HomeMy WebLinkAboutBuilding Permit #780 - 240 CHARLES STREET 4/27/2012TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
permit N0:
4.
Date Issued: ORTANT: Applicant must c
LOCATION 5+ /
Print
�,-„.,,,-,,,Tv nWNF.R ��2cA�2 �--Y4w�2.c,►�c
Date Received
:5` Print
MAP NO: PARCEL: ZONING DISTRICT:
TYPE OF MF
❑ New Buil
❑ Addition
❑ Alteration
❑ Repair, re
❑ Demolitioi
o,s pti
K�� Water/S��
all items on this
; c w St N A
6 i s -6<<
Historic District yes no
Machine Shop Village yes no
100 year-old structure yes no
'ROVEMENT
PROPOSED USE
Residential
Non- Residential
ing
❑ One family
0 Two or more family
❑ Industrial
No. of units:
❑ Commercial
placement
❑ Assessory Bldg
❑ Others:
i
❑ Other
'Well #�� � � �'
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DESCRIPTION
OF WORK TO BE PERFORMED:
1 l r1aW `Z a ” Fo z�-a
(Identification Please Type or Print Clearly)
OWNER: Nie �. .��c �g-..,r- n 5(-m 4 Phone:
Address:
CONTRACTOR Name: wlt= oEtj �Dn Phone: �33D2 DD��
Address:
--i
Supervisor's Construction Licensee 1 ' � `7G �� Exp. Date:
Home Improvement License:
Exp. Date:
ARCH ITECVENGINEER .k�Q6-=rL/SC t4 Phone: '6 '4q'7 76�
CArA o c M it,
2"
Address: � s S -'c: is �' t X36 _eg. 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: $,meq (, L l a l , p0 FEE: $ 51 o
-5 Receipt No.: 2 5"�z 5'3
Check No.:
NOTE: Persons contracting with unregistered contractors do not have access ythe ga`anra)dy�nd
Location
No. 7,F- 0
Date -2-7 / 2_
Check #
25243
TOWN OF NORTH ANDOVER
Certificate of Occupancy
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee
TOTAL
B ilding Inspector
I
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
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 ❑
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:
Conservation Decis
Comments
Comme
Water & Sewer Connection/Signature & Date Drivewav Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
COMMENTS
pimension
Number of stories:_ Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter lyes ion, mast or service drop requires approval of
Electrical Inspector
DANGER ZONE LITERATURE: Yes
No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
Doc:.Building Permit Revised 2011 Jumelmi
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
o 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
o Workers Comp Affidavit
o Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
o Floor/CrossectionlElevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o 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
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
o 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: Doc.Buildiag Permit Revised 2008mi
KLE/NFELDER
Bright People. Right Solutions.
June 17, 2013
Mr. Gerald Brown
Building Department
Town of North Andover
120 Main Street
North Andover, MA 01845
RE: Greater Lawrence Sanitary District I
Wastewater Pumping Station Improvements & For<
i
Dear Mr. Brown:
Kleinfelder/S E A designed and performed Construction Ac
referenced project.
The project was designed in accordance with the Massa
my knowledge, information and belief the construction ha
with the plans and specifications and the Massachusetts B
substantially complete on April 19, 2013.
Respectfully yours,
KLEINFELDER/S E A CONSULTANTS
/V 4 -fl r el e—
Mark J. Thompson, P.E.
cc: Mr. Richard Weare, GLSD
SEA
S E A CONSULTANTS INC.
2Ao Ck G -n I e -s
SkL�L�
215 First Street, Suite 320, Cambridge, Massachusetts 02142 T: 617.497.7800 F: 617.498.4630 www.seacon.com
Cambridge, MA 0 Framingham. MA • New Bedford, MA 0 Augusta, ME • Manchester, NH • Rocky Hill, CT
KLE/NFELDER r; S E A
Bright People. Right Solutions.�_
S E A CONSULTANTS INC.
