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HomeMy WebLinkAboutBuilding Permit #671-2017 - 29 NORTH MAIN STREET 12/29/2016BUILDING PERMIT TOWN OF NORTH ANDOVER. APPLICATION FOR PLAN EXAMINATION Date Received TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial C.Repair, replacement ❑ Assessory Bldg ❑Others: ❑ Demolition ❑ Other Septic ` OWell O Floodplain D Weirands r ❑Watershed Dist icfi .. r tzESGKIP I JUN ur wuKtt I U nr- t-r-MrUM1V1=v. PO -0 )I-- a 6-ec id 6; n- 00 OWNER: Name: - Address Idengca#on - Please TgTe or Print �rlearly AGN' (2 0 it IL`t/` .1� t 0'/e�/Y GCC F Contactor Narrie= U�_ 'hone:.. ��._._.. C. © Ex 4 Date K_ Supervisor's Construction License _F p K Home Im0,b vemer t License _ _ Exp Date 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 C®St: $ ©d FEE: $ Check No.: lb Z Receipt No„ (NOTE: Persons contracting with gistered contractors do not have: access to the guaranty fund inr at rFP,rif Anent/(�ininPr Sidnature of contractor; i 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 Dempster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY. INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On COMMENTS Signature. CONSERVATION Reviewed on Signature COMMENTS HEALTH COMMENTS Reviewed on Zoning Board of Appeals: Variance, Petition N t Planning Board Decision: Conservation Decision: Comments Comments Signature Zoning Decision/receipt submitted yes Wafer & Sewer Connection/Signature & Date Driveway Permit DPW Tomo Engineer: Signature: FIRE DEPARTMENT'- Temp Dumpster on site yes Located at 124 Main Street Fire Department signatureldate COMMENTS, Located 384 no Street iimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: r- ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No ®ANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine Doc.Building Permit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. r 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 ❑ Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (if Applicable) ❑ Mass check Energy Compliance Report (If Applicable) o Engineering Affidavits for Engineered products 'VOTE: 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 ❑ 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 DOTE: 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 Location ,�5 /U No. () // -�2cll Check#/-' / 2- 17 Date TOWN OF NORTH ANDOVER Certificate of Occupancy $- Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Builaing Inspector E 0 3 0 H qA Stail LL O m O t = Y 0 o LL a0+ N a N Z Z Q m O i+ c0 LL W T v E U ro LL o LU tail Z Z m D d °�° of m LL o U LU coif Z V N W LU K O Z Ln o LL a: O Z to 1' LL z Q W 0 LU LU U. N E m O Z v N a-+ w v O N tuno O _ O p : Q o •C L Q d MMj 0) t Q - O O E Q :, 2' L y yam+ _ C rp+ O Qy � • `; o O O (i i N 0 0 3 01CL J L m Assam: CD > Cc q_ O = G) > Cl) o c �ccUa N L t .a E"- o 070z - ..10' C Lc o �T_ 3 '•> o o CL CL a) (D Alloop _ cc 0 i- NCL == = m H p y (D .2 co cts W = -0— O O LU:E .2 LL 2 0 N C ELN W •E V a. a M F: wy °'>y=c H -= O 0"= 0 f- t Z CLOV O LU COV 0 m x Z O� CD ~� Z V Cl) aZ UJ O W U H W CL Z �i H ."i It ti o� lw 4t www rnassgovldia Wa kers' CompensationTnsurmce Affidavit: Builders/Con-txactoxs/EXectriczans/Plnmbexs. TO BE WffH TBE I ERMITTING AUT130RxI y - Print � Name (Busmess/Oxg mzaton/ladivi("al) _ Address: If 1) X d t r ae1Q City/Siate)Zip Moflit�-TMJ�L S�— U -e l" vM Md Are you an employer? G7?ecktIieroprsatebox: 1.[g.,j,�a employer with 12 employees (full and/or part time). 2.0 jam a sole proprietor ar parf aershrp and have no employees Working forme in oworkers' comp. insmanee regnim l any capacrty. V- 3. ] I am ahomaowner doing allworkmysf'lf. jNnworkers' comp, insurancerequired ] 4.❑Iamahomeowneranclv0behi,ingcol&actmtocondneiaUworkonmyproPmty- lV'Z ensmethat all cogtractbis either have workers' compensation inane or are sole proprietors with.no employees. 5.� I am a general contractor P4 3haveehirean he ssu wcoont=torsrlistedp. 'n �nancethe �ched sheet These sub -contractors have employ 6.Q We are a corporation and ifs. offcdm have exercised.their rigbt ofexemption per MGL e_ hav' no empldyees. [No workers' comp. insurance required.] Type of project (reqIxa'e�= 7. F1NOW'constEdd-Eion 8. Remodeling 9. [] Demolition 10 [] Buildingn additio 11.