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HomeMy WebLinkAboutBuilding Permit #387 - 209 JOHNSON STREET 11/16/2007 BUILDING PERMIT 0� "ORTN q� TOWN OF NORTH ANDOVER G 4 APPLICATION FOR PLAN EXAMINATION Permit N0: v Date Received SSACHU`�� Date Issued: IMPORTANT: Applicant must complete all items on this page AN a z @ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ' "New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial kAlteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other s � ii, M sn, DESCRIPTION OF WORK TO BE PREFORMED: ,!5fE2G G2 �Q 'X S'd` - �d cx ti sl —e T 00 �Crz den 'fication P15use Type or Print Clearly) OWNER: Name: 17 o V A UM ed Phone: 13 i Address: CU 9� 1&0—k7-9r1-r7 "t ispq r —Add r :g �y ° ARCHITECT/ENGINEER Phone: Address: 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: $ FEE: $ -30- , Check No.: 9�tz_ Receipt No.: .2 0 S 0 NOTE: Persons contractin wi unre2is ed contractors do not have access to the guaranty fund 1 Signature of Agent/Owne nature of contractope/,4�'- e 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 ❑ t 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 'Located 412? �F>l�e ©eke>r��nel�#�s�g�at�llt'•e"��a�c �� � � °� �,�� � wgpAll «x ,�• 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 ...__......._...__..._.....---............- - 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 o 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 o?0 -1 0P)h j6h S-1 1,-2 ✓ / v No. � o "� Date / ^l NaRTN TOWN OF NORTH ANDOVER 0 n Certificate of Occupancy $ 1 �'ssACHusE< Building/Frame Permit Fee $ �'— Foundation Permit Fee $ : Other Permit Fee $ TOTAL $ Check # " 2- 2 0 8 - 20 & _ Building Inspector ; NORTH q Town of ._ Andover N t 8 o. * I •/C •0 = A o dover, Mass., COCHICHEWICK �J,9 a°RATED `S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT.. .. .. Av� ?. ............................... -.. ......... Foundation r has permission to erect........................................ buildings on . l.. dJ T g ... . ........... _ Rough to be occupied as y0.� Tae .T • Chimney ........... ...... . .. . . ..... . . .. .. . .................................................... provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final 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 30 — PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO Rough ............................. ............................................................................... Service BUILDING INSPECTOR 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 SIDE Smoke Det. ��ie �anzmc�nure�. o��.-��aa:uzcfiu,�e� Board of Building Regulations and Standards Construction Supervisor License License: CS 60219 �y. Birthdate: 4/27/1954 ' Expiration: 4/27/2009 Tr# 11766 Restriction: 00 MARK TRAINA 33 HANFORD RD STONEHAM, MA 02180 Commissioner aRi N ANr,>aVe2 MA i F } x � v G t i i t� J The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600ington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Plean Print Legibly Name(Business/Orgmization/Individuai): . V E Address: City/State/Zip: Phone.#: Zoe°/= 07-rj Are you an employer?Check the appropriate box: Type of project(required): 1.,® I am a employer with 4. E] I am a general contractor and 1 6. E]New construction employees(full and/or part-time).* have hired the sub-contractors 2.E] I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, E]Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp.insurance comp•insurance.# required.] 5. Ej We area corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their' I Ln Plumbing repairs or additions myself. [No workers'comp. right bf exemption per MGL 12.❑Roof repairs _ inmr-arce required.]t c. 152, §1(4),and we have no employees.[No workers' 13. tither t°flI • 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. tContractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. if the sub-contractors have employees,they must provide their workers'comp.policy number. lam an employer that is providing workers compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: e (/j Policy#or Self-ins.Lic.#:_ 0 7Expiration Date: 0 1 D Job Site Address: �VO�h S /tet City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to securecoverage 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 the pains•analties of perjury that the information provided above is true and correct. Signature Date: ,T7 Phone M Oficial use only. Do not write in this area,tb 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 S.Plumbing Inspector 6.Other I Contact Person: Phone M i Client#:46743 PETERPARI ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 10/03/07 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION USI Ins.Services of MA,Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 12 Gill Street Suite 5500 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR PO Box 4043 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Woburn,MA 