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HomeMy WebLinkAboutBuilding Permit #517-2017 - 26 ANDOVER STREET 11/15/2016II� AAW +e-L� BUILDING PERMIT NORTN q TOWN OF NORTH ANDOVER o ��t`eD ,ba tic F- M APPLICATION FOR PLAN EXAMINATION Permit No#: ,5—/ 7r ;'017 Date Received ��' ' "k ° SvA Date Issued: It - 57lz9L0/ /0 gSSACHUS IMPORTANT: Applicant must complete all items on this page LOCATION 2(0- AY4-4V U-S� Print PROPERTY OWNER (n e- r� -e Lett` ou Pgt 100 Year Structure MAP PARCEL:_ ZONING DISTRICT: Historic District Machine Shop Village yes no yes no yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑ Addition ❑ Two or more family ❑ Industrial [!�<Iteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed Distract ❑ Water/Sewer DESCRIPTION OF WORK TO BE PERFORM D;, s -c C.1, r,n`I � .. ('tt by L ave I n /a Identification - Please Type or Print Clearly OWNER: Name: Gi f K( L.P Q V -f Address: 2�e 14VYncQLr,3 Contractor Name: Email: ton Address: 0 t, 3Slo - 314 i l Supervisor's Construction License: � � Z� �— Exp. Date: S Z S- t -:� Home Improvement License: l -V3�-i Exp. Date: b ) k I t g 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: $29 U 1 . b0 FEE: $ 3 Check No.: 2) ®? % Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Location ;2 (o 4 AI b oyr 1z ( - Jc . No. Sl i - RC) 1-7 Date /I Check #3V3-7 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $3*---, Foundation Permit Fee $ Other Permit Fee $ TOTAL $ i s Building Inspector 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. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF e U FORM PLANNING & DEVELOPMENT Reviewed On Signature. COMMENTS CONSERVATION Reviewed on Sianature COMMENTS HEALTH r COMMENTS. t Reviewed nature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments t Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FAIRE DEP�ARAT�MEN�T,s °Ttremp�Dump�ster�onisite�yes� ,,_ µ = o�► _ �`� ��Lo ted at�i1�24�MaintStreetp _ � ; �" t C�MMEN�TSa r. _ 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 MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine NOTES and DATA — (For d ❑ Notified for pickup Call Date Doc.Suilding Permit Revised 2014 rtment use Time Contact Name No 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 4 Building Permit Application 4.. 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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks :aE 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/Cross Section/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 TE: 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 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 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: 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: Building Permit Revised 2014 DEC; -22-95 FR I 12:07 CERTIFICATE OF INSURANCE Prodd c r MartN' I ramCe Agency Inc. PbO.BOX 92 g ji1�xn§35-4 501-0665 Code - Sub Code �ffrLIM ons Inc- & arrInc. Somervi X�tless Gutters, Te, Ma. 02143 (25-S 7/90) This cerrifica�E taormat on p e cert t� icate of men extenc pp�e po1J.cles EASTE1RN CLASUALT) Company Letter I Company Letter C Company Letter I Company Letter I P. 0 1. Y Issue Date 12/22/95 is issued as a mater of a dd ca ers no is u on hoo;d a�terlcoverage alfo 'lea below. CO'VEk�AGES tg1s , is to certify that polis' es of , j,z4surcliace l'sted be�ow hove been issued to t e insured name abpve r t e Brio in aca e otwit staz� n an re uire- Rocum nt WIR resp t mgt teem or cp dition o ny , c�nt act or otnier . whlcfppi j�., iii cegr1ciG t a oe issuerd or ma to n, tie �nsur nce a�forcieed by coUtionseofasuci�po isles, mltsus own mayahave been reauce byipaie� Mims. C Type of Insurance Policy Number Eff Date Exp Date Liability Limits G NERAL LTAII�ITY Comrcij eneral General. Aggregate it rbi m�Calms �a�e Occur. Prod-Comp/Ops Agg Own i s Contractors der.