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HomeMy WebLinkAboutBuilding Permit #574-14 - 22 PUTNAM ROAD 2/3/2014 BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION ; s e Pefmit NW_-) � Date Received Date Issued: 2 1� �9SS�cNus IMPORTANT: Applicant must complete all items on this page LOCATION ,2�2 Print PROPERTY OWNERS �- Print MAP NO:_�_LPARCEL:32rzONING DISTRICT: Historic District yeso Machine Shop Village yes o TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 20ne family ❑Addition ❑Two or more family ❑ Industrial 21Alteration No. of units: ❑ Commercial dRepair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer roup- Gcu Identiifiication Please Type or Print Clearly) OWNER: Name: G tlL%� f Phone: Address: CONTRACTOR Name: Yy TPhone: 617 83 i 1s�7 Address: 6[ ynd 0-4k 1� . ���� 6 12-1 e- C)k vo 3 Supervisor's Construction License: (fS/03W? Exp. Date: FIs /3 Home Improvement License: �1 � Exp. Date: z-// 7 /� 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 Co : $ ob FEE: $ Sq Check No.: Receipt No.: 4 NOTE: : Parsons co tracting with unregistered contractors do not have access to the guarantyfund Signature of Agent/Owner Signature of contractor s� TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION P Permit,NO:_,__ Date Received , Date Issued: IMPORTANT: Applicant must com Tete all items on this page LOCATION - Print PROPERTY OWNER - Print 100 Year Old Structure yes no MAP NO: _ PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no .TYPE OF IMPROVEMENT, PROPOSED USE Non- Residential Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family El Industrial ❑Alteration No. of units: Li Commercial ❑ Repair, replacement ElAssessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Floodplain ❑Wetlands 0 Watershed District Septic ❑Well p Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: - F TRACTOR Name: Phone: ess: rvisor's Construction License: Exp. Date::_ e Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ ti Check No.: ; Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund SI nature of contractor Signature of - ent/Owner g: - Plans Submitted Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Plans Submitted ❑ ' Plans-lNaived-❑ Certified Plot Plan ❑ Stamped Plans ❑ -4 TYPE_OF-.SEWERAGEDiSP.OSAL - - Public Sewer ❑ Tanning/Massage/Body Art ❑ .Swimming Pools ❑ Well ❑ Tobacc o Sale ❑ s Food Packa in LSales Elg g 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 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 hPW ToNv;2 Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMr iVT Temp bum ps er on site yes_ no Located at124Mair, Street # ' i`` ` - { Fire Depat rtmer- -rI sigiatu're/latest ►" `k ;;' �. s ,}°t_ :�r COMMENTS � .. F Di1 -erasion, .. 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 7 DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A-F and G min.$100-$1000fine NOTES and DATA— (For department use i ® Notified for pickup - Date E Doc.Building Permit Revised 2010 - 1 Building Department -`rhe fol�_)wing is"a Iist of the required.forms to be filled out'for the appropriate.permit to'.be obtained. Roofing, Siding, Interior Rehabilitation Permits Li­ Bbilding Permit Application o Workers Comp Affidavit El Photo Copy Of H.I.C. And/Or C.S.L Licenses o Copy of Contract Li ..Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster.permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit Li Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) o Building Permit Application Li Certified Proposed Plot Plan Li Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o Mass check Energy Compliance Report o 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 apw-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.tted with the building application Doc: Doc,BuhNiing Permit Revised 2012 . i Location No. Date . - TOWN OF NORTH ANDOVER • Certificate of Occupancy $! �i— Building/Frame Permit Fee $ Foundation Permit Fee $ Other.Permit Fee $ TOTAL $ Check t" 0 Building Inspector i t% R TH F Town of Z.. 10 20 No. S — * - h , ver, Mass, coc«Ic«ewIc« 1' Opp S U BOARD OF HEALTH Food/Kitchen PERMIT T LD i Septic System THIS CERTIFIES THAT .......... BUILDING INSPECTOR .............. .... ..................... ... . has permission to erect ... buildin s on ., .. , !,�,*W. ,�Q� Foundation Rough to be occupied as .... .... . ... .. . .. ....... .. . .. . ... .. .......................................................... Chimney 0 provided that the person accepting thi ermit 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR 3 UNLESS CONSTRUCTION S TS Rough Service .......................... . .............. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. IF SEE REVERSE SIDE Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS403907 STEVEN L PEPS 20 EMERSON ROAD Watertown MA 02472 Expiration Commissioner 08/05/2015 V 17C�0771777Q771f/CClI�/l R�UI'LC79JlIClll[JCIl.7 Office of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR egistration: 166139 Type: xpiration_ 4/27/2016 Private Corporatio► YOUR SPACE LANDSCAPE&CONSTR,INC. STEVEN PEPE 2 BLANCHARD RD. BURLINGTON,MA 01803 Undersecretary The Commonwealth of Massachusetts Print Form -_- _ Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston,MA 02114-2017 j www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Your Space Land.&Const.,Inc. Address: 2 Blanchard Rd. City/State/Zip:Burlington, MA 018003 Phone#:781-273-1950 Are you an employer?Check the appropriate box: Type of project(required): 1.❑✓ I am a employer with 10 4. FJI am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑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. E]Demolition working for me in any capacity. employees and have workers' insurance.: 9. E]Building addition [No workers comp.comp.insurance p• 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.R]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. Insurance Company Name:Utica National Policy#or Self-ins.Lic.#.4519337 Expiration Date:3/6/14 Job Site Address:22 Putnam Rd. City/State/Zip:N.Andover, MA 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. 1 do hereb certify under the an enalties o e 'u that the information provided above is true and correct Si nature:E Date /3/14 77 Phone#: 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#: TOWN OF NORTH ANDOVER AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application MGL c. 142 A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion, improvement, removal,demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units...or to structures which are adjacent to such residence or building"be done by registered contractors, with certain exception, along with other requirements. Type of Work: �C �� f�`�- Est. Costes Address of Work �� P� "`�"'^'� Pd , Owner Name: � L (" Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): For office Use Only Work excluded by law Permit No. Job under$1,000 Date Building not owner-occupied Owner pulling own permit Other (specify) Notice is hereby -given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FIND LINER MGL c. 142A. Signed under penalties of perjury: I hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. OR: Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property: Date Owner Name ACC)I CERTIFICATE OF LIABILITY INSURANCEDATE(MMIDD"M 114� 1 1/23/2014 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). PRODUCER CONTACT NAME: Albert J. Tonry & Co. , Inc. PHONE (617)773_9200 FAXC.Noja(617)773-9920 300 Congress Stmt ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC f Quincy MA 02169 INSURERA Utica National Assurance Co 10687 INSURED INSURERB:Safety Indemnity 33618 Your Space Landscape & Construction, Inc. INSURERCUtica Mutual Insurance Company 5976 2 Blanchard Road INSURERDUtica National Insurance 43478 INSURER E Burl]AgtOA MA 01803 INSURERF: COVERAGES CERTIFICATE NUMBER:CL1372406948 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 ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 100,000 A CLAIMS-MADE R OCCUR 4672020 /8/2013 /6/2014 MED EXP(Any one person) $ 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 POLICY X PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident 1 000,000 ANY AUTO BODILY IN.AIRY(Per person) $ B ALL OWNEDSCHEDULED 3949129 /6/2013 /6/2014 AUTOS X AUTOS BODILY IN 1JRY(Per accident) $ NON-OWNED PP'acad�DAMAGEX HIREDAUTOS AUTOS eet $ X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 5,000,000 EXCESS LIAB C CLAIMS-MADE AGGREGATE $ 5,000,000 DEDX I RETENTION$ 10,000 4672019 /8/2013 /6/2014 $ D WORKERS COMPENSATION X WC STATU-L'MITS OTH- FR AND EMPLOYERS'LIABILITY OFFICEOPRIETEREXCLUDED? CUTIVE NN NIA E.L.EACH ACCIDENT $ 500,00 519337 /6/2013 /6/2014 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTIONOFOPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 A Equipment Floater 4672020 /8/2013 /6/2014 Leased/Rented $75,000 H (Attach ACORD 101 Additional Remarks Schedule if more ace is required) DESCRIPTION OF OPERATIONS!LOCATIONS f VEHICLES (A space q d) Operations usual to a landscape contractor. Certificate Holder is an Additional Insured, including completed operations, when required by written contract, but only to the extent provided in the Additional Insured endorsement(s) attached to the policy, a copy of which is available upon request. When required by written contract, Additional Insured status is provided on a primary and non-contributory basis. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Ci Of Medford ACCORDANCE WITH THE POLICY PROVISIONS. Eng i Bering Department 85 Oe ge Hassett Drive AUTHORI2EDREPRESENTATIVE Room 30 Medford, 02155 L Tonry Jr./KATEPR """ ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INSO95l7mnnsl n1 Tho arnon namo onrt Innn aro ronie4orort martre rvr arnon