June 17, 2013
Mr. Gerald Brown
Building Department
Town of North Andover
120 Main Street
North Andover, MA 01845
RE: Greater Lawrence Sanitary District
Wastewater Pumping Station Improvements & Force Main Replacement Project
Dear Mr. Brown:
Kleinfelder/S E A designed and performed Construction Administration services for the above -
referenced project.
The project was designed in accordance with the Massachusetts Building Code. To the best of
my knowledge, information and belief the construction has been constructed in conformance
with the plans and specifications and the Massachusetts Building Code. The project was
substantially complete on April 19, 2013.
Respectfully yours,
KLEINFELDER/S E A CONSULTANTS
/Y 4-(1 1.? %V -
Mark J. Thompson, P.E.
cc: Mr. Richard Weare, GLSD
215 First Street, Suite 320, Cambridge, Massachusetts 02142 T: 617.497.7800 F: 617.498.4630 -.vAvw.seacon.com
Cambridge, MA 0 Framingham, MA 0 New Bedford, MA • Augusta, ME • Manchester, NH 0 Rocky Hill, CT
KLE/NFELDER n S E A
�Bright People. Right Solutions w--•-•----
� S E A CONSULTANTS INC.
June 17, 2013
Mr. Gerald Brown
Building Department
Town of North Andover
120 Main Street
North Andover, MA 01845
RE: Greater Lawrence Sanitary District
Wastewater Pumping Station Improvements & Force Main Replacement Project
Dear Mr. Brown:
Kleinfelder/S E A designed and performed Construction Administration services for the above -
referenced project.
The project was designed in accordance with the Massachusetts Building Code. To the best of
my knowledge, information and belief the construction has been constructed in conformance
with the plans and specifications and the Massachusetts Building Code. The project was
substantially complete on April 19, 2013.
Respectfully yours,
KLEINFELDER/S E A CONSULTANTS
Mark J. Thompson, P.E.
cc: Mr. Richard Weare, GLSD
215 First Street, Suite 320, Cambridge, Massachusetts 02142 T: 617.497.7800 F: 617.498.4630 vvivw.seacon.com
Cambridge, MA 0 Framingham, MA • New Bedford, MA • Augusta, ME • Manchester, NH • Rocky Hill, CT
HENMhusn
CONSTRUCTION
June 17, 2013
Mr. Gerald Brown
Building Department
Town of North Andover
120 Main Street
North Andover, MA 01845
RE: Greater Lawrence Sanitary District
Wastewater Pumping Station Improvements & Force Main Replacement
Dear Mr. Brown,
Methuen Construction performed the construction services for the above referenced project.
To the best of my knowledge the construction was performed in accordance with the plans and
specifications as designed by Kleinfelder/SEA. The project was substantially complete on April 19, 2013.
Feel free to contact me directly should you have any questions regarding this matter.
Sincerely,
Cri'L/
Jason C. Babbidge
Project Manager
Methuen Construction
CC: Richard Weare (GLSD)
Mark Thompson (Kieinfelder/SEA)
Methuen Construction Co., Inc. 140 Lowell Road i Salem, NH 03079 1 Phone: 603.328.2222 I Fax: 603.328.2233
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The Commonweatth of Massachusetts
Department oflndustriat.accidents
Office oflnvestigationg
600 Mashington Street
Boston, MA 02111
V
www.massgov/dia
Workers' Compensation Insurance Affidavit: guilders/Contractors/Electricians/Plumbers
plicant In%rmafion
riease rant Legibly
Name (Business/Organization/Individual):VM-It-����
ti3
�-�t-U L1 i
0 rJ Cn
Address: 0 Lo we l l
IRO Art>
-City/State/Zip:_ pti M'
.
d `1c� one Ph #: � 3
A,rre,yo an employer? Check the appropriate bo
1• LYI am a 7aam
Type of
employer with g �_
4. a general contract or and I
project (required):
employees (full and/or part time).*
2• ❑ I am a sole proprietor or
have hired the sub -contractors
listed
6. ❑ New construction
partner-
ship and have no employees
on the attached shiet. 4
These sub -contractors have
7. ❑ Remodeling
8' 01 Demblition
working for mein any capacity.
