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HomeMy WebLinkAboutBuilding Permit #Exception - 315 TURNPIKE STREET 5/1/2018 poRTh BUILDING PERMIT °`(IL.ED ;61 "o y,ti tl �•'.,6 0 TOWN OF NORTH ANDOVER i °; - -'• . APPLICATION FOR PLAN EXAMINATION �t Permit NO: Date Received L �qs gAT[C SACHUS Date Issued: IMPORTANT Applicant must complete all items on this page +K'R. '6'ky` •ra+y. �. ?'°P'rif" s�}�•:}-h ,zez"•« 'aev 5r��.�„-' fi r`�'Al .3'` 31'`5 ' F .y.,:u. raM 27. +a s.-r' t.°+f,�, +� ♦� t MR mwlaa-t, .. Si {` !W-11---r1--RN%,,'' �-� r`x 'a:.� =`77-5-7 �T" � ,��` A;��. :a;F��j'.= s rJ J .aS 3 ;;,'"^'�'r'KJ� rr,�1111���'�' .,r x,+- �"�T' y j' �'rj*�e� '!s r �• 5 '°"� .�� MAF' p� ��� :��PP►F�CEL�=�°�'��� z�0 INt��D:l_� 1R1 a,���� ��:.�His'to�lc �s�Ftct"�,°���;�: y es���fio�� �'�T,°`a lam`" .�➢[.� ��..cw ,�' x'r .��_��� }� g SIS� ?t+,�6 f� zs r r.'�"'C'r x �.rc �".. t '"0 4 ^�"ta,�,. TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 0 One family 0 Addition ❑Two or more family . El Industrial 0 Alteration No. of units: [I Commercial 0 Repair, replacement ❑Assessory Bldg 2,8thers: %w-`- 11 Demolition ❑ Other y Z ' x� Flootl ain � �WetEands �� ryk ��`Watepshedstr{olw �` , ,D �.* ,moi .�� �•+� ,� � 4 a n `� ..,, .°"'t ;:' B 4., ; "'{ `x.r }'- E -3`v •s .!?`"' 4 ^t'],T .*§' Z ` ,[ _ ae/Sew�r .. �°. �h-.M,i rz _'x.t .�=ate*x.,. -m .: r,. s,..,Y 3,,;�f 4;i','ter .�- " °-?.J ;!?.;."!-. t. . :xf `•h` ..c.>.? DESCRIPTION OF WORK TO BE PREFORMED: Dr Gl/eUl f /// 7e vf,4 ef/,/4 VdZle Identification Please Type or Print Clearly) OWNER: Name: Phone: -5"203 Address: ��5� �rh �T 4/1 /�/`'mfl ,�- .. 'f q ✓ ' '�`1.r i.�fi`ta ,g'F 'R�^. 2'.y',."',S' ''"*. - ,r-,e-+r�"`"`�,i.-�'' »3-F s k�' 3'.a"r`s 7§., '•e.a�.,.ar�t'N�-".EY r A T CONTP;ATORt1aie � a Y h h- Phone= � dr' "r w •' -�F -X 'Yea -• "P a �,r�a.�r,� ? `t r'`� ar, ,y`v. i "'. :, h• a_ Y" ^s„ez�r a q .�� -�a as ;� �- +•.5i C, '�x� �'�.3� x•` �� 5£�`"� '#a'Ez- t .L A s _71- -S ��L�'�.��%���•��r'� 2 F` n 7 s. s 'a"`t� E,�a�'�S'�. Aix`!S{.o-- ' tsac�q .h Y ..* - 't.+w,.,y.s.v.+c.cn'•'vr,*'�='v1'`^z'�i. '4`i .fC'+fir.' u .- kl'w� -t R,aj:4 �'� ' �,rt :C +, �Y' b�'"�` "'+.' 4.''*x.F< Y Y _ } r• 's'r.i*a`s „:s's "`"."*4`"yp e'k ..-.-r'`. --w C� s3i'�+'r,.�` r v .r"''-• + �t^'2 v -c .k kv' P.r - S .1 ; 7" v•pi}- M Y_ r�s".r Superv{sar�s Consrct{onL�cer�se � � },n �xp SY '�+9• Ti,'L=s x.r M,. 'ri'y r - t" 7,ha�t$P`� k '.S'f ',` s`" .- -t'1y,s ',''" �. t,, *`*.ar''� tv f� `r.�'tuF.`'a4. �..�.:t,.,F'F t i��� '� fig. .? 3 f''��f�' a� ���:, �y. �z�, `%-?x, '� y•; � r'�z�, 'X� -x.� t a"' a�#i ��r .�. y 'tr ?,3,e u�� ,.x '�`. -{+r + ^F .#�q �a""�f�.'t"._7.�-*",� �n�`°'i� r xt�5•s"��,. r P �� "y S�' 'y�� a �F"s.r �.. �.,�"� .1��k.`�2�'x'x�2',.`.. ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.,BOLDING PERMIT.,$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ �S FEE: $ - Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund i h YS{gnat {re o#contractor { nature of A ent/Owner '. � ` '� g iu. 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 DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ 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 Located at 384 Osgood Street 3FIRE5 DEPiARTMENT' `Tern'>Dumstet`onsite es i$ WENT, r `Nain Street€ Y `tee. av .. Locate a#�2 ; -1� ,q..;,-'tt-t, .a�. �e._ .