 4Yes� o 'ARA�RCREL T_ ZONING DISTRI�cT Hist,or ®ist`ricti TYPE OF IMPROVEMENT PROPOSED USE Reside tial Non-Residential ❑ New Building [4-6ne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑Commercial impair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic '`)Well ❑ Floodplain �Wetl`ends ❑ 11Vatershie�d�Distract y ❑.Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: WE S / L.Ou) SUS e p Ttiti4 tification- Please T e or Print Clearly i L, ��� Phone: / Address: S eti Phone= xr ;Address .. f' �"' �1 ..ate ,' s y'»�. a =-tip �� ,, .:.: s't r"-'os-rt � h-- i . ,s»xqw. .y °a..k^^.�e.'• `-r� � Ir fi,.Lf, �_�..r ' f'��_^'Vj :�k,�a`t � +,. s a;• ,,. � ����, T� ♦� ,�f,�F� f� ��t�53,� - Su ervisor' © suctt�nLicense `' Exp Datec. [� .; e h ,S-'}...: .S t - '-F-r -.cyg a :,.,"'�s, r. ..:a'' a+",�l''r,•i f"`i`"� r - .1 `as.+. -..-.;w i .�,.'.', ?. -;� _- - s- ARCH ITECT/ENGINEER Phone: i Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$92-00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: FEE: $Nv J � � Check No.- /3- -3 / Receipt No.; 3 NOTE: Persons contracting with unregistered contra ors do no ve:access to the guaranty fund Sigratu�e of_Agerit/Owner` Signature of �f 1 Location No.©tqf� ,off Date�� • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $, Foundation Permit Fee $ Other Permit Fee $ i TOTAL $ Check 4t I f I J�3 Building Inspector Plans Submitted ❑ Plans Waived Certified Plot Plan ❑ Stamped Plans ❑ [Piuiblhic YPE OF SEWERAGE DISPOSAL Sewer ❑ Tanning/Massage/Body ArtSwi,nming Poolsell ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Pennanent Dumpster on Site ❑ t THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS �!oning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes >� 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 yes no Located at 124 Main Street Fire Department signature/date COMMENTS limension 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 droprequires approval of Electrical Inspector Yes No ®ANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine - I NOTES and DATA— (For department use) I I - i i i I I I I I ` ❑ Notified for pickup Call Email ate Time Contact Name ° Doc.Building Permit Revised 2014 _. Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. r 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 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/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 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 j ❑ Engineering Affidavits for Engineered products 40TE: 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:Building Permit Revised 2014 NORTH Town o . _ ndover 0 1. oh ver, Mass, 0943 .4 coc«ec».wK« . A�R�TE O #P" S V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ......Co.$#-A-4......4.... .................................................... ... BUILDING INSPECTOR I� A14to . Foundation has permission to erect .......................... buildings on ..C.16.Zr..... ..... . Rough to be occupied as A. ...... .. .���!... �R�'�iG�' ..................................... Chimney provided that the person accepting this permit shall in eve 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 I XB11!62NiS�PE/FOR Rough Service Final I 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. ............ ------------ ....... All. > be- .......... I.o VD 7 17 'k ID- °The Commonwealth of Massachusetts _ Department of lndustrial.A.celdents r 1 C;,ongne,ss Street,,5`ai 100 ostort, 2YIA 6214 2017 www rnotss.gov/dza • Workers'Compensatiortrusuxaaee,Affcdavirt:BLdldexs/Coin'actoxslElectricxax�.s/�'l�runbexs. TO BE P�W�'SHE PMS G A(� (�Itt��'. ..Please Pxim�t D 1 A '"licantInformatiou U r S -, aniza#on/Iudividual): !Jl 4 //IRP �V Name(Business/Org Address:) l �,,�� 1 L MR D 1S's a Phone City/State/ jP: .... �� e keyonau.—PIoyez?Checkth ppropriatebox: Type ofproject(reclunt a)= loyees(fuII andlorpart iive). 7. ❑NeY`COnstnlcfiort 1.[A I am.a employer with—�P g- ❑remodeling 2.❑ -ve Iamasolo pmprietorOrpaztnfish'p�anadha ncereoq�d]yeesworkingfor mein 9. []Demolition any copm LY jNo�vorkers'comp• oworkers'comp.insurmoerequired]' 10[1 Building addition 3.E]T am ahomeowner doing all work myself[N Twill 4-❑T am ahomeowner mdvO be bmng coatraezm to tontine'al[work onmy property. 1l.❑Elecirieal repairs or additions enso ethat alt cordlactats dffierhaveworkers'compensation inn-nee or are sole <_,, 12.[].prw:abxvg repairs or additions pr�etazs with.no employees. 