HomeMy WebLinkAboutBuilding Permit #661-13 - 315 TURNPIKE STREET 4/11/2013PermitNO: �1�I
Date Issued: �� 1
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
IMPORTANT: Applicant must complete all items on this
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LOCATION 31 _FarnPl �e "recd' L 0'9 rii 4 PI-A-zA
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PROPERTYOWNER Mev'r'7V✓1aC_ l�0 11eRe_
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MAP NO.: PARCEL:
TYPE AND USE OF BUILDING
ZONING DISTRICT:
HISTORIC DISTRICT YES ❑
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
❑ Addition
L Alteration
❑ One family
❑ Two or more family
No. of units:
❑ Industrial
Repair, replacement
Demolition
❑ Assessory Bldg
❑ Commercial
Moving (relocation)
❑ Other
R Others:
❑' Foundation only
DESCRIPTION OF WORK TO BE PREFORMED
Dh 4Zis&_5 � We- cOZ/ 1;1-7s7t*// a �o x90 Tx_NT"do ik
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Identification Please Type or Print Clearly)
OWNER: Name: Phone:
Address:
CONTRACTOR Name:ChL1.STAI% 64 n ken J Phone:
Address: /e e_//h,lon Pelvo, Mlll-�, Nth 03AH
Supervisor's Construction License: Exp. Date:
Home Improvement License:
Exp. Date:
ARCHITECT/ENGINEER Name: Phone:
Address: Reg. No.
FEE SCHEDULE. BULDING PERMIT. $12.00 PER %7000.00 OF THE TOTAL ESTIMATED COST BASED ON 5725.00 PER S.F.
Total Project Cost :$ ,16e)6 • ®e FEE:$
Check No.: Receipt No.: Z7
Page lor'4
TYPE OF SEWERAGE DISPOSAL
Tanning/Massage/Body Art p
Swimming Pools C
Public Sewer
Tobacco Sales
Food Packaging/Sales
Well
Permanent Dumpster on Site
Private (septic tank, etc. :_.!
Electric Meter location to
project
NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund
Signature of Agent/Owner
Plans Submitted ❑
Plans Waived ❑
Signature of contractor
Certified Plot Plan ❑ Stamped Plans ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE REJECTED DATE APPROVED
❑ ❑
DATE REJECTED DATE APPROVED
❑ ❑
FIRE DEPARTMENT - Temp Dumpster on site yes
Fire Department signature/date
COMMENTS
no
Zoning Board of Appeals: Variance, Petition No: 'Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer connection/Si nature & Date Driveway Permit
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Building Setback (ft.)
Front Yard
Side Yard
Rear Yard
Required
Provided
Required
Provides
Required
Provided
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
r4v i r.n ana UA rA — (For department use
Pagc 3 (44
SER
Crewed JNIC. Jan 2006
M
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
Addition Or Decks
❑ Building Permit Application
❑ Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract -
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
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
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: INSPECTIONAL SERVICES DEPAR'rN1ENT':BPF0RM05
Page 4 of 4
Location A /4 /DPI
No. Date�T44114
Check # �G i5�
26271
TOWN OF NORTH ANDOVER
Certificate of Occupancy $-
Building/Frame Permit Fee $ -3!4
Foundation Permit Fee
Other Permit Fee
TOTAL $
MV)
Building Inspector
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4/10/13 315 Turnpike St, North Andover, MA- Google Maps
Address 315 Turnpike St
Go—Merrimack College, North
Andover, MA 01845
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p� �•! ,Oka, Crest Or
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Map data 3 Google
https:Hmaps.g oog Ie.conVmapsW=q &source=s_q&hl=en&geocode=&q=31S+Turrole+SL+North+Ando\er,+MA&aq=0&oq=315+turnpiW+st+&sl I=37.6,-95.66... 1/1
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The Commonwealth of Massachusetts
1� Department of Industrial Accidents
r Office of Investigations
/ 600 Washington Street
Boston, MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
C�h
Ch rt//v'/sf /:A/�
Name (Business/Organizadon/Individual): S �iAy� %e / t V�'r X t- /'M6,jjY�ryiz, Ln4 . p g_7 /ZEAj-TAA
Address: l ()k r7 �yh P r i d6
City/State/Zip: �o, j 1'5 , `V1d Q36 Ll 9 Phone #: 6 6 3 " 8'g9-.�;3 Z6
Are you an employer? Check the appropriate box:
1. Eg'fam a employer with _ 2 -
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. t
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
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.[�ther _72 S
*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 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: cevfivrleree-
it r-Ithee—
Policy # or Self -ins. Lic. #: VV6 d D q 2� 1653 9 Expiration Date:
Job Site Address:_
City/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 of perju! y that the information provided above is true and correct
Phone #: �� 1J ` t?93
Official 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
11
- i6.-� D CERTIFICATE OF LIABILITY INSURANCE
nATE(MMlDDIYIYY)
9/5/2012
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 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(ies) must be endorsed. If 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 endorsement(s).
