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HomeMy WebLinkAboutBuilding Permit #700-15 - 19 SECOND STREET 3/4/2015�t, �,IZA )JAk AA&A 4% Ci - BUILDING PERMIT / TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION O0�f� Date R,.� Permit NO: Received Date Issued: IMPORTANT: Applicant must complete all items on this vaize LOCATION / ' c�ti > .S ?t?Ci57 A,41 Print PROPERTY OWNER U &/ C 7-0%' e'j g�.�, Print its MAP NO: t�� PARCELt1v�! ZONING DISTRICT: Historic District Machine Shop Villageves �no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial B'kepair, replacement ❑ Assessory Bldg ❑ Others: N�demolition ❑ Other ❑ Septic 0 Well ❑ Floodplain Q Wetlands ❑ Watershed District ❑ Water/Sewer RE,4-00N6 A1"�o 2UO .Sa F7 4 L) A-6 U �-,U n, Lk( Z Liv et A ���Ved o4 -n fie& //1if(1GA-7/vrl/ •A/t--o 71;646t 1 Identification Please Type or Print Clearly) • Z • e It O 3 OWNER: Name: U K F_ -7� /PA/ 7D A/ Phone:`)l d ' b gr•,5,-f S—,? Address: CONTRACTOR Name: 7 --- Phone: Address• '� Lr t o-,�t� A114- AJA 1V 44. () 306 z- fi Supervisor's Construction License:©� Exp. Date: ? �, ... Home Improvement License: Exp. Date: Z,7 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: 3./S- FEE: $ SIJ Check No.: ui ( Receipt No.: NOTE: Persons contracting wjthpnregistered contractors do not have access to the guaranty fund 1 Ir IN r. r Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPF.OF SEWERAGE DISPOSAL Public Sewer 11Tanning/Massage/Body Art ElSwimming Pools El Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On COMMENTS Signature CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS s 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: Locatea :RK vsgooa Street J FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street t'- Fire Department signature/date COMMENTS 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 Nr)TFS and DATA — (For denartment use) Doc.Building Permit Revised 2014 ❑ Notified for pickup Call Email - Date 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. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract o 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 o Building Permit Application ❑ Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Li Mass check Energy Compliance Report (If Applicable) o 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 o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract ❑ Mass check Energy Compliance Report o 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: Building Permit Revised 2014 Location /I vim/ <r h- No. -) av— , j Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ , Building/Frame Permit Fee $ Foundation Permit Fee $ �� Other Permit Fee $ TOTAL $ Check # �t Building Inspector O y .a n' 0 U) 0 CD CD U) N U) v z eOf CD O 1 J of I" v < 0 -0 p -I r- C U) = < m cn = cn `D, CD O n Y Z p _� ='-O�+ —1 O O N 0 -- O 't1 rt O O rt Q --ti S O O ill N O CDW n O N rt O N C rD07 CD O �' Or.L " U) CD D fD p S (Q to rILcn rt O O C c W D�� Z 'O CL c (�D r m m ;ato =' O <_ `a f'1 �- to X O 0' Oq W z CD O o cr 0 m 'I.=r O H z N D C7 \ c0 O 0 - -� �vrn Q N_ < (D CD (0)CD O =_ o 1 fD v N ny ( ^ =� =� _ . CLQ. ZCD 1� S C)r N z� rt D ��D . . O O =3W z 0 O -h =to ; C m =� —I cn � rt � o rD O <D 0. CD m Z O• = ci : O � -� ' D <D Z �, v_ C'n 'a D O 91) _ M 0 = O O m O - C z 1 J of I" v y a UD * bs Ow 0 e O fD N C rD07 O �' S O O fD p S CD c (�D f'1 �- Oq 7 Q s S prD fD v N O =3W S 'n m r rD rD m D O oy �, v_ D z D r C) O AN N H 2 - I M m D M z A M y a UD * bs Ow 0 e 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 d'ro:p*'regvires 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 Call Email r Date Time Contact Name Doc.Building Permit Revised 2014 The Commonwealth of Massachusetts d Department of Industrial Accidents a I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organiz ation/Individual): Address: 2 I P/` 6 6, ci EL( AZ� City/State/Zip: Phone #: Are you an employer? Check the appropriate box: I. E] I am a employer with employees (full and/or part-time).* 2.❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3711 am a homeowner doing all work myself. [No workers' comp. insurance required.] t 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 proprietors with no employees. 5.❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] .5�-D Type of project (required): 7. ❑ New construction 8. ET eemodeling 9. 3'5emolition 10 ❑ Building addition 1 l.❑ Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13.❑Roof repairs n 14. F]OtherbV& L REPS *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. $Contractors that 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. 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. Liicc. #:-7 P J U.6�P - 9 9 ���L a Expiration Date: S / Job Site Address:/! S)5�C4N D S'?' City/State/Zip: �G/lt?,a /•�-Ni�y�SP Attach a copy of the workers' compensation 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 WORK 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 cert er t aims and penalties of perjury that the information provided abgve is1rue and correct. 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 #: 0 U) z 0 az \O° « $ zk\... c ( \ « ' a Up C: ?/$c S$q" \ ® Cl) % m m \0 k M •0 \ \ \ o. K«� _ . �2 ? of 33 ~ 0 U) z 0 ¥ zk\... \$\ �\ w nVk (o 1) U-�k%. \ •0 \ \ A�� �® CERTIFICATE OF LIABILITY INSURANCE 7/142014 ' 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 EA Stevens Company, Inc. 389 Main St. P. 0. BOX 188 Malden MA 02148 CONTACT Rose S Munoz PHONE (781) 322-2324 FAXIAIC. (781)397-7672 -MAIL INSURER(S) AFFORDING COVERAGE NAIC A INSURER A -Admiral Insurance Company INSURED Alpine Environmental, Inc. 21 Progress Avenue, Unit 1 Chelmsford MA 01824 INSURERB:Safety Indemnity Company 3618 INSURERC:Central Mutual Insurance INSURERD:Travelers Indemnit INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:2014-2015 Master RFVISI0N NUMRFR- 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. TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS rA GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE Fx_] OCCUR To Be Assigned Includes Pollution Liab 1,000,000 Per Occurence 2,000,000 Aggregate /18/2014 /18/2015 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMIE $ 50,000 MED EXP (Any oneperson) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X1 POLICY PRO LOC PRODUCTS . COMP/OP AGG $ 2,000,000 $ B AUTOMOBILE LIABILITY ANY AUTO ALL OWNEDX SCHEDULED AUTOS AUTOS X HIRED AUTOS X NON-OWNEDPAUTOS 6224004 /18/2014 E/18/2015BODILY COMBINED SINGLE LIMIT BODILY INJURY (Per person) $ 1,000,000 INJURY (Per accident) $ PROPER'accidZ DAMAGE $ Uninsured motorist BI split limit $ A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE o Be Assigned /18/2014 /18/2015 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 DED I I RETENTION $ D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A PJUB-5B98513-8 /14/2014 /14/2015 WC STATU- X OTH- I EEL_ E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE - POLICY LIMIT $ 500,000 C Contractors Equipment CLP 9178326 /18/2014 /18/2015 $1,000 Deductible $124,848 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Sample Only AGUKU Z5 (ZUIUIU5) INS025 rgmnmi m ILV1CI SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Cares, Jr/RS ©1988-2010 ACORD CORPORATION. All rights reserved. The Ar:rll2n nomo nnrl Inn^ am mniefarael mnrire of A!'npin