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Home My WebLink AboutBuilding Permit #545-11 - 21 HIGH STREET 1/28/2011TOWN OF NORTH ANDOVER APPLICATION FOP, PLAN EXAMINATION Permit NO: Date Received Date Issued: 1 'ANT: Applicant must complete all items on this 1 Cr k4 P iA PROPERTY OWNER , Print MAP NO: PARCEL: �� ZONING•DISTRICT: Historic District e' no Machine Shop Village (ZeD no 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 €D�Septc Q1WelI _ I�'F_1'oodp (D Wetlands; �' (®1 Watershed+District. �O Water/Sewer _ DESCRIPTION OF WORK TO BE PERFORMED: 1N4,J 1-6 Z-,W<--t�`1S N V36 to t9uTV-SV2 r,*, aA-z Z W l�L�rSS v 9 rrAr ® C \LV:;)N �� O `'-fes c 63 O ►ti.. Identification- Please Type or Print Clearly) OWNF,R: Name: �1 v 0 5 t Q o-� C- M Phone: ��' 61 S- if3 J v t, Ts- 1 �—� Address: �`�- �— �H s a ��,�Z t �3 CONTRACTOR Name: K9 02,-J W A M -,— Address: �3 t (C11 c K It &1�ro lam, Supervisor's Construction License: "C S � 633-4- Exp. Date: Home Improvement License: (+'q Exp. Date: r Phone: 0-L I 0� 'Pt1-LGlit C9 6' W ARCHITECT/ENGINEER �� y L' Phone: 61-7- E 9 Z- r6 d'1--• Address:sy oGs-1 ✓'A 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: $ S� ��-- FEE: $ 1 qI -L X k - Check No.:'`''. Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL , Public Sewer ❑ Tanning/MassageBody Art ❑ Swimming 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 - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS r 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: FIRE DEPARTMENT 'Temp Dumpster o site yes Located at 124 Main Street Fire Department signature/date COMMENTS Located 384 Osgood Street 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 A NOTES and DATA — (For department use ® Notified for pickup - Date Doc:.Building Permit Revised 2008 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 o Floor/Crossection/Elevation Plan Of --Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ ;Muss check Energy Compliance Report -(If Applicable)- Engineering pplicable) Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issua6c6VBldg 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 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 Chat 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: Doc.Building Permit Revised 2008mi Location < h No. 9," Date NORM TOWN OF NORTH ANDOVER t 1,y O 0 A 9 Certificate of Occupancy $ ' Building/Frame /Frame Permit Fee $ s►cMusE 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 9 � 23E, U O Building Inspector P Location A 4, No. Date r )) MORTh TOWN OF NORTH ANDOVER R 9 _Certificate of Occupancy $ BuiIdinIFraPermit Fee $ SACHUSE 9 me Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # /00PL) 239'17 Building Inspector p CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 545-2011 Date: February 25, 2011 THIS CERTIFIES THAT THE BUILDING LOCATED ON 21 High Street, North Andover MA 01845 Swim Fish Computer MAY BE OCCUPIED AS build out as per plans IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Fee: 100.00 Receipt: l00 yo RCG, N.A. Mills, LLC 21 High Street North Andover, MA 01845 Building Inspector I m m X m mm 2 y .0 C � d 10 O co c� Z CO) CCD O 'C d 0 C. = y ato -0 O n c v co CD O CLQ CD CD o CD mw a. C.O W CL C2 CO)O CD C2 CO) O � Z CD � O CD 0 CD 0 V _V tz z` C co Z 0 CD 0 _ m O C a CD O C. CLO CO) m ro ��s r.] �o. �o r % n t'' �y O Q S O N -0H o n114 o• O o c7 H n C C2 CD =r= M m ai ca �i a=d m CD O H CA �O 0mm O m a = c �+ c Z •� O, H C2 ?7� :I H C2-�_�o o O Or N C. m ;W co)O Wy' cr cl. go CO CD N CD C4) m O {n co C' .. :�0 =r ' Y CD O C! ...