[No workers' comp, insurance
workers' comp, insurance.
5. ❑ We ate a corporation and its
9' ❑ Building addition
required.]
3. ❑ I am a homeowner doing all work
'Officers have exercised their
right of exemption
10.❑ BIectrical repairs or additions
Myself [No workers' comp,
per MGL
c.152, §1(4), andwe have no
11.❑Plumbing repairs or additions
insurance requiredJ t
employees. [No
12❑ of repairs
comp insurance
13. Mn csc-& db� R
requued.] �
'"Any applicantthat checks box#1 must also fill out the section below showing their workers' compensation policy infomretion CeM e
t Homeowners who submit this affidavit indigating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
tContractors 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
r\SvC c,nee-
Policy # or Self -ins. Lie. #: A M (} p o ( 0 4 -) (z,'
Expiration Date.___y / _LL5__
5
rob Site Address: kc, :f=s Sic -,e—t
Attach a copy of the workers' cCity/State/Zip: P a .
ompensation 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
flue 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 D9 for insurance coverage verification.
rdo hereby certify under the pains andpenaltles ofperjury that the information provided above zs true and correct. `
-- ature:
Mone k- 0 Qg-
lujiaccal use only. Do not Write in this area, to he completed by city or town official
City or Town: Permit/License #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk
6 Other 4. Electrical Inspector 5. Plumbing Inspector
Contact person:
Phone #:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers 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 shaU'wlthhold 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 ofpublic 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 -contractors) 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 maybe 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 appropriate 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 (ifnecessary) 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 is 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 Xnidustrial Accidents
Office of Investigations
600 Washington Street
Boston; MA, 0211 X
Tel. # 617-727-4900 east 406 or 1.-877 MA.ssAFE
Revised 5-26- . 05 Fax # 617"727•-7744
www.amass.govMa.
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METHUEN CONSTRUCTION CO.
40 LOWELL ROAD
SALEM, NH 03079
AS OF THIS DATE, 4/24/12, SUBCONTRACTORS HAVE NOT YET BEEN IDENTIFIED FOR THIS PROJECT
GLSD-72" FORCE MAIN REPLACEMENT
METHCON-01
'4� �'* CERTIFICATE OF LIABILITY INSURANCE I DAT13012012
3130!2012
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 AMENDI 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: N the certificate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. It SUBROGATION iS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsemenL A Statement on this certificate does not confer rights to the
certificate holder in lieu of such endomemen s .
CONT
PRODUCER N ME:
CT
TD Insurance, Inc. MA 800 723-2877 Ne : 877 775-0110
PO Box 406 E-MAIL
Portland, ME D4112
INSURED
Methuen Construction Co., Inc.
.40 Lowell Road
Salem, NH 03078
rIMICDAGKQ CERTIFICATE NUMBER*
Wausau Underwriters Insurance Corr
Starr Indemnity & Liability Co
ABC MA WC SELF-INSURED GROUP
HANOVER INSURANCE COMPANY
LIBERTY MUTUAL INSURANCE COM
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 CONTRACTOR 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.
