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HomeMy WebLinkAboutBuilding Permit #0813-2017 - 1980 TURNPIKE STREET 3/1/2017 BUILDING PERMIT NoRTH QF�ttso p, ,Q TOWN OF NORTH ANDOVER o APPLICATION FOR PLAN EXAMINATION Permit No#: �� P�(� Date Received �qA°j�wrED . . SsgcHus� Date Issued: r7 fl �`T EVIPORTANT:Applicant must complete all items on this page LOCATION- � Tys � � PROPERTY OWNER _ _ f -lam►�.1. I :t� 5n�'.Q t _Pnnt 100•Yea St�uctue� es no _ Y MAP PARCEL: . ZONING'DISTRICT: tHistortc D'istnct+.. - yes no t _ Machine ShopVillage yes n,o 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 ❑ Septic 01Nell ❑ Floodplain D Wetlands . Watershed District.- D.Water/Sewer. DESCRIPTION OF WORK TO DE PERFORMED: t vrvrn r .5 n u,1 Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: ` Name:n � - . . � Or .. . cP X C hone� :. .. Address'.. Supervisor's Construction License: SLt-1.� ` �1--_..__._. Exp. Dater Home lrmpi.overrient License: Exp. Date:: _K ARCHITECT/ENGINEER Phone: _ Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED $925.00 PER S.F. ,Total Project Cost: $ �(�. 06 FEE: $ -- Check No.: �� Receipt No.: 1 DOTE: Persons contracting with unregistered contractors do not have.access to the guaranty fund Si natu�e_of_Agent/Owner Signature of Plans Submitted ❑ Plans Waived Certified Plot Plan ❑ Stamped Plans ❑ F RIF SEWERAGE DISPOSALc Sewer ❑ Tanning/Massage/Body Art ❑ S�ri�rining Pools❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank, etc. ❑ Permanent Dempster on Site ❑ 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 g Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes P-lanning 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 s no n/ Located at 124 Main Street p O ' ( �(' Fire Department signature/date -4�' '094-6 COMMENTS -imension 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 ®ANGER 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 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. 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 ❑ Engineering Affidavits for Engineered products DOTE: 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 No.V J� `4 t Date e,1 • - TOWN OF NORTH ANDOVER • Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $� Other Permit Fee $ TOTAL $ 4 Check# �. r �; Building Inspector �'` NORTIy Town of � _ ., sAndover No. ( ,� * � " _ ,� C, ver, Mass, 3 coc»Ic"9WICK �1. �as RATED PPa��S U BOARD OF HEALTH Food/Kitchen PERMI -T T LD Septic System THIS CERTIFIES THAT �y. BUILDING INSPECTOR ...... has permission to erect .......................... buildings on .l. .. ....... ,/.�... Foundation Rough tobe occupied as ... .......................................................................... Chimney provided that the person accepting this permit shall In ery 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 CONST T10 Rough Service .. .. .......... ....... ...... Final BUILDING SPE OR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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. The Commonweaith of Massachuseds _ Department of XndustriaiAccidents X Congress Street,,5IW 100 Boston,.VA 02114 2017 w•ww mass.gov/dia *t3Vk,&Compensation me T P B OAUT OsR Y- clans/"lmnbexs. TO BEMfff Please LrmL t Leably A ' licantXnfbrmatlon n C alionllndivid34- 5 Name(BusznesslnOrganiz . Address- ``�. G. �� - el 101 City/Statefzip: 2 ��e�� t�� W�'�� (fit `_ Ph ...,~.. : Axeyou employer?(heck.the appropriate box: Type oi<pxoject(required); em to es full and/or part tune)- 7. ❑NevT'construciaon 1, am aemployerwith_ ��,___ p Ye g. [�Remodeling 2.0 I am a sole proprietor or partnership andhaye no employees Vorking forme in 9. [[Demolition any capacity.[NO workers'comp.insmance required] oworkers'comp.insurance required.] 101]Building addition 3.1]I am ahomeownez doing all workmysel�[N e I will 4.❑lam ahomeowneraudwMbehiringcontractorstoconduciaUWorkoumypro F 1tY- 1LEI Elec`tdcalrep2lzsoY additions ensurethat all contractFots ei#herhave workers'compensation insurance or are sole 12,]�PlwzrRag repairs or additions proprietorswthno employees. 13•.[]R.00f repairs 5.[7I am a general contractor and I h ye bu:ed.the sub-contractors listed onthe attached sheet These sub-contractors have employees and—have walkers'comp.insorancet 14.N Qther 6.F j We area corporatiov.and its,officers =e exera sedtheirrigbt of'•exemption perMGL c. 152,§1(4),andiyehayano employees.jNowodrers'pomp.insurance_required_] . a newaffidaytindicaung such. Anyapplicaucthai checks box#1 must also fill outthe sectionbelow showingtheirworkers'compensationpolicymfoima#iom Homeowners who submrE thLs affidavit mdicatmgthey are doing aIt-work o sub-contractorsd eh� and state mnst whether or not(hose entitles have Co�ractors that checkthis boxmust at#ached an additional sheetshowing ------ . . employees. If the sub-contractors have employees,they must provide thein workers'comp.policy mm�ber. X can an employer that is providingivorkers'compensation irnsuxance for•my emTZoyee8 Below is the policy arzd j obi szte information. Insurance CompanyNamu-, S� �� 1 rl WC ���q�`� _ ExpirationDate' Policy#or Self-ins.Lic.