& Adger. Inj. j. rotective Each Occurrence Fire Damage Medical Expense A ,1OMOBILE LIABILITY - Comb. Single Lim. auto w e Autos C e u e Autos $pdily n u (PersbnlfA Cx ent) HNire Au o property Damage GaragenE�ajv�Qsy E CESS LIABILITYpggregateccurr. �^ .A Other than Umbrella A.WORKER'SMPENSATION 'WCP0006163 11/01/95 11/01/96 SSAR W to � i s EMPLOXER'S LIABILITY imp i DJ.e: OTHER -DESCRIPTION OF OPERATIONS/LOC,ATIONS/VEHICLtS/SPECIAL ITEMS CERTIFICATE HOLDER Should py o the Above describe �ali ies �e c nce le be ore te irattion Moo trie eo ne IssVin com �n wz1-1 endeavp ,to ma Ms s wV ttgn no �c to the ce t�#1v e,h�older, bu to ma u b not e �m ose no o xgata. ���abiity o ani d upon the compa y, its s or re ent S. AUTHORI$UD R3M SEIgTATI y CD .0•r z CD O CLr r�•F CL >to O 00 CD CrCL M �G CD o �o CD CL o M CD U) CD O LWi U) O U) F O cn n CDO CCD v CA CDN O O CD 0 CD O Z CC '-1 0 U) MU —1r- y �, ( F> CD O — CD n 0 CD n • O 0CL Z7 Z O _� O� O di r•r O O. 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(? � %013 0S 0 :� T ^; o CD CD " U44 I v_ CD 0% 1 C sv o O a; :vo*AV CL Is 1 V7 VI W T.o T N au T x T 3 Y c j O > O O j O j 3 O O N O (D d . c a < c n� c c c 'a O 0 �* � to n z < T O (D O rv* O C �n Cl fD m C C 3 _ a O O m W D A Z G1 O H x m m m D z A O 2 • �,qp RISE ENGINEERING 60 Shawmut Road, Unit 2 1 Canton, MA 02021( 339-502-6335 www.RISEengineering.com OWNER AUTHORIZATION FORM Carrie Leary (Owner's Name) owner of the property located at: 26 Andover Street (Property Address) North Andover, MA 01845 (Property Address) hereby authorize QWN G/ 1�SV� (,✓%1ph� �/l/� , (Subcontractor) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property. This form is only valid with a signed contract. Owner's Signature Er / 1 C (�.. Date !_�: �%'©ter • �l --16 --Fm PRO � LIS A CONMCT pw I awea� m (ry18�T/1�781 4 Om aea+aw aas� _ Gamin •OU06om 26 Andowec 8� � � Z6 Aada� S9uerd - - .. en,r at+nss CD - Ono NatL Aon MA 0 4 1 A�baver. MA 01845 ... --- . JOBDUCRwnON pHASBCl1E- �misaeteodaryar. � pfd iapoaoen.�mmemow.p� �••�••�•�•�••—.•. _----.FAme - ' ag�dpo�eaNmdoorabr�j.Mm�bmba�edtosaed�rrbom�aa_�et�ails►fo�saoda0ia aomrwsoft' ido�aairboul�am �Aasbsoteoa �elpaa id�afefri�EeaBma13 °� s�� q'mamIhadatr° dooraailbroaan�ioa I 4m sm =420 :HUS 3217AO .....o.—M l3"m w l� tISE A in a * dv*b& &&aft mu W U*#&C ft,UAM= FAX t�anie Leety Saw=s R M IU&IW Sheet ftftd10# fecododfw me= *owe CONMCT ftp Z 1ammxwntaOlm gum -- aiga N81f1 tva�a�mse (47M1.4781 01/q M16 422M 00003 26 Amdfww Sheat "Mm amsaaas mum aerisas . r NO& MOM MA 01845 NoA Andow, MA 01845 JOB DSSCREMON peeia� Ivanapfames®sadvv"twwwjobs. 3673A Aar --eanua m�efatX60aadgra Asa ,� bytheaalh � �I�a�6adt6elb�elfeo� bag�ntitadaftxaao a6���►e�dea�� iia theoomi�ias ss�b►at'�� eadvamer � 71dS1�a�fsea�90 aad isrtaomat fayaa 'fwaloIfle w b" , if rols$kl1Q Tofah $2"AO pin hweasm 82M cudwwTot* Oun �e svewesr�o*meoa�aa casco era��r.