5.0 I am a generd contr4ctor and Thal 4 ebff� � c �aetCrsmPsEe�d�o�n�ached sheet 110 Roo1 repairs Tbese snb-contactors have emp Y 14. Other 6.Q We are a corporation and ifs,offices have exudsedtheirright of'exemptionperMGL c. o ees oworkme comp.insurauce_required-] 152,§1(4),andvvehaveno empl v . .� a hcaac)�atchecksbbx#1, 'sdooesectionbelo�zshowingtheirworkers'compensatienpoficymfaffiation" PP 6thaIIwork aud-ffimbira outside contractors must submit anew affidavi L indica�ng sneIr I Ilomecwnem wha suQt•this affidavit indicatmgtlrep aze doing Contractors that cher Box nmvsf attached additional sheetshowing thename of the sab contractors and sfate whether or notthose entitles ave t rovidetheir workers'comp.policy number. employees. If the sub-contractors have employees,they mus P ZO ees. Below is tTiepOltcy cazdJoTi Site I am an employer that isproWdingWorkers'compensation insur=ancefor my erne y infonnadon. S Insurance CompauyName: � C d� a n d 4 n 0 G��/ 9 FxpirationDOe: /0— Policy#or Self-ins.Lic.#: ��B�S e 1 ii,/�£R�I��� ��_ City/State/Zip: .�l oDU�' lob Site Address: 'Q e gb oWbg the policy number and expiia ion date). Attach a cope Of the�s'orkexs'conzpeusationpolzcy declaratzonpag ( to$1,500-00 Failure to secure coverage ag required undexM enol iesZin§th2e o fA is a craSTOP WORK ORDER and a fine°up to $250.00 a and/or one year lmprisonmen as well as civil p day against the violator.A copy of this statement may be forwarded to the Offfce of Investigations of the DIA for ins tante coverage Ver f ration. Ido Hereby certif3'under tTiepains andpenaltles OfpeYjujy that the infonnatiore provided wave true orad correct Date: ��— O�d� Si at im: phone#: ! Official rise only. Do not write ire this a?ea,to Tie cornpleted Try city or to tv�i OfficiaL I exnzit/Licease# City or Toyvn: IssuingA.utltoxity(circle one): i ector Z.Board of llealtiz Z.building Department 3.CztyjTOvvn Clerk 4.Wectrical Xnspector .Plumbing xnslr 6.Other Plloxte#: Contact Person• r Information and Instructions Massachusetts Genexal 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 ofhiie, express or implied,oral or written." An employer is d'efiried 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,orthe receivet'or ttastde of an individual,partnership,association or other legal entity,employing emplbyees..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,con&artion or repair work on such dwelling house or on the grounds or budding 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 rene A of a license or permit to operate a business onto construct buildings in the commonwealth for any applicaAtwlto has not produced-acceptable evidence of compliance with the insurance coverage xeg&ed." 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 rcTurements 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=contractar(s)name(s),address(es)aadphonenumber(s)alongwiththeircarocate(s)of insurance. LimitedLiabilityCompanies(LLC)or Limited Liability Partnerships(LLP)withno 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. b e 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 retained to the city or town that the application for the permit or license is being requested,not the Department of Indus W.—Accidents. Should you have any questions regarding the law or if you are required to obtain a wkikers, compensation policy,please call the Department at the number listed below. Self-insured companies should entertheir self'--insurance license number onthe appropriate line. City or Town Officials Please be sure thatthe affidavit is complete and printed legibly. The Department has provided a space atthe bottom of affidavit for you to fill out in the event tb.e Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/liceme number which will be used as a reference number. Ln addition,an applicant that must submit multiple ponaiit/license applications in any given year,need only submit one affidavit indicating current Policy information(if necessary)and under"lob Site Address"the applicant should write Fall locations in (city or town)"A copy ofthe affidavit thathas been officially stamped or marked by the city ortovutma.y beprovidedto the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filed out each year.Where ahome,owner or citizen is obtaining alicense orpermitnotrelated to any business or commercial venture (i.e_a dog license or permit to bum leaves etc.)said person is NOTrequited to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Depait ment of lndustrialAccidents 1 Congress Street, Suite 100 Boston,MA 02114.2017 Tel.