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HomeMy WebLinkAboutBuilding Permit #591-12 - 1875 Turnpike Street 2/7/2012 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: / Date Received Date Issued: 9/7 7 /Z IMPORTANT:Applicant must complete all items on this page LOCATION ld'7�z �r� J Pr' t PROPERTY OWNER Own 2 Unit# rint MAP NO:1©�PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no 100 year-old structure 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 ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑Other R Flo ami v n{ds Wat rs_hed k strict �- a t a DESCRIPTION OF WORK TO BE PERFORMED: (Identification Please Type or Print Clearly) OWNER: Name: -7'0z!K/ 11X 6::'A1-R 7Z Phone: 97dQ Address: IdO7�Z CONTRACTOR Name: �'✓ SD�7A Phone: ;�Se/ ;7,?--7 /&'Y Address: AX. 0t,070->_ Supervisor's Construction License: /dam 70;7 Exp. Date: Home Improvement License: Exp. Date: I ARCHITECT/ENGINEER Phone: 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: $ Check No.: o`15�0/ Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund77 , Signature of�Agent%Ownert :°: Signature of}contactnr1� Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewermmin Pools ❑ ❑* Tanning/Massage/Body Art ❑ Swig 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 Siqnature COMMENTS V Zoning 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 rnr rn a�rrra 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 servicedroprequires approval of Electrical Inspector Yes 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 Doc:.Building Permit Revised 2011 June/mi 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 j ❑ 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/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 N®TE: 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: Doe.Building Permit Revised 2008mi Location �J 7 7 No. ��� Z Date -?171" 2 • TOWN OF NORTH ANDOVER O e Certificate of Occupancy $ P;v ' Building/Frame Permit Fee $ Wit? 0.0 Foundation Permit Fee `<, Other Permit Fee $ TOTAL $ Check# Sb e t `Z 25014 Bdliding Inspector Nov. 18. 2011 2: 11PM No. 3151 P. 3/3 Nov..Lo is j--j-.1.3 KEVIN J HAGERTY FAX 978-686--ia-(4 t'. 2 } G.L.C.A.C., INC. • - ,.,• 350 ESSEX STREET: LAWRENCE, MA 01840 WEATHERIZATION ASSISTANCE PROGRAM WORK PERMITT 1, certify that-I Am the o N autho ' ed agent for the propertyet. V (Address) ` - i further certify that I have given my permisslon to allow work on the property listed above 1p.aacordance with the follovAng provisions-t 1, WEATHBRIIATION Z HFAWN TING 81(STENi WORK K 3. 4. • and such other par dliira as may be attached to this agreement. SIGNED: rj G DA". Xft1kWAUTH0R4WDAqPT ' F ..ti . j T_he Commonwealth of Ma ssachusetis = Department of Industrial Accidents Office of Investigations _ I-Congress Stree4 Suite 100 Boston,M4 02114-2017 www massy ov/did _ Workers' Compensation Insurance.Affidavit: Bluilders/Contractors/ElectriciansTlumbers Aa■ nLcarit4h> o>Fination - Please Print Legibly ...6 ee at ft N3IriE(Busixes lOWr►izationlindividual): � 3UAnON co r. LYNN,MA 01902 Address; City/State/Zip- Phone M Are you an employer?Check the-appropriate box: Type of project(required): 1.2-am a employer with y-_ - 4. ❑ 1 am a general contractor and 1 employees(full and/or part-time).* have hired the sub-contractors 6. E]New construction 2.❑ 1 am a sole proprietor or partner- 1isted on the attached sheet. 7. E] Remodeling ship and have no employees These sub-contractors have g_ ❑Demolition working formein-any capacity. employees and have workers' [No workers' comp, insurance -comp.insurance. $ 9. E] Building addition - required.] 5: ❑ .We are a corporation and its 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work. officers have exercised their I LE]Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL I2:0 Roof repairs insurance required.]t c. 152, §l(4),and we have no ` employees. [No workers' 13.Q"Other�%15C/ Q1f/D,✓ comp. insurance required.] *Any applicant that cheeks box#I must also fill out the section bdow.showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside cormactors must submita new affidavit indicating such- IContraeors that check this box must attached an additional sheet showing the name of the sub-contrauars and state whether or not those entities have employees. If the sub-contmctols have employees,they must provide their workers'comp.policy number. I am an employer that a providing workers'compensation insurance for my employeeL Below is the policy and job site information. o [ Insurance Company Name: /")A Policy#or Self-ins.Lic.