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HomeMy WebLinkAboutBuilding Permit #741 - 315 TURNPIKE STREET 4/16/2012Permit NO: � q I Date I 15Z TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 'ANT: Date Received must complete all items on this page . , COX r Print PROPERTY OWNR �erh/✓YI aC, " e, e Unit # Print MAP NO: PARCEL: Historic District yesno, Machine Shop Village yes no 100 year-old structure yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg hers: /�1f ❑ Demolition ❑ Other O'Septic ❑Well' 'F1'oodplain, q'Wet_l_'and's4 r D'Watershed0istrict O Water/Sewer; DESCRIPTION OF WORK TO BE PERFORMED - D4 ��� w� uii// itXXD J d/?e // itin ,Pleae l� /V%AelMoie%l 61kle Ao- oTMZZ.-,��/clr 004 �e- e)')-74����Z , v (Identification Plgase Type or Print Clearly) OWNER: Name: Address: 31S- ��/ OOA %/8=0-,, / 7 CONTRACTOR Name��!!-Y,��iS �r�3' G'{his J� / Phone:�� Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: A-�#ff-E Gl��4weI%/ �Ci /01 Phone: �0,4 Address: O//� k"17 ��'- A1# 03D90Reg. No. FEE SCHEDULE. BULDINGLLPP/ERMIT.• $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ T FEE: $ '56) Check No.: -5-2- 7( Receipt No.: Q S` 3 NOTE: Persons contracting with unregistered contractors do not have access to the uaranty fund ,,Signature of Agent/Owner �'y% _ Signature_of contracto Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans- , •- TYPE OF SEWERAGE DISPOSAL _ Public Sewer ❑Swimming Tanning/Massage/Body Art ❑ Pools ,` ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dumpster ori Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED PLANNING & DEVELOPMENT ❑ COMMENTS DATE APPROVED El 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 DPW Town Engineer: Signature: FIRE DEPARTMENT - Temp Located at 124 Main Street-: Fire Department signature/date COMMENTS Located 384 Osgood Street CONSERVATION COMMENTS Reviewed on I i yjakN—e / Signature J 61kk 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 DPW Town Engineer: Signature: FIRE DEPARTMENT - Temp Located at 124 Main Street-: Fire Department signature/date COMMENTS Located 384 Osgood Street 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 No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA — For department use ❑ Notified for pickup - Date Doc:.Building Permit Revised 2011 June/mi 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 ❑ 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 ❑ Flo or/Crossection/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 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 ❑ 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.Building Permit Revised 2008mi Location 3l zTv�,� 1 s No. St Check #J L 7 �� 25193 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $' TOTAL Building Inspector o � UJ z o w v cn a U A co w w U m—coW w a W o w q x 0 o � UJ z o w v cn a U A co w w U m—coW w a W o w q x a W o w cn '� q t�. O o r C w z w a cA cn o co o � UJ z c c m c � I"• :.� , r Z o o ` w c•r O N T- oQp� v: o � UJ z z 0 w w a 6 O Ocm C_ CA p 'C Co O O 'E m m CD CL a=..• CD 3.0 O O 00 e_vv o a o *"� c C ev v d O ♦D C G3 C.3 Nl � C C ■ C H c c m c o ` c•r O N T- C O v: LD G,,O CL ev ev m O OCc CD 4 caa m 0 a r H EE 0 c� 0 O Q .. u os 4mc E CL= 0m a c h �m3 h = r N C=M m H m .0 y C H cc 0 E1400 m mo CLU m H cD= �. O C cm C H Qc CO m V •yZ O r.+ R O� c C= O CM c m � y -.m c •c = m ay=+3o N y ev t m ._.. •N O C •E CL v 0 •y Z o C.3 a �� mE 3 F= A 0 ti •O :0 aim z 0 w w a 6 O Ocm C_ CA p 'C Co O O 'E m m CD CL a=..• CD 3.0 O O 00 e_vv o a o *"� c C ev v d O ♦D C G3 C.3 Nl � C C ■ C H A4* RCERTIFICATE OF LIABILITY INSURANCE 8/31/ oil") THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER, IMPORTANT: if the certificate holder is an ADDITIONAL INSURED, the pollcy(ies) 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 Tebbetts Insurance Agency P.O. gOx 84$ 3 Village Marketplace Hollis NH 03049 CONTACT LuCi Fitzpatrick PHONE(603)9&5-3333 FAX (603)465-6800 E-DMAILRES luCi@tebbettsina . com INSURE AFFORDING COVERAGE NAIC9 INSURER A:Citizens Insurance Com an of 31534 INSURED Christian Delivery & Chair Services, Inc. D/B/A Christian Party Rental 18 Clinton Drive Hollis NH 03049 INSURERB:Hanover Insurance Company 22292 INSURER C:Commerce and Industry Insurance 15172 INSURER O: INSURER E : INSURER F: COVERAGES CERTIFICATE NtJMRFR-CL1183101187 RFViC1nN 141IMRFR- 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. L TYPE OF INSURANCE POLICY