INSLIMITS
LTR
TY PE OF INSURANCE
POLICY NUMBER
MMID
MMR)
A
GENERAL LIABILITY
X COMMERCIAL GENERALLUIBWTY
CLAIMS -MADE ❑X OCCUR
X
X
ICOMBINED
JZ11260416011
7/1/2011
7/112012
EACH OCCURRENCE S 1.000,00
PR MIS $_� 100'00
MED EXP( eneperoon S 10.00
PERSONAL & ADV INJURY S 1,000,00
GENERAL AGGREGATE $ 2,000,00
GENLAGGREGATE LIMIT APPLIES PER:
POLICY FRI P.91?, LOCI
PRODUCTS -COMPIOPAGG S 2,000,00
s;
B
AUTOMOBILE LIABILITY
L O AEO SCHEDULED
AUTOS
Ix ANYAUTO
HIRED AUTOS X AAUTOSONO$ ED
X
X
ASJZ11260415031
71112011
711/2012
SINGLE LIMIT
a wm 1,000,00
BODILYINJURY(Perpenwl)
BODILYINJURY(Perecodenq S
Pereed AMA i
i
C
X
UMBRELLAUAB
EXCESS LIAB
X
OCCUR
CLAna 4WE
X
X
SISCCCLO1625611
711/2011
711/2012
EACHOCCURRENCE $ 11,000,00
AGGREGATE $ 11,000,000
DED I X I RETENTIONS
S
D
WORKERS COMPENSATION -
AND EMPLOYERS'LABILITY'
ANY PROPRIETORIPARTNERVMUTIVEYQ
OFFICERUMEMBER EXCLUDED?
(Marwin&MInNH)
It yEw deealbe under
DESCRIPTION DF OPERATIONS bobw
NIA
ABCMAOCID4712
111/2012
111/2013
X LAC TA 0TH•
E.LEACHACCIDENT $ 1,000,00
E.LDISEASE -EAEMPLOYE S 1.000,00
EL DISEASE - POLICY LIMB s 1,000,00
E
F-
Builders Risk
Owners/Contr. Protec
IHE92OD738
TF1Z71260416-202
611/2011
511/2012
611/2012
511/2013
Ded $5,000 10,000,00
$1MW$2MM Limit
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Aaech ACORD 101, AddWonal Remaft Schedule, U more spas to requlnx6
RE: Greater Lawrence Sanitary District (GLSD) Riverside Pump Station Modifications and 72" Force Main Repplacement, CWSRF 03491 Project.
Includes: Railroad Protective Liability policy with Liberty Mutual; Policy Number TE1411-260415.212; 5M12012 to 61112013;
$2,000.000 Each Occurrence, $6,000,000 Ag9gregate Limits.
Additional Insured and Waiver of Subrogallon appilea per written contract and Is subject to policy terms and conditions. Full Additional insured Name:
Greater Lawrence Sanitary District, Klelnfekfed S EA Consultants. Coverage Is primary for owner & engineer.
Greater Lawrence Sanitary District
215 Flrst Street, Suite 320
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WiTH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
TD Insurance, Inc.
vel Tyea-LU"IU A�,ur�u a.vrcrvrw i rvn. na r,guw .com •oo.
ACORD 26 (2010105) The ACORD name and logo are registered marks of ACORD
11
Policy Number YVJ ZII-260415-011
Issued by WAIUSAIU UNDERWRITERS INSURANCE COWAN tl
THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY.
NOTICE OF CANCELLATION TO THIRD PARTIES
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE PART
MOTOR CARRIER COVERAGE PART
GARAGE COVERAGE PART
TRUCKERS COVERAGE PART
EXCESS AUTOMOBILE LIABILITY INDEMNITY COVERAGE PART
SELF-INSURED TRUCKER EXCESS LIABILITY COVERAGE PART
COMMERCIAL GENERAL LIABILITY COVERAGE PART
EXCESS COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
LIQUOR LIABILITY COVERAGE PART
Schedule
Name of Other Person(s) / Email Address or mailing address: Number Days Notice:
Or ankation s :
Per -Schedule on file with the
Company
A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or
organizations shown in the Schedule above. We will send notice to the emall or mailing address listed above
at least 10 days, or the number of days listed above, If any, before the cancellation becomes effective. In no
event does the notice to the third party exceed the notice to the first named insured.
B. This advance notinc atton of a pending cancellation of coverage Is Intended as a courtesy only. Our failure to
provide such advance notification will not extend the policy cancellation date nor negate cancellation of the
policy.
All other terns and conditions of this policy remain unchanged.
BED LIM 99 010511
0 2011 Liberty Mutual Group of Companies, All rights reserved. Page 1 of 1
Includes copyrighted material of Insurance Services Office, Inc., with
Its .permission.