#: 0 6 o 7 Expiration Date:Q Q�/ L Job Site Address:«71Y 4/RV-p//C r�� cit34tate/zip:' Attach a copy of the workers'.compensation policy­ ration 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 critninal 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. I dohereby c under the pains and penalties ofpedury that the information provided above is true and correct 4 Si�tattire: p` Date " _ 9-dl.Phone#: O/ _ 7 AW/ Oficial use only. Do not write in this area,to be completed by city or town official. City or Town: PermitUcense# 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#: ACORQ CERTIFICATE OF LIABILITY INSURANCE /YYYY) DATE(MMlDDo2/os/2012 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 endorsement(s). PRODUCER Go T NAME: FAX Duffy Insurance Agency, Inc. PH AIC,N :NE, (781)593-1200 A/C,No:(781)593-7260 F,# 317 Broadway ADDRESS: Wyoma Square INSURERS)AFFORDING COVERAGE NAIC# Lynn, MA 01904-2602 INSURERA: Arbella Protection Insurance Co INSURED Danetti Insulation INSURER B: Safety Insurance Company C/o Edward Champigny INSURERC: Commerce & Industry Insurance Co 362 Eastern Avenue INSURER D: Lynn, MA 01902-1626 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:001 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. LTR TYPE OF INSURANCE INSR WVO POLICY NUMBER JMMIDDIYYYYI MM10D LIMITS GENERAL LIABILITY 850004041 06/2212011 06/22/2012 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ S0,000 CLAIMS MADE ❑X OCCUR MED EXP(Arty one person) $ S'000 A PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEML AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY JEC- LOC $ AUTOMOBILE LIABILITY S022140 07/08/2011 07/08/2012 (Ea accident) $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ B AUTOS X AUTOS X HIRED AUTOS X AUT08ED Per accident)PROPERTY DAMAUE $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED t I RETENTION$ $ WORKERS COMPENSATION WC00160572 01/04/2012 01/04/2013 X AND EMPLOYERS LIABILITY TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXEC Y/N E.L.EACH ACCIDENT $ S00,000 C OFFICERIMEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ S00,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,K more space is required) reater Lawrence Community Action Council, BAY STATE GAS, Community Team Work Inc. ACTION INC.,NATIONAL rid Corporate Services LLC, dba National Grid, Boston Gas Company, Colonial Gas Company, and Essex Gas ompany are listed as additional insured. CERTIFICATE HOLDER CANCELLATION FAX: 978.681.4980 SHOULD ANY OF THE ABOVE DESCRIBE LIGES BE CANCELLED BEFORE EXPIRATION DATE THEREOF,NO E BE DELIVERED IN PR SIO Greater Lawrence Community Action (C7DANCE WITH THE POLICY Weatherization Program Division ATTN: Energy Director ATH D RESENTA 305 EssexStreet La rence, MA 01840 198 010 KRORV79MOYAYIO II rights reserved ACORD 26(2010/05) The ACORD name and logo are regis red marks of ACORD x.10RTH Town of 0 No. ,�"9/ /Z N .,hAOL ,. -C LAKE o , '� dover, Mass., -ZZ211� OC HICHEWICK �1t• ADRATED � -®C BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THISCERTIFIES THAT............4'✓''J.. /�/....t` rI.. .. �./. ............................................................................................. Foundation o p� � s - has permission to erect........................................ buildings on ��� '/ has U<'� g ::. ......... ........................... ..................... Rough l�i' �0 LJ Chimney to be occupied as.................. l.4. . s� 0�1'�' provided that the person accepting this permit shall in every respect conform to the terms of the application 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 CONSTRI,..JCTIO TARTS Rough -,r............................................... 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 FIR_E_DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIK] Smoke Det. AXe -� ti Office of Consumer Affa'lifs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvei �.'-Qontractor Registration - Registration: 135956 Type: Supplement Card r Expiration: 5/28/2012 DANETTI INSULATION CO. - ALBERT SOUZA 362 EASTERN AVE. LYNN, MA 01902 Update Address and return"card.Mark reason for change. Address [] Renewal n Employment F] Lost Card DPS-CA1 0 50M-W04-6101216 T11.&0..a ttoea/.11i a�'✓�avaaclu�ae�a Office of Consumer Affairs&Business Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation Registration:;::-X35956 Type: 10 Park Plaza-Suite 5170 Expiraoi {gp12 Supplement Card Boston,MA 02116 DANETTI1NSULA' CO ALBERT SOUZA — 362 EASTERN AVE LYNN,MA 01902 Undersecretary Not valid without signature