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HomeMy WebLinkAboutBuilding Permit #594-15 - 200 SUTTON STREET 1/8/2015 ND oT 6 q1,A BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received, P R ATRP s Date Issued: " sACKus IMPORTANT:Applicant must complete all items on this page y 4��4'� � ���SClttt�ll 5trett�� �l.Rll k�kt{i��G�t V1JI��� LQCATION R C @ C k hY y 1 k ,Yv- PROP:ERT'YWNE LgMal 1'i�st }.� *i L'""E MR ,�H�stb�c } c# yds rto� Village yes : TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition rl Two or more family F Industrial ❑Alteration No. of units: ut Commercial ® Repair, replacement ❑Assessory Bldg C Others: ❑ Demolition ❑ Other SepticIloodplainWa#erstaed tiistric# Y. YY6K To replace 12 window units with clear anodized aluminum frames and 1"insulated low a safety plass windows with vents and screens. Identification Please Type or Print Clearly) OWNER: Name: LBM Realty Trusi Phone: 978-688-2327 Address: 200 SV ('('oa 6�a.eeT, t�oQTII o1Fd-S CONTRA 'Name, ,. r Pht�ne 6 97�sss 92s � � Chart s�Cor�tructlpn 4rmpatr�lnc" �Y�� .�� "� .�' Ad�1 esv� _ s,�, � "gay w ; �` +h,�gV �a �"F _ 5 Y' •` 200°5uttan Street lkgwoitir Arrt"Qr�er,`M.d t11.845 � � rv X ti-, Super�tsoronstruction,Ltcene pate t i C5M�05712 � w xt1123I.?(1NS P Home lmgvemht Ltc�► se , EXp ��, x°a" ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:SULDING PERMIT.•$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 28,000.00 FEE: Check No.: � � Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signa#tide oer#/Owri � � �gtr a rcfl toto '3 .7777 a' �. Plans Submitted ❑ Plans Waived ❑. Certified Plot Plan ❑ Stamped Plans ❑ TYPF OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art E] Swunming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ t Private(septic tank,etc. ❑ ❑ Permanent Dumpster 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 x 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 _ Locate_ d at 124.MahStreet Fire PDepartm6nt signature/date.-.- COMMENTS _ Dimension Number of Stories: Total square feet of floor area, based on,EJ terior 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 NOTES and DATA— (For department use) J 4'..L ❑ 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 ❑ 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 i ❑ 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 I New Construction (Single and Two Family) ❑ Building pp 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 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 i LocatioaD D V,1 No. L�— � Date C ��+ •� R • • TOWN OF NORTH ANDOVER • �, - Certificate of Occupancy $ en ems'' Building/Frame Permit Fee $ Foundation Permit Fee $ �In Other Permit Fee $ TOTAL $ Check#' 20407 26 Building Inspector NORTH Town of �. : :_ R ndover ;ics 16 h ver, Mass, coc«icMe —Akh wrcw �1 p°RA P'Pa U BOARD OF HEALTH Food/Kitchen PERMIT D Septic System S'OrTHIS CERTIFIES THAT ....._...••.••.• BUILDING INSPECTOR ................ .................................. ..... .......................... Foundation has permission to erect .......................... buildings onl�i 0..... �............... Rough to be occupied as ... . ...�-all �!! v ....... ..... ..... ....... ....... ..... ..................... Chimney provided that the person acce ting this perml 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 CONSTRUCTION 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 Print Form Department of Industrial Accidents Office of Investigations _ 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information /Please Print Legibly Name (Business/Organization/Individual): C Wr/aVP.(.l=S CJ N SSV G'R p �+O :L N C . Address: ?100 o A, . City/State/Zip: OI°v 4 Phone t L Are you an employer?Check the appropriate box: �-,� Type of project(required): N 1. 1 am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. E]New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition workingfor me in an capacity. employees and have workers' y p �'• 9. E] Building addition [No workers' comp. insurance comp.insurance.$ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their i l.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp.insurance required.] *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. T T Insurance Company Name: I Policy#or Self-ins.Lic.#: (0 Qj 0 b M 24 Expiration Date: (0 11 j Job Site Address: ?-°& 6Jff0a 5[. Ms p+J OyWA_# HA. City/State/Zip: d'J Attach a copy of the workers' compensation policy declaration 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 criminal 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. Ido hereby c f2hi under the pains and penalties o er'uy that the in ormation provided above is true and correct. Signature: - __--- _-.__ _ .__ _ ____-hatelF u Phone#: 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#: f }y} Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Superr icor License: CS-005712 STEVEN C MATSS ' 202 SUTTON ST N ANDOVER MA 01845 - .J.• .�tJ Expiration Commissioner 10/23/2015 ACORU® DATE(MMIDDNYM CERTIFICATE OF LIABILITY INSURANCE 1/8/2015 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: Mathias Insurance Agency, Inc PHONE 978-688-5531 FAX 200 Sutton Street, Suite 160 E-MAIL Ext): {Arc,N°):978-687-7460 ADDRESS: North Andover, MA 01845 INSURER(S) AFFORDING COVERAGE NAICA INSURER A: Navigators Specialty Insurance Co INSURED Charles Construction Company, Inc. INSURER B: Safety Insurance Co PO BOX 847 INSURER C: First Mercury Insurance Co North Andover, MA 01845 INSURER D: Travelers Insurance Company 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. POLICY EFF POLICY EXP ILTR TYPE OF INSURANCE INSID UBD POLICY NUMBER (MWDD (MWD LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE F;;-771 OCCUR PREMISES a occurrence $ NYI4CGL133112IC 05/16/14 05/16/15 MED EXP(Any one person) $ A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ X POLICY EIJE T F]LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY C O BINED1SINGLE LIMIT $ 1,000,000 ANYAUTO BODILY INJURY(Per person) $ B ALL OOWNED X SCHEDULED LED 6213523 .06/06/14 06/OS/15 80DiLV INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS eraccidern) $ 1,000,000 $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 C EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 NJEX000004370101 05/16/14 05/16/15 DED I I RETENTION $ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY �,I N STATUTE ER D ANY OFFICERIMEMBE RIPARTUDEECUTIVE ❑NIA E.L.EACH ACCIDENT $ 1,000,000 (Mandatory in NH) 6HUB-980ON24-7-14 06/11/14 06/11/15 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached if more space Is required) CERTIFICATE HOLDER CANCELLATION Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Building Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED III ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood Street Bldg 20, Suite 2035 AUTHORIZED�EP ESENTATIVE North Andover, MA 01845 �` 1 A 0 ©194 ACORD CORPORATION. All rights reserved. ACORD25(2014/01) The ACORD name and logo are registered,marks�) CRD 2 oZ! y 401 /gj ol-� , t t Wl ifi � r t �._ �-..1_Z�'�,�✓tel_...�.':�-�, ;�' - , . car l :