#: �p �r-�y0i Citylstate/Zip: IJoccN 4 A►►.S t�c1�<</' Y✓l►-'� Job Site Address: � e shovai¢zg tTae poficy numb ex and egpiratxoaa.date). Attach a copy of the evorkexs' compensation polzcy declaration pag Failure to secure coverage as requireduaderMGL c_152,§ �£na o£ TO-Violation W0 ORDER aid a ane Of to $250.00 a and/or ona_year'imprisonment,as well as civil penalizes m be forwarded to t day against the violator.A copy of this statement may he Office of Xnvestigations of the DIA.for insurance coverage verification. andpen I'es ofperjury that the information provided above is true and correct I do Iiere-byunder tliepairzs Date: Si at m: phone#: Official use only. Do notwrite ire this area,to be completed by city or town Official • Fermiit/License# City or TO-VM-- Issuing Anthoxzty(circle one): ' y/Town Clerk 4,Electrical Xnsp ector 5.P1uxnToiug Xnspectox I.Board of lfealth 2.Building Department 3.Cit 6.Other 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 hue, express or implied,oral or written.- An employer is def'uied 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 receivefor trusted cif an individual,partnership,association or other legal entity,employing employeeg However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant ofthe dwelling house of another who employs persons to do maintenance,construction or repair work on such dwellirig 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 Io cal licensing agency shall withhold the issuance or renewal of a Incense or permit to opdrate a business or to construct buildings in the commonwealth for any applicaAtwlid has notproduced-acceptable evidence of compinancewith the insurance coverage required." Additionally,MGL chapter 152, §25C(1)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." .A.ppficants Please f ll out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply su-b=contractor(s)name(s),addresses)andphonenumber(s)along with-their cextifcate(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 dogs have employees,a policy is required. Be advised'that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation ofinsurance 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 requ(Fted,not the Department of Industrial.Accidenis. Should you have any questions regarding the law or if you are required to obtain,a-�rorkers' compensation,policy,please call the Department at the number listed below. Self-insured conipanies should enter their self insurance license number onthe appropriate line. City or Town.Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space atthe 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 Min the p ermit/license number which will be used as a reference number. Iu 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"lob 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. Anew affidavit must be$lied out each. year.Where a home owner or citizen is obtaining a license or permit notrelated to any business or commercial venture (i.e.a dog license or permit to burnt 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 02114-2017 Tel.#617.727-4900 ext.7406 or 1-877 MAS,SAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia LUONG-1 OP ID:SG CERTIFICATE OF LIABILITY INSURANCE 70T3101/2017(MM/DDIYYYY)E 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 CONTACT NAME: NorthStar Ins.Services,Inc. PHONE FAX 300 First Ave,Suite 100 A/c No Ell:781-431-2500 ,vc No): 781-431-6134 Needham,MA 02494 E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC# INSURER A:Central Insurance Company 20230 INSURED Luongo Sprinklers, LLC INSURER B:Evanston Insurance James Luongo INSURER C:Hanover Insurance Company 22292 PO Box 463 Billerica, MA 01821 INSURER D: 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 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMBS LTR POLICY NUMBER MMIDDIYYYY IY MM/DDYYY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CLP8871996 05/16/2016 05/16/2017 DAMAGEPREMISESS( RENTED 300 000 Ea occurrence $ CLAIMS-MADE 7 OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY X PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 Ea accident $ C ANY AUTO AWPA58255502 04/20/2016 04/20/2017 BODILY INJURY(Per person) $ ALL OWNEDX SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS PER ACCIDENT $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 B EXCESS LIAB CLAIMS-MADE XOBW6260116 05/16/2016 05/1612017 AGGREGATE $ 2,000,000 DED I X I RETENTION$ 0 $ WORKERS COMPENSATION X I WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS R A ANY PROPRIETOR/PARTNER/EXECUTIVE YIN NIA WC887199719 05/16/2016 05/16/2017 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 i-L I DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Proof of Insurance CERTIFICATE HOLDER CANCELLATION PROOFOF SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Proof of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts � ® Department of Public Safety j License: SC-114814 i Sprinkler Contractor 1 1 JAMES R LUONGO 198 STOW ROAD STOW ME 04037 Expiration: Commissioner 0412212018