PRODUCER
Tebbetts insurance Agency
P.O. Box 848aoMn11
3 Market Place
Hollis NH 03049
NAMeCT Luci Fitzpatrick
PHONE(603)465-3333 F�uo:(603)465-6800
.luci@tebbettsins.com
INSU AFFORDING COVERAGE NUC#
INSURERA:Ci tizens Insurance Com an of X1534
INSURED
INSURER B Iianover Insurance q2MRany 22292
Christian Delivery & Chair Service Inc.
D/B/A Christian Party Rental
wsuRERc:Commerce and Industry Insurance 15172
INSURER D:
18 Clinton Drive
INSURER E :
Hollis NH 03049
INSURER F:
CVVt.KAUt=S CERTIFICATE NUMRER-CL129501357 acvlcinu ut lurc>=o.
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
POLICY
POLICY EFF
MMIDO
POL)CY EXP
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY
DAMAGE
R AGE REN
occurrence)$ 100,000
A
CLAIMS -MADE OCCUR
BV0844363
/1/2012
/1/2013
MED EXP (Any one person) $ 5,000
PERSONAL&ADV INJURY 5 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS -COMPIOPAGG $ 21,000,000
X POLICY M. dpF'CT LOC
S
AUTOMOBILE LIABILITY
COM SINGLE LIMIT
1,000,000
A
X ANYAUTO
BODILY INJURY(Perperson) $
ALL OWNED SCHEDULED
AUTOS AUTOS
077.6909
9/1/2012
/1/2013
BODILY INJURY(Peracridant) $
NOWOWNED
PORED AUTOS AUTOS
PROPERTY DAMAGE
Peracddent $
EIBE $
$
UMBRELLA LIARHC0LcAc,MS-MAE
UR
EACH OCCURRENCE $ 4,000,000
B
EXCESS UAB
D
AGGREGATE $ 4,000,000
DED % RETENTION
$
0944365
/1/2012
/1/2013
C
WORKERS COMPENSATION
X WC STATU- X OTH-
ANDEMPLOYERS' LUIBILJTYER
Y! N
E L EACH ACCIDENT $ _ 11000,000
ANY PROPRIETORIPARTNER/EXECUTNE
OFRCERIMEMBER EXCLUDED? �
NIA
E.L DISEASE - EA EMPLOYE $ 11000,000
(Mandatory in NH)
WC009870539
/1/2012
/1/2013
If yes, describe under
F
E.L. DISEASE -POLICY LIMIT I $ 1,000,000
DESCRIPTION OF OPERATIONS below--�]
DESCRIPTION OF OPERATIONS I LOCATIONS f VEHICLES (Attach ACORD 101, Additional Renlaft Schedule, If more space Is required)
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
-- iseth Tebbetts/LUCi
ACORD 25 (2010105) a)1999-2090 ACORD CORPnRATION_ All Arth4a rounrucrl
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