�onm aarataaeae�was 11m1roalrasmeas< «tee pmy.Tw*& ooRws 30 am .TS se�as�oesrsasaaor- �nos�eomumn+� ma.aissiesa�r���+soaavasexnc 0 The Commonwealth of Massachusetts Department of Industrial Accidents Ogee of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant information Please Print Lmibly Name (Business/Organization/Individual): � (uJ +, C6_ lock l•111Qr(1 1 `V`�� Address: f• 0 Gu X 3 4 4 ii): k OjWiI U -N rl tA () \1 3 5 Phone #: Are you an employer? Check the appropriate box: 1. [!f'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. ® 1 am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.t required.] 5. ® We are a corporation and its 3. ® I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t 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 11.® 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. 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:Nad i bL 1 ESQ X11 \C L, CO3 — Policy # or Self -ins. Lic. #: tZ, p 3 0 0 3 7 Expiration Date: �4 30 2Q 2(2 �l�%xf S�0t els Job Site Address: Cit/State/Zip l 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 of perjury that the information provided above is true and correct. Phone #: C1 -t • 3 Slo "3`t 3 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License #_ 111►l"�o 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 #: DATE(MMIDDIYYM ACOREP CERTIFICATE OF LIABILITY INSURANCE 10/18/2016 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). cog NTAcr Me Munroe PRODUCER NAME: FAX PHE MARTIN J. CLAYTON INSURANCE AGENCY INC A/CONNo Ext; (413) 536-0804 A/c No: E-MAIL annp;m_ mmunroe@miclayton.com 1649 NORTHAMPTON ST., RTE 5 INSURERS AFFORDING COVERAGE NAIC a HOLYOKE MA 01041 INSURERA: ACADIA INS CO 31325 INSURED INSURER B: GAUTHIER INSULATION INC INSURERC: INSURER D: PO BOX 344 INSURER E: IPSWICH MA 01938 INSURER F: COVERAGES CERTIFICATE NUMBER: 94521 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. ADDL SUBR POLICY EFF POLICY EXP LIMITS INSR TYPE OF INSURANCE POLICY NUMBER MM/DD MWDD/Y COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS MADE OCCUR PREMISES Ea occurrence $ MED EXP (Any one person) $ N/A PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY ❑J RO FILOC PRODUCTS - COMP/OP AGG $ OTHER: COMBINED SINGLE LIMIT JAN LIABILITY Ea accident $ BODILY INJURY (Per person) $ O ED SCHEDULED RIA BODILY INJURY (Per accident) $ AUTOS PROPERTY DAMAGE $ NON -OWNED Per accident UTOS AUTOS $ LALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE N/A AGGREGATE $ DED RETENTION $PER WORKERS COMPENSATION X STATUTE ERH AND EMPLOYERS' LIABILITY Y / N E.L. EACH ACCIDENT $ 500,000 ANYPROPRI ETOR/PARTN E R/EXECUTIVE A OFFICER/MEMBER EXCLUDED? WA WA WA MAARP300327 10/30/2016 10/30/2017 E.L. DISEASE - EA EMPLOYEE $ 500,000 (Mandatory in NH) If yes, describe under E.L. DISEASE - POLICY LIMIT s 500,000 DESCRIPTION OF OPERATIONS below _T N/A_ OF OPERATIONS / LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued (unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage -Coverage Verification Search tool at www.mass.gov/lwdtworkers-compensation/investigations/. CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. TOWN OF NORTH ANDOVER 1200 OSGOOD STREET AUTHORIZED REPRESENTATIVE NORTH ANDOVER MA 01845 Daniel M. C y, CPCU, Vice President— Residual Market — WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014A1) The ACORD name and logo are registered marks of ACORD ���A::E ;u 2ZD C D�== oOmm w D�� coo toZ0p ? �• A O .0. a yo (Apo ,.. a d O. m o �p R g >n e O 0 � ���A::E ;u 2ZD C D�== oOmm w D�� coo , 2 - o w CL § ' ® 2 } m Cr -E k }rb _ »