01888-4043 INSURERS AFFORDING COVERAGE INSURED NAIC# INSURER A: St.Paul Fire and Marine Insurance C 24767 Peterson Party Center,Inc. 139 Swanton Street INSURER B: North River Insurance Co. 99999 Winchester,MA 01890-1918 INSURER C: Commerce&Industry Insurance Compan 19410 INSURER D: INSURER E: COVERAGES 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 NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION DATE MMA)DIYY DATE MM/DD/YY LIMITS A GENERAL LIABILITY BINDERCK00219639 10/03/07 10/03/08 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTEDPREMISES(Fa occurrenCe $100,000 CLAIMS MADE a OCCUR MED EXP(Any one person) $5-10--00- PERSONAL 8 ADV INJURY $11000.000 GENERAL AGGREGATE $2 000 OQQ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY RO- PRODUCTS-COMP/OP AGG s2,000,000 P JECT MLOC A AUTOMOBILE LIABILITY BINDERMA00200328 10/03/07 10/03/08 ANY AUTO COMBINED SINGLE LIMIT(Ea accident) $1 000000 ALL OWNED AUTOS X SCHEDULED AUTOS BODILY INJURY(Per (Per person) X HIRED AUTOS BODILY INJURY X NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY ANY AUTO AUTO ONLY-EA ACCIDENT $ OTHER THAN EA ACC $ AUTO ONLY: AGG $ B EXCESS/UMBRELLA-LIABILITY BINDER5530892346 10/03/07 10/03/08 EACH OCCURRENCE $5.000.000 X OCCUR ❑CLAIMS MADE AGGREGATE $5,000,000 DEDUCTIBLE $ X RETENTION $10000 $ C WORKERS COMPENSATION AND BINDERWC5310744 10/09/07 10/09/08X WC STATU- OTH- EMPLOYERS'LIABILITY ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? If yes,describe under E.L.DISEASE-EA EMPLOYEE $500,000 SPECIAL PROVISIONS below OTHER E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Re: Insured's operations renting equipment for business&social functions,including erecting tents. Statutory cancellation of Workers Compensation is 10 days. GSA-Boston Courthouse,BCMA LCC,Urban Retail Properties,their affiliates and designees are additional insureds on General Liability. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WALL ENDEAVOR TO MAIL 'An DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2001/08) of 2 #S177924/M177923 AGDCD 0 ACORD CORPORATION 1988 a ��r��ru�����u-u������v; IMPORTANT ®O C U M E N T�'��'�r��EMO -.r�n�u���r�� o 5 5 Certifietate of la ARes 's 5 ISSUED BY S Date of Shipment o- � o APPLICATION 5 5 ,��` cNgR R. 06/08/04 5 5 NUMBER r 't NNDUSTRIE INC. 5 5 r� Psi EVANSVILLE, INDIANA 47725 Tent Identification S 5 F-140.1 �� EMS °~ MANUFACTURERS OF THE FINISHED 03850284 5 5 TENT PRODUCTS DESCRIBED HEREIN 5 5 This is to certify that the materials described have been flame-retardant treated 5 5 (or are inherently noninflammable) and were supplied to: 5 5657150 5 SPETERSON PARTY CENTER INC 5 S139 SWANSON ST 5 5 WINCHESTER MA 01890 5 S 5 5 S 5 5 5 5 5 Certification is hereby made that: 5 SThe articles described on this Certificate have been treated with a flame-retardant approved S chemical and that the application of said chemical was done In conformance with California 5 55 Fire Marshal Code. All fabric has been tested and passes NFPA 701-99, CPAI 84, ULC 109. 5 5 # 8047000(2) 5Serial 5 5 5 5 Description of item certified: 5 NAVITRAC END 40WX20 SNYDER WHITE VINYL 5] 5 Flame Retardant Process Used Will Not Be Removed By S 5 5 Washing And Is Effective For The Life Of The Fabric 5 5 SNYDER MFG NEW PHILADELPHIA,OH ' S 5 Signed: �-�. �,, � J •L`C 5 "'SPECIAL EVENTS DIVISION-ANCHOR INDUSTRIES INC. 5 � rJ�rJ�rJ�cJ�r�c.Pr.PrJ�rJ�r.P�r��Pr�rJ�rJ�r�r.PrJ�rJ�r�r��PrJ�r��PrJ�r��P�.I��PrJ��P�Pr�r�r��PcJ�rJ�rJ�rlrJ�rJ�r.Pr.PrJ�rJ�r.J�rJ��PrJ�rJ�r.P�P�.P�PcJ�rJflJ�rJ��PrJ�rlrJ��PcPcJ�r�r�rJr�rJ� � IMPORTANT ®OCUMENT 5 Certificate of Fla Resin ce s � 5 �� t�2 S S REGISTRATION ISSUED BY S o-� �'�' o Date of Shipment APPLICATION 5 5i NCHOR® 06/08/04 NUMBER 5 5 INDUSTRIES INC. Tent Identification S EVANSVILLE, INDIANA 47725 5 F140.1 ° MANUFACTURERS OF THE FINISHED o3ssozs4 0 STENT PRODUCTS DESCRIBED HEREIN 5 SThis is to certify that the materials described have been flame-retardant treated 5 S (or are inherently noninflammable) and were supplied to:657150 5 5 PETERSON PARTY CENTER INC 5 5 139 SWANSON ST 5 SWINCHESTER MA 01890 5 S 5 5 5 5 5 5 5 S S Certification is hereby made that: 5 5 The articles described on this Certificate have been treated with a flame-retardant approved 5 S5 chemical and that the application of said chemical was done in conformance with California 5 Fire Marshal Code. All fabric has been tested and passes NFPA 701-99, CPAI 84, ULC 109. 5 5 Serial # 8047000(z) 5 5 5 SDescription of item certified: 5 S NAVITRAC END 40WX20 SNYDER S 5 WHITE VINYL 5 5 Flame Retardant Process Used Will Not Be Removed By 5 5 Washing And Is Effective For The Life Of The Fabric 5 5 SNYDER MFG NEW PHILADELPHIA,OH Signed: 4 . 5 -`SPECIAL EVENTS DIVISION-ANCHOR INDUSTRIES INC. rj � rJ�rJ�rJ�rJ�cPr�rJ�rJ�r�rl�Pr��.l�r�cPrl�cPcJ-rJ�cPrJ��Pr�cPrlr�rJ�rJ�rJ�rJ�rJ�rsrJ��Pr�rJ�rJ�rJ�r�r�r�tJ�r�rJ�rJ�rJ�rJ�r�r�rJflJ�rJ�r�r�rJ�r��.PrJ�rJ��rJ�rJ�rJ�cPr�rJ��PrJ��.PrJ�rJ�rJ� �