❑ Electrical repairs or. additions 12. �:prju b ng repairs or additions 13..E]Rb6frepaird 14.n Other 152,§l(4),andvye e r . *Any applicarsthat cher�s bbx#1 must also izI1 ouithe seciionbelow shownigtheirworkers' compensationpoficyibm t ane n ' affidavit indicafingthey are doing aI1 work Bud ihenhire oufside contractors must submit a new af5davit indieatrng such i Homeowners who submiiihis. tContractors that checkthis li'o�mh�ea mP �e ��o� Pr � e � n� �e comp- coj&actors mm�ber.and staii whether or notfihose eniii?es= ave employees.Ifthcsub-coutr�c � b,Site X ttm an empioyeriliat is px'oviding7-vox7cers' compensation ins iurance for my employees �. infor'madon.Y 1 1 �ni(0 Aa L I� ill I (�/ Insurance Company L` u)e7d t /� Below is tliepolicy an Jo ExpirationDate• 3 l Policy # or Self-rvs. zc. C °1 �/YhaI�1 5 /1/rf �i� � Yqq -City/State/zip:, fit° er Job Site Address: ' iration date) - Attach a copy of the Workers' compensation policy declarationis Page naT.� ati e Policy b�bp a and up t $1.,500-00 Failure to secure coverage as required under MGL c. ), i- §�5A and/or one-year imprisonment; as well as civil penalties in the form of a STOP WORK ORDER and a fine ofup to $250.00 a ed to the O day against the violator. A copy of this statement may be forward ffice of Suvestigations of the DTA for inset ante rnvara¢e verification. d d move is txrre end correct X do /zeYe/iy certify under' arzdpenalties ofperjury that the infarvnatzon prom e 0= Official use only. Do notwrzte ire t/tis aj ea, to lie completed by city or• town official. Perm.it/Licewe # City or ToNm- lssuingA.uthoxity(circle one): ector �.Pluanbixigxnspector J.. Board of I(ealth 2. Building Department 3. CityjTown Clexk 4. Electrical Rasp 6. Other phoxae Contact Person• ne Cor mouwealth of Massachusetts Deptax'tnent oflndustrialAccidlents _ Suite 100 r 1 Cong-ress ,Sheet, Boston, 02114-2017 _VA 4t www rnassgovldia Wa kers' CompensationTnsurmce Affidavit: Builders/Con-txactoxs/EXectriczans/Plnmbexs. TO BE WffH TBE I ERMITTING AUT130RxI y - Print � Name (Busmess/Oxg mzaton/ladivi("al) _ Address: If 1) X d t r ae1Q City/Siate)Zip Moflit�-TMJ�L S�— U -e l" vM Md Are you an employer? G7?ecktIieroprsatebox: 1.[g.,j,�a employer with 12 employees (full and/or part time). 2.0 jam a sole proprietor ar parf aershrp and have no employees Working forme in oworkers' comp. insmanee regnim l any capacrty. V- 3. ] I am ahomaowner doing allworkmysf'lf. jNnworkers' comp, insurancerequired ] 4.❑Iamahomeowneranclv0behi,ingcol&actmtocondneiaUworkonmyproPmty- lV'Z ensmethat all cogtractbis either have workers' compensation inane or are sole proprietors with.no employees. 5.� I am a general contractor P4 3haveehirean he ssu wcoont=torsrlistedp. 'n �nancethe �ched sheet These sub -contractors have employ 6.Q We are a corporation and ifs. offcdm have exercised.their rigbt ofexemption per MGL e_ hav' no empldyees. [No workers' comp. insurance required.] Type of project (reqIxa'e�= 7. F1NOW'constEdd-Eion 8. Remodeling 9. [] Demolition 10 [] Buildingn additio 11.❑ Electrical repairs or. additions 12. �:prju b ng repairs or additions 13..E]Rb6frepaird 14.n Other 152,§l(4),andvye e r . *Any applicarsthat cher�s bbx#1 must also izI1 ouithe seciionbelow shownigtheirworkers' compensationpoficyibm t ane n ' affidavit indicafingthey are doing aI1 work Bud ihenhire oufside contractors must submit a new af5davit indieatrng such i Homeowners who submiiihis. tContractors that checkthis li'o�mh�ea mP �e ��o� Pr � e � n� �e comp- coj&actors mm�ber.and staii whether or notfihose eniii?es= ave employees.Ifthcsub-coutr�c � b,Site X ttm an empioyeriliat is px'oviding7-vox7cers' compensation ins iurance for my employees �. infor'madon.Y 1 1 �ni(0 Aa L I� ill I (�/ Insurance Company L` u)e7d t /� Below is tliepolicy an Jo ExpirationDate• 3 l Policy # or Self-rvs. zc. C °1 �/YhaI�1 5 /1/rf �i� � Yqq -City/State/zip:, fit° er Job Site Address: ' iration date) - Attach a copy of the Workers' compensation policy declarationis Page naT.