NUMBER POLCY EF MMID POLICY EXP MID LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITYR CLAIMS -MADE a OCCUR I ZBV0844363 I /1/2011 /1/2012 EACH OCCURRENCE S 1,000,000 I S Ea "AGE TO RENTED $ 100,000 MED EXP (Any one ) $ 5,000 PERSONAL & AOV INJURY $ 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER X POLICY JFCT PRC LOC PRODUCTS - COMPIOP AGG S 2,000,000 $ A AUTOMOBILELIA6ILITY X ANY AUTO Al.L OWNED I SCHEDULED AUTOS AUTOS HIRED AUTOS AAUTOS EO NBV0716909 /1/2011 /1/2012 CP,Oaad D NGLELIMIT $ 11000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTYDAMAGE $ Uninsured motorist amtpnd $ 11000,000 B X UMBRELLA LiA6OCCUR EXCESS UA13 HCLAIMS-MADE MMOS44365 /1/2011 /1/2012 EACH OCCURRENCE $ 4,000,000 AGGREGATE $ 4,000,000 DEO I X I RETENTIONS 10,00C $ C WORKERS COMPENSATIONX AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE YIN OFFICERIMEMBER EXCLUDED? IMandatoryIn NH) DESG�RIPT ON OF OPERATIONS be;ow NIA 0009870539 /1/2011 /1/2012 VdC STATU- 0jr EL EACH ACCIDENT $ 11000,000 EL DISEASE -EA EMPLOYE $ 1,000,000 E.L. DISEASE- POLICY LIMIT 1 $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more apace 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 Seth Tebbetts/LUCI ACORD 25 (20101051 ©1999-2010 ACORD CORPORATION_ All rinhts resarvnrt INS025on1nn51 M Tim Af`110I7 name and Innn ore ranFekamel marlrc of ARnion The Contmonivealth of Massachusetts Department of Industrkd Accidents Office of Investigations 600 Washington Street Boston, MA 02111 UV www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information PIease Print Legibly Name (Business/Organization/individual): (hY' sf,N'1 b jyer�J fi (..f a r Set- y►cc, z14- C>HH 7 kn P-1-.4y— Address: Q -.4y— iA 1 Address: City/State/Zip: ):L I 117 6 30 K Phone #: .Are you an employer? Check the appropriate box: 1.N I am a employer with 3-�— 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.] f employees. [No workers' comp. insurance required.] Type of project (required): b. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.1;3 Other, _T NTj *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new 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 tl:at isproviding workers' conspensation insurance for my employees. Below is thepolicy and job site information. /% Insurance Company Name: L C1V1' WIerCe a v1Gi 10>MSr SYI SUi-an!C' , Policy # or Self -ins. Lie. #:�1 C Q D 9-7053 9 Expiration Date: 9 Ll JZZ 12 - Job Site Address:y�;- jYdll?/ City/State/Zip: �,��Cr, 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 foiwarded to the Office of Investig4tions of the DIA for insurance coverage verification. I do hereby cert undef the pgWnsm%penaffles of pefAyy that the information provided above is true and correct e9- -S3Z61 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 b. Other Contact Person: Phone #: (.1Gertifitate of iffame Rett'.5tante REG*TERED ISSUED BY: ma Veafad APPUCATM AZTEC TENTS �i CONCERN NO. 490 ALASKA AVENUE Oq f.��b► TORRANCE, CA 90603 y CAL COMB F�fTe 0t' (310)328.6060 JIM This is to certify Brat the matedlals described below hereof have been flame retardant treated (or are inher- en8y nonflammable). FOR CHIaf8MN PAMREMTALS ADDRESS is CLNTON DRNE crrY HOLIJS STATE NH, 0.4045 Certification is hereby made that: (check "a" or "b') (a) The articles described below this certificate have been treated with a flame retardant chemical approved and registered by the State Fire Marshal and that the application of said chemical was done In confor- mance with the laws of the State of Califomla and the Rules and Regulations of the State Fire Marshal. Name of chemical used .»....» ...»....»...»................. Chem. Reg. No. ...... ».......... ».» Meathcdof application ....... .... ........................................ ...M...�.» (b) The articles described below hereof are made from a flame -resistant fabric or material registered and approved by the State Fire Marshal for such use; Fabric has been tested and passes NFPA701-96. Trade name of flame- reslstaM fabric or material used,. Reg No ... ». The Flame Retardant Process Used ALL NOT,... Be Removed by Washing (wm or wig not) David Bradley Chuck Miller - President NersaAppi =or Kom= supeft CUSTOMER ORDER NO. R159657 ITEMS MANUFACTURED: I- 100x40'(2 PC.) SERIES 2000 M ULTRA WHM 2-20Y4O'(1PG)QWIKTOP ONLY- ULTRA WHITE 2.205130'(1 PC) QWIKTOP ONLY- ULTRA WHRE PDF created with pdfFactory trial version www.pdffactory.com