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HomeMy WebLinkAboutBuilding Permit #1230-16 - 2 STACY DRIVE 5/24/2016 (3) NORTH BUILDING PERMIT 16 ti TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINA-11G ' :: :: � . 4 Permit No#: /2 Date Received p°'�wreD gSSACHUSE� Date Issued: & G IMP RTANT: A plicant must complete all items on this,page LOCATION ,� Print PROPERTY OWNER �/`etG�f�' yl Jta 6i4e_- �S P int 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 ❑ Industrial 11Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic El Well, ❑ Floodplain El ❑ Watershed District 0 Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: . t-tZCa- S cc. Phone: Address: Contractor Name: V i rl vl S � Phone: OM� - Email: nil r Address: F r Supervisor's Construction License: ('S 2 _Exp.. Date: s Home Improvement License: �l0 3r1(v Exp: Qate ::. Zg ARCHITECT/ENGINEER Phone: Address: Reg..No_. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED C$r,,BA5EFQff$125.00 PER S.F. G � Total Project Cost: $ `�` 3�S� FEE: $ _ D Check No.: �7L.� Receipt Na:. 5`2� NOTE: Persons contracting with unregistered contractors do not have'-'acc*e's's�,ta'-the,,guaran fund ■ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody Art ❑ ✓iimming pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank, etc. ❑ permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF m U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Si nature COMMENTS c 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: --� FIREDEPAR�TMENT Tem D _. _ ,—et - �W s• ._ p _,umpsteron�site° ryes,__ Inoa Locatedaf 1241MaihtStreeta ' Fire,Departmentxsgnatu're/date,-..�_. COMMENTS- ■ Dimension r, Number of Stories: Total square feet of floor area, baso-awederior dimensions. Total land area, sq. t.: Y; ELECTRICAL: Movement of Meter location, mast or service drop-m-q{iires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes N® - MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA-- (For department use) ® Notified for pickup Call Email Date Time Contact Name DocHailding Permit Revised 2014 .;tip: 1 - 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 OTE: 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 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 OTE: 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:Building Permit Revised 2014 Location t No. 1 fir. -�t. Date ��� �� 4 • - TOWN OF NORTH ANDOVER >;y Certificate of Occupancy $ s Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ d TOTAL $ Check# 5, 1 J Building Inspector 1 �J AN�Q h'I pb N r , NORTH - �� S s _ _ At -c . . ver No. - 3 _ - h , ver, Mass,LAKR y lk CO[.41cme WICK R^TEo i`P�`�g5 U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT .....!�` e-'5-C C' Hv r �Q� BUILDING INSPECTOR ....... .............. ....... .. ........... .. s G �w� Foundation has permission to erect .......................... buildings on ... !.:-!. .`/.. ...................................... Rough to be occupied as .........�/.k�Sfi.lZ.. �I. ....( F. ............................................. Chimney �y provided that the person accepting this permit shall in every respect conform to the terms of the application Final ve /© 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 CONSTRUCTION STARTS Rough . ............................. Service ................... ........... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinje 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. 1 r 1 V tAORTk O No. Mir- - 13 h ver, Mass, �A cocc"t." 1�R .0 .�A rIE PP����S �S V BOARD OF HEALTH Food/Kitchen PERMIT T D L Septic System THIS CERTIFIES THAT v`��'SC�''�..! v� 7 BUILDING INSPECTOR 111 a .. ...��. .. c < v� has permission to erect .......................... buildings on .�J.. ./.:...................................... Foundation // Rough to be occupied as ............ .... ............ p ... . ... ...r .. . (,: . .. ..... ...... 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 CONSTRUCTIONS ARTS Rough Service ................... ........... .. ............................. Final BUILDING INSPECTOR 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 Commonwealth of'Massachusetts: z Department of IndustriadAccidents 1 Congress Street,Suite 100 ' Boston,MA 02114-2017 .y�;V,t www mass.gov/dna Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE PILED WITH THE PERMITTING AUTHORITY. . Applicant Information Please Print Legib Name(Business/Organization&dividual): &Ifir'7n h Address: D/'{4'/S City/State/Zip: M rdal jt7" /hfq-6 l9 9j_9 Phone#: �7�" 77Y Are you an employer?Check&appropriate box: Type of project(required): IV I am.a.employer with /0..!! employees(full and/or part-time).* 7. [l New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. F1 Demolition 3.Q I am a homeowner doing all work myself[No workers'comp.-insurance required.]t []4.F1 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. 12..[]Plumbing repairs or additions 5.F1 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.FA Roof repairs These siib-contractors have employees and have workers'comp.insurance.$ 6.❑We are a corporation and its,of gers have exercised their right o£exemption per MGL c. 14.. Other 152,§1(4),and we have no-employees.[No workers'comp.insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. Homeowners who subriif'this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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-corilractors Have employees,'they must provide their workers'comp.policy number. I am* an employer that is pi'ovidiing workers'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name: '�+A.r (ASUf4 V1U Policy#or Self-ins,Lic.