#617-727-4900 ext.7406 or 1-877-MASSApE Fax#617-727-7749 Revised 02-23-15 WWW.nlass_gov/dia Date Prepared: 09/17/16 DIRECT BILL WORKERS' COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY MERCHANTS MUTUAL INSURANCE COMPANY BUFFALO, NY 14202 NCCI COMPANY NUMBER: 15652 INFORMATION PAGE POLICY NUMBER: WCA9098619 TRANSACTION TYPE: RENEWAL AGENCY/BROKER: BYAM-BROS-MAHONEY INS AGENCY RENEWAL OF NUMBER: WCA9098619 AGENT CODE: 39627/NERO6/032 BUSINESS TYPE: CORPORATION 1. THE DAVID M MURPHY PLUMBING INTERSTATE/INTRASTATE RISK ID: INSURED HEATING AND GAS FITTING INC BOARD FILE NUMBER: MAILING 3 CHAMBERS STREET ADDRESS LOWELL, MA 01852-4165 FEDERAL EMPLOYER IDENTIFICATION NUMBER: 043086385 OTHER WORKPLACES NOT SHOWN ABOVE: (ADDRESS,CITY, STATE, ZIP CODE) 2. POLICY PERIOD is from 10/17/16 to 10/17/17 12:01 AM standard time at the insured's mailing address. 3. A. Workers' Compensation Insurance: Part One of the policy applies to the Workers' Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $1 ,000,000 each accident Bodily Injury by Disease $1 ,000,000 policy limit Bodily Injury by Disease $1 ,000,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: D. This policy includes these endorsements and schedules: MS IU 05 11 99 MU 06 3J 10 14 WC 00 00 00 C WC 00 00 01 A WC 00 04 06 A WC 00 04 21 C WC000422B WC 20 03 01 WC200302A WC200303D WC 20 04 01 WC 20 04 03 WC 20 04 04 WC 20 06 01 A 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Code Premium Basis Rates Per Estimated Annual Classifications No. Total Estimated Annual $100 of Premium Remuneration Remuneration SEE EXTENSION OF INFORMATION PAGE MINIMUM PREMIUM $ 330 DEPOSIT PREMIUM $ 11 ,877 TOTAL ESTIMATED ANNUAL PREMIUM $ 11 ,877 Interim adjustments of premiums shall be made: ANNUAL Countersigned by: �. Authoriz representativ Date COPYRIGHT 1987 NATIONAL COUNCIL ON COMPENSATION INSURANCE WC 00 00 01 A INSURED COPY 03-01-`17 10:54 FROM-Byam BrosMahony Inc 978-937-0745 T-799 P0001/0001 F-196 A`ORR * DATEIMMIDOAIYYY) CERTIFICATE OF LIABILITY INSURANCE 0310112017 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(s an ADDITIONAL INSURED,the policy(les)must be endorsed. It SUBROGATION IS WAIVED,subject to f 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 otsuch endorsement(s). PRODUCER CONTACT Wg am Bros aBros Mahoney Ins.Agency NAME: Fax 1m Pawtucket Blvd a Nn E=1:978-4542926 AIC No:975-937-0745 Lowell,MA 01854 EMAIL Byam Bros INSURERS AFFORDING COVERAGE - NAIC e INSURERA.Merchants Insurance Co. t INSURED David M.Murphy Plumbing INSURER B• 1 Heating&Gas Fitting Inc. 3 Chambers Street INSURER C Lowell,MA 01852 INSURER 0,- INSURER :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 i 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. [TbN P EFF OLICY EXP R TYPE OF INSURANCE l POLICY NUMBER MMIDDmm MM/DDIYYY LIMrtb A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE _ 11000,00 I CLAIM$4ME F�l OCCUR B01121072405 0511512016 05/1512017 >i 500100 MED EXP(Any ane petsan) S 16,00 PERSONAL&ADV INJURY S Included OEML AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE E 2,000,00 POLICY❑PRO- JECT 0 LOC PRODUCYS-COMPIOPAGO $ 21000,00 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S 1,000,00 A ANY AUTO MCA0000041 09112(2015 09112/2017 BDOILY INJURY(Per pt SW S ALLOWNED �( SCHEDULED BODILY INJURY(PoraaidoM) S AUTO$ AUTOS I X q� AO PROPERTY Pfa ! AMAGE HIRED AUT08 Sewn S i S X UMBRELLA LIAR X OCCUR EACH OCCURRENCE 11 2,000,00 A EXCESSUAS CLAIM34WOE CUP9145800 05/1512016 05/15/2017 AGGREGATE $ 2,000,0011 DEO I X I RETENTIONS 10,000 : WORKERS COMPENSATION X RTA LITE ERH ANO EMPLOYERS'LIABILITY A ANY PROPRIETORIPARTNERIEXEWIVE YIN WCA9098619 1011712016 10/1712017 E.L.EACH ACCIDENT S 1,000,00 OFFICER/MEmBEREXOLUDE09 NN NIA {MandatorylnNH) E.L.DI8EASE-EA EMPLOYEE S 1,000,00 11 d68.de.ClDe tilde/ DESCRIPTION OF OP6RATIDNSbulow E.L.DISEASE-POLICY LIMIT a 11000.00 ; t f i I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,AddNlonal Remarks Schedule,may ba aRaehad It more lgecs Is raqulrad) I 1 CERTIFICATE HOLDER CANCELLATION TowoFAN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 120 Main Street North Andover,MA 01845 AUTHORIZED Byam Br 0196 ti reserved. ACORD 26(2014101) The ACORD name and logo are registered marks o RD Fold,Then Detach Along All Perforations n OQ61 MONWEALTW OF MA S BOARD-OF _ PLUMBE ZS"-W.' GASF TTEi2S ISSUES THE FOLLOWINd L IC IVSE aGEI�SED AS A FWASTE'RPLUMBER W DAugD fVi INURPHY 934:.,FAIRMOUNT,..ST LOWELL,MA 01852-379.9 y' 9723 Q810112018._ 45113