� ati e Policy b�bp a and up t $1.,500-00 Failure to secure coverage as required under MGL c. ), i- §�5A and/or one-year imprisonment; as well as civil penalties in the form of a STOP WORK ORDER and a fine ofup to $250.00 a ed to the O day against the violator. A copy of this statement may be forward ffice of Suvestigations of the DTA for inset ante rnvara¢e verification. d d move is txrre end correct X do /zeYe/iy certify under' arzdpenalties ofperjury that the infarvnatzon prom e 0= Official use only. Do notwrzte ire t/tis aj ea, to lie completed by city or• town official. Perm.it/Licewe # City or ToNm- lssuingA.uthoxity(circle one): ector �.Pluanbixigxnspector J.. Board of I(ealth 2. Building Department 3. CityjTown Clexk 4. Electrical Rasp 6. Other phoxae Contact Person• Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their empldYees. Pursuant to this statute, an employee is defined as "._.every person in the service of another under any contract of kite, 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 receiv6For trustdd 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 ocoupant 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 shalt 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 shall withhold the issuance or renewal of a license or permit to operate a business or to construct bnildnngs in the commonwealth for any applicantwhd Ras not produced -acceptable evidence of compliance with the insurance coverage req'uiuited." Additionally, MGL chapter 152, §25C(�) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public 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), addresses) andphonenumber(s) along with their cerdficate(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. B e advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of7nsura ce coverage. Also be sure to sign and date the affidavit. The affidavit should be retum:ed 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 vrorkers' 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 Deportment has provided a space attire 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 pertnMicense applications in- any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write •"all locations in (city or town)." A copy of the affidavit that has b eon officially stamp ed or marked by the city or town. may b e provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be flied 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 p ermit to burg leaves etc) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-•201.7 Tel. # 617-727-4900 ext. 7406 or 1-877-MA.SSAFE Fax # 617-727-7749 Revised 02-23-15 www.mms.gov/dia OP ID: OUJA ACORO-DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 12/28/2016 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, subje6t 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 Macdonald & Pangione Insurance 104 Main Street North Andover, MA 01845 Donald Schemack CONTACT Hannah Courtemanche, AAI, CISRAX PHONE AIC No Ell:978-688-6921 A/c No): 978-688-5350 E-MAIL hannah@mpins.net ADDRESS: PRODUCER DGCON-1 CUSTOMER ID II: INSURER(S) AFFORDING COVERAGE NAIC 0 INSURED D G Contracting, Inc 428 Pleasant St North Andover, MA 01845 INSURER A: Travelers Prop & Casualty CL 25674 INSURER B: Safety Insurance Company 39454 INSURER C: National Liabili 8; Fire Ins INSURER D: INSURER E: INSURER F: r`AVFRAr:FC CPRTIFICATF NIIMRFR- 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 LTR TYPE OF INSURANCE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Building Dept POLICY NUMBER POLICY EFF MMIDDYl E LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE Fx_] OCCUR 680-1553R18 05/17/2016 05/17/2017 EACH OCCURRENCE $ 1,000,00 DAMAGE TO RENTFff_ PREMISES Ea occurrence $ 300,00 MED EXP (Any one person) $ 5,00 PERSONAL 8 ADV INJURY $ 1,000,00( GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: POLICYX PRO- LOC PRODUCTS - COMP/OP AGG $ 2,000,00 $ B AUTOMOBILE X X X LIABILITY ANY AUTO ALLOWNEDAUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS 3116538 07/12/201607/12/2017 COMBINED SINGLE LIMIT $ 1,000,00 (Ea accident) BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (PER ACCIDENT) $ $ A X UMBRELLA LIAB EXCESSLIAB X OCCUR CLAIMS -MADE CUP -0090153321 05/17/2016 05/17/2017 EACH OCCURRENCE $ 1,000,00 AGGREGATE $ 1,000,00 DEDUCTIBLE RETENTION $ $ $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVEY/N OFFICER/MEMBER EXCLUDED9 (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A V9WC704542 03/31/2016 03/31/2017 X I WC STATU- OTH- TORY LIMIT ER E.L. EACH ACCIDENT Is 1,000,00 E.L. DISEASE - EA EMPLOYEE $ 1,000,00 E.L. DISEASE -POLICY LIMIT $ 1,000,00 A Property 680-15531118 05/17/2016 05/17/2017 �Lsd/Rent 20,000 Equip DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) r1=RTIFIrATF HAI nFR CANCELLATION @ 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Building Dept 1600 Osgood Street North Andover, MA 01845 AUTHORIZED REPRESENTATIVE @ 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD i f O N nNNW - V O =aQ dW= �C? •i�at- o "z OCO i