#: (� (� .3 J Expiration Date: o2 ou0 Job Site Address: 'a oy`G City/State/Zip: /Vc 4*1 A14 Attach a copy of the workers'6ompepsation 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 certify under the pains and penalties of pejury that the information provided above is true and correct. Sign e: jjjAYA� c4n(_Z�'� Date: Phone#• 7 7 t' ZDV 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): i 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: 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 ofhire, 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 trustee of an individual,partnership,association or other legal entity,employing employees. 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 b6 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 performance of public work until acceptable evidence of compliance with the insurance 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=contractors)name(s),address(es)and-phone number(s)along with their certificate(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 does have employees,a policy is required. Be 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 returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you'are required to obtain a workers' compensation policy,please call the Department•at the number listed below. Self-insured companies shouldenter their• self-insurance 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"Job 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 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 02114-2017 Tel. # 617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia 7 ® DATE(MMIDDIYYYY) ACORU CERTIFICATE OF LIABILITY INSURANCE 2/11/2016 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 certificate holder In lieu of such endorsement(s). ONUT PRODUCER AME McSweeney&Ricci Insurance Agency, Inc. PHONE alX No _ - 420 Washington Street E-MAIL Braintree MA 02185 INSURERS AFFORDING COVERAGE NAIC/{ INSURER A INSURED UNI-P-1 INSURER B:Star Insurance Company Uni-Ply Roofing Inc INSURERC: 3 Forms Way INSURER D: Middleton MA 01949 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER:688057472 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 g POLICY NUMBER ADDLISUISR POLICY EFF MMIDDY EXP LIMITS TR A GENERAL LIABILITY CPA0074506 2/15/2016 2/15/2017 EACH OCCURRENCE $1,000,000 DAMX COMMERCIAL GENERAL LIABILITY PREMISES S( a GE TO 1Roccu erica _$260.000 CLAIMS-MADE a OCCUR MED EXP(Any one emon) $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 17 POLICYFX_ PRO- LOC COMBINED 5IIqMFrr9= $ A AUTOMOBILE LIABILITY MAA0074476 2/15/2016 2/15/2017 Ea accidentl $1,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY $X HIRED AUTOS AUTOS ( err accident) $ A UMBRELLA LIAR I OCCUR CUA0074507 2/15/2016 2/15/2017 EACH OCCURRENCE $1,000,000 X X EXCESS LIAR CLAIMS-MADE AGGREGATE $1,000,000 DED X I RETENTION$O $ B WORKERS COMPENSATION WC0719336 2/26/2016 2/26/2017 X I MySTA,,,TUjOTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE QNIA E.L.EACH ACCIDENT $500,000 OFFICERIMEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOY%$500,000 Iles describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attaeh ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION 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 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 26(2010105) The ACORD name and logo are registered marks of ACORD == Commonwealth of Massachusetts Massachusetts-Department of Public Safety Department of Public Safety Board of Building Regulations and Standards Construction Supen-isor License: HE-076413 License: CS-084282 At Hoisting Engineer 0 r �� KEVIN A CAMPONESCKI KEVIN A CA11IP — 3 NORMAN ROAD 3 Norman Road ' READING MA 01867 Reading MA 01817 c Expiration Commis�sio7ner' 02/04/2017 ^^� vim—' Expiration: Commissioner 02/04/2018 r��couu»reii[rirrrl/�n C�l(rJJnC�lr3Pf�J y� License or registration valid for individul use only Office of Consumer Affairs&Business Regulation before the expiration date. If found return to: HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation Registration: 140376 Type' 10 Park Plaza-Suite 5170 Expiration: 10/28/2017 Individual Boston,NIA 02116 > KEVIN A CAMPONESCKI I KEVIN CAMPONESCKI I 3 NORMAN RD — READING,MA 01867 Undersecretary Not valid without senature MEDICAL EXAMINER'S CERTIFICATE LAatlfYmetleta mmived 1 Z' L.in c(: Iattanitva wllM1 lbtl:.^.ml MetorGane:it!<- ... *t—�"c-._-�- � __ - �Reevlathm(4 CFRJ91AIJ91A91.nd xllM1 lmowhdgf oflhe drlvlo{dotin,IDed lM1bpmov ugoallfied,ud,ll.pplkabk.ovh whn: rfA;- - gntM1q p 'tlmf �drfvinE wl161vmaempt lvintlty rone(49CFR39IA2) S�E(TT� RIVER' [3•n lir tdby pmdo,of49CFFby SWR t.0 E..bnbgCMlRn,t(SPE) -..�` Al wtirerh:empllvn Ogvtllfud by opmtloa of d9 CFR]9L61 LICENSE USA TM1e lnformedwlbM•e prmMed nSArdlnT lhD phydnlesaminADoe6Due.ndeompMa Atolopkle nenWlbv farm with taytmthmanl embodln c.y 1 6 MA f Dvdi.p anpMIIY tad­­"Y,tad It on Ilk lA mY oma. y K t '1C Y SIGNATIfRt OF MHDICAL fi:(AMI//NHR TELEPHONE DATE 9aEND 4d NUMBER ��. � G'�cL1^ n107 �) y!�l—%.SSS Gl�l9�/6 :NONE 51834351:3.:, MP ICALEXAMINER'SNAME(PRDfn MD OChlrapne er /�.,� CIA'.aAnd Pnena Nv EXF �':'\ �,AQB ,"'.. "A A �(.i h/ P 167)1 /:I�r10 O PM1ylltlta Anhnnl O Olber Pnefttbver 111 _ S IJ �Zo4-1975 MEDICAL EXAMINER'S LICENSE OR NATIONAL REGISTRY NO. t' is SEX"M' 19 MGT$09.1 CE FICATENOJISSUING STATE ✓J') '1/-?U SIGNATLREOFDRIVER INTRASTATE ONLY CDL DRIVER'S WCENSENO. STATE s 'E '`.`.' ?res OYFS SI Z r�S /rte gg .ASCKr r- ONO )?no "yTI „ L..y.:t'�,EIG' '..y"r. 1 ADDRESS OF DRIVER B NORMAN RD 1 /L!/1rAtL (J'.'- l�-<<..�. /-�c (JI<1C•7 I READING,MA 01867.2714 _ -MEDIC.¢CERTIFICATION EXPIRATION DATE p 5D 02.06.2015Rev07.1S2009 I