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HomeMy WebLinkAboutBuilding Permit #596 - 200 SUTTON STREET 3/13/2007 NORTIl BUILDING PERMIT O�St�So "tio TOWN OF NORTH ANDOVER 32 a APPLICATION FOR PLAN EXAMINATION Permit N0: Date Received 7gATID Vol`cy �SSACHus�� Date Issued: " Q IMPORTANT: Applicant must complete all items on this page P" t ✓ INE 1'^ ✓ s m .s„was,. C� .Fk sq k FNS `�. # A^axYA �OCATItN " X3 `x • a a„ - �� a es ��Tlt PRQPEYOtNEf � � � ,i� > MAP'N } PAFEL� ••`: tN1NC IISTFt�' HISO bio ._ m.. . ,4 ,ro<.F TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial N4teration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other •;Septic ( Well �uQ� Fl$ fiat �(Il aw C3 Wa�ers� YYutv.+ wraa+ .•, ,.» - .. a' � �. y � f '..ki ME; ll DESCRIPTION OF WORK TO BE PREFORMED: 'PE�IyJ� E1ct�n�.1c Gt_a, �at� I�SrCt.c.. �.� Identification Please Type or Print Clearly) OWNER: Name: TEhg,- Phone: q18 6 88'Z32.1 Address: 2.00 G✓v Ttn� ` e -1' , '� 'Ib.�vaJ�c, t-�t�... �- �� fawn �)' •.h- ,h hW '.. yy� � +Yi > � -,4 NSN x, ., C"`ys t krceb''si�'M �tNTRAT � 4d°dress 2� q V71perY�a�`LJI 4T .�1tl RILr . ` ' 8 �e z cornea impr `ement. A erg e W ARCHITECT/ENGINEER Phone: Address: too '3-JMAJ Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ oo -X2— FEE: $ Check No.: Receipt No.: � NOTE: Persons contracting with unreetst red contractors do not have access to the guaranty fund I Signature of Agent/Owner — Signature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF- U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ . Swimming Pools ❑ Well ❑ ' Tobacco Sales- - ❑ Food Packaging/Sales [� Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ 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 Located at 384 Osgood Street FIRE�DEPARMEN�; -rtem�Dumpster on slt yes �� n K Located'at 124 MM ire St ee � r a `� Iiia Depart51 ment s"b"1111 refdafe y � A V 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-$1000 fine NOTES and DATA— For department use ❑ Notified for pickup - Date I Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ) ❑ Engineering Affidavits for Engineered products New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 Location —7zp s4i4q -r 1 ` )c No. Date NO�,M TOWN OF NORTH ANDOVER Certificate of Occupancy$ s •E< Building/Frame Permit Fee s s�cwus �-.- Foundation Permit Fee $ Other Permit Fee $ v �� TOTAL $ Check # Building Inspector — — ,; ,_—. ✓fie yr omiriw�aus�ac�uc�ella ' BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR j Number CS 005712 BirtWAte 1}2371955 i { rr '1 pirm$10/2372007 Tr.no: 7807.0 lel Rest`ric d AO j STEVEN C MATSES {i 2021;UTTON ST 1 ;` ✓ C /y N"ANDOVER, MA 01845 -' =Comrriissroner AORTH Town of Andover 0 No. 0 -LA Vover, Mass., '09 7 0. 0 004- COCHICHEVVICICK A. 0'04'ATED BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System ADIer o BUILDING INSPECTOR ....... 4j Jrb THIS CERTIFIES THAT........................................... . . ............................................. Foundation has permission to erect........................................ buildings an .........ZCXP......2&J, OJOA.....4.4. ....................... Rough Chimney to be occupied as....... .... .. .... I... ......C .4 tew-e� provided that the person accepting this per it shall in eve respect conform to t terms of the application on file in Final �i this office, and to the provisions of the Codes and By-Laws relating to the Inspe ion, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough [°l S' PERMIT EXPIRES IN 6 MONTHS Final ELECTRICAL INSPECTOR UNLESS CONSTRUCLAR Rough ........................ Service BUILDING CTOR 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 FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIPILJI Smoke Det. Z88 North BroadwayX----ov II0w%0QM„rs%-AItwubbNUiAMEND,EXTEND OR LER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Salem, NH 03079 Aithael Caruso INSURERS AFFORDING COVERAGEImsm MAIC# System Bui ders Inc INsuRER A: Nauti 1 us Ins Co 202 Sutton Street INSURER B: St Paul Travelers Insurance Co North Andover, MA 01845 INSURER C: Hartford INSURER D: INSURER E: COVI=RAGES 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,AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS- LTR N3 TYPE OF INSURANCE POLICY NUMBERpA� pUp PDATE DON LIMIT$ GENERAL LIABILITYNC450070 03/31/2006 03/31/2007 EACH OCCURRENCE b )( COMMERCIAL GENERAL 110001000 rAL^� CLAIMS MADE I x I OCCUR PREMISES °s Ce 5 Inn L_I Mfa EXP(Any one pemrj) S A X PERSONAL&ADV INJURY g 5,000 1 GENERAL ACsGREGATE S 2 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUGTS COMP/OP AGG b POLICY CCCT LOG 2, 0,OO AUTOMOBILE LIABILITY BA-4841CO24-06 04/01/2006 04/01/2007 COMBINED SINGLE LIMIT X ANYAUTO (Essecidenl) S ALL OWNED AUTOS 1,000,000 SCHEDULED AUTOS (Per LYDILYj INJURY S B HIRED AUTOS NON-OWNED AUTOS BODILY INJURY b (Peracddeno X Comp ded $500 X PROPERTY DAMAGE Collded $500 S (Per acciaenq GARAGE LIABILITY AUTO ONLY-EA ACCIDENT 5 ANY AUTO OTHER THAN EA ACC S AUTO ONLY: AGG b EXCESWUMBRELLA LIABJUTY EACH OCCURRENCE S OCCUR ❑CLAIMS MADE AGGREGATE b DEDUCTIBLE 5 RETENTION S S S WORKERS COMPENSATION AND **6S600-5 116C43 EMPLOYERS'LIABILITLABIUTY -8-06 05/12/2006 05/1!/2007 X / TORY LIMITSER C EKVTCUTWE OFFICRER/MEMBER 0=uDED? E.L.EACH ACCIDENT S 100,000 If yes,describe under EL DISEASE-EA EMPLOYEE S 100,000 SPECIAL PROVISIONS below OTHER E.L.DISEASE-POLICY LIMIT S S001000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLILSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISS ith respects to the General Liability and Automobile policies theIONcertificate holder is listed as an s an Additional Insured CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 81WORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILLENDEAVOR TO MAIL _10_DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURETO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABIVTY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRES AUTHORRED REPRESENTATIVE ACORD 25(2001/08) FAX. (978)683-2379 ©ACORD CORPORATION 1988 The Commonwealth of Massachusetts klDepartment of Industrial Accidents Office of Invesdgations ip 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Awlicant Information Please Print Legibly Name(Business/Organization/Individual): J'yS JZ' , Address: r- n_��'c�,�i2,,, r/ ems City/State/Zip: , - ' � � ,� Phone.#:���� Are you an employer?Check the appropriate bog: . I am a general contractor and I Type of project(required): 4 . 1.❑ I am a employer with ❑ g 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' insurance,# 9• ❑Building addition [No workers'comp.insurance comp. required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12.[1Roof 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 isproviding workers'compensation insurance for my employees Below is thepolicy and job site information. _ Insurance Company Name: '61-1 / I' co —�- Policy#or Self-ins.Li c.M 5 c 0 ')Q Expiration Date: Job Site Address: n �8 ��7 � v City/State/Zip:, 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. I do hereby certify under thepains and pen a/ties ofperjury that the Information provided above is true and correct Signature: Date: Phone#: Offlcial 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employdrs 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 hire, 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 be 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-contiactor(s)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 should enter their self-insurance license number on the a ro riate 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. A new 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 bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone-and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext.406 or 1-877-MASSAFE Fair#617427-7749— Revised 17=-727-774 -Revised 11-22-06 www.mass.gov/dia