� CD O m CD ' r CDCDH :i CD cd CL's r C-)� O =o CA c o :G CD "O CD . ro ��s r.] �o. �o r % n t'' :vo rb -11�pdro o �C/) p C1� o n114 M �� e Office of In vestigatio. ns 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name (Business/Organization/Individual): R. t. 6— Ls L Address: 1 q17 %J A " 0 _,�= -� V (1-0 ( D 0 City/State/Zip: -Sv MSYw 1 I LL e q, pi 0--1 4-? Phone #: 6 1`7 _ 6 LS_ -- r �? f-�_ Are you an employer? Check the appropriate box: I.Ef I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. I ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t These sub -contractors have workers' comp. insurance. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions I 1.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: W W 9 3 Expiration Date: 2- i Job Site Address: �' IvVt 1 f�wat?JCity/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 the pains and penalties ofperjury that the information provided above is true and correct. Sianature: f v� Date: d G t7" Phone #• ci L _ 16 -�� Oficial 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 #: [_IionfAm 004r.] ACORD- CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DD/YYYY) T6/02/2010 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. PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION INSURANCE MARKETING AGENCIES ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 306 MAIN STREET HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR LIMITS ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. WORCESTER, MA 01608 GENERAL LIABILITY 508 753-7233 INSURERS AFFORDING COVERAGE NAIC # INSURED RCG LLC INSURERA: Wesco Insurance Company 25011 INSURER B: 17 Ivaloo Street, Suite 100 INSURER C: Somerville, MA 02143-3656 INSURER D: TO RENTED $ INSURER E: 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. LT NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MM/DD POLICY EXPIRATION DATE MM/DD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITYDAMAGE TO RENTED $ CLAIMS MADE F—IOCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ POLICY RQ LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ AGGREGATE $ OCCUR ❑ CLAIMS MADE DEDUCTIBLE $ $ RETENTION $ A WORKERS COMPENSATION AND WWC3010833 05/15110 05/15/11 X WCKOTH- R LI Mrr EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $500,000 ANY PROPRIETOR/PARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? YES E.L. DISEASE - EA EMPLOYEE $5OO OOO II yes, describe under E.L. DISEASE - POLICY LIMIT $500,000 SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION 10 Davs for Non -Pa ment SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION FOR INFORMATIONAL PURPOSES DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL _2fl DAYS WRITrEN 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 A%.UKU ZO (ZUU7/UU) 1 of 2 #S188839/M188838 11 _ .- I GCE 0 ACORD CORPORATION 1988 VYV 011:9 L l 0 1, OZILIZ L o < W U) - - - - C) C3 LO LU w 'u, z w > 0 (nu) > z U) WJ ULU w Lu U) W=O OC7 < LU C) LU Z z < It co < OW z w Q Z w 0 Z z 2 2 p- < W <OwLL f- < > U) � LU I lo I a L) LU oe y � VYV 011:9 L l 0 1, OZILIZ L §014 o < W U) - - - - - F- LO Lij <U) w � 0 LL ---- 0 Z LL §014 Swimfish Estimated Cost Schedule of Values Demolition $750.00 Dumpsters $0.00 Building materials $1,000.00 Insulate $200.00 Glass Entry Door $0.00 Drywall and tape $800.00 Prime and Paint $2,000.00 Carpet $5,000.00 Vinyl base $250.00 Electrical $3,000.00 Sprinklers $0.00 HVAC $0.00 Final clean $150.00 Sub -total $13,150.00 RCG Builders fee $1,972.50 Total $15,122.50 Plus Building Permit $192.00 Total Construction $15,314.50 z O;..Z y.... ` - OD -� / S LZS-OD • e C •/V � 3 i 0 t r y� C. -Z wW � m # l a CL Y r m m m X m v m y C d d � O co a Z CO) r 0. O n• c _� q O. . 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