�E..e -T..,.:f �p-''7k' v .mf: � 7 _�x§�+a,,�' ;.:�'..a �'t:• Z ��� .'s.?'�.� ��.:�L.�w "'1•.�.: Y a F..w .+..,za^ ...�-�' �s.. "�..-r ...k�»'�'3.�x-.-.��"�>-'sem - :cc�e;. s��'.�s�.� ''�- .�F,�' �` f,t�.v.. � �-� �.#�•»r: ARK " fi_..�$..-.M-Mx t .:.&"'?-^3 "".f:..r.4''`fd.P.'.....2._swr X'"": ._•,2'i� '� air r �,,,,,,yya NPI,�' .7 `• t' i� Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: 'I 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) II i ❑ Notified for pickup - Date Doc.Building Permit Revised 2007 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 1 ❑ 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/Crossection/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 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 o 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 o 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 0 INSPECTIONAL SERVICES DEPARTMENT:BPFORM 7 Doc.INSPEC J I Revised 2.2007 The Cori:monwealth of Massachusetts Department of Industritzi Accidents 10 Office of Invesilgations kvi 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information L Please Print LeLribPRA ly Name(Business/Organization4ndividual):C h l^i sf,;k I 1 i uer�J t Chair.fer v►cc,X1,g• Pa Kerr14 Address: 18 Cl ri Illy) 0r+ V c, City/State/Zip: P Q 11 jS, N# 03LOW Phone#: (Pd3—&93'. 32& Are you an employer?Check the appropriate box: Type of project(required): 1.( I am a employer with 2!�_ 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.x Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp,insurance, g, ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.[]Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] 13.�Other 7-�/CITS *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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lam an employer t/:at isprovidirrg workers'conspensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: CNm m rc qYI Tnsuiwn!j Policy#or Self-ins.Lic.#: d 093-70533. Expiration Date, Q l�l�t 2— Job Job Site Address: ke ST 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 Investig4tions of the DIA for insurance coverage verification_ Ido hereby certify under the pains and penalties erjury that the information provided above is true and correct Si ate: 7. Phone# _� r 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#: ACERTIFICATE OF LIABILITY INSURANCE 8171/011 Y' 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). PRODUCER CONTACT Luci Fitzpatrick Tebbetts Insurance Agency PHONE (603)465-3333 FAX .(603)465-6800 P.O. BOX 848 A DRL .luci@tebbettsi.ns.com 3 Village Marketplace INSUR"R( AFFORDING COVERAGE NAIC11 Hollis NH 03449 INSURERA:CitiZenS Insurance CmpAny of 31534 INSURED INSURER B;Hanover Insurance Company 22292 Christian Delivery & Chair Services, Inc. INSURERC:CommerCe and Industry Tnsurance 15172 D/B/A Christian Party Rental INSURER D: 16 Clinton Drive INSURER E; Hollis NH 03049 INS RF: COVERAGES CERTIFICATE NUMBER-CL1183101187 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, NSR ADDL 5U59 TYPE OF INSURANCE POLICY NUMBER MMND FF MMIDCY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 MNTE X COMMERCIAL GENERAL LIABILITY DAMAGFTU R IS. 'Esocwranee $ 100,000 A CLAIMS-MADE a OCCUR MMS44363 /1/2011 /1/2012 MED EXP(Any one arson) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PEP: PRODUCTS-COMPlOPAGG $ 2,000,000 X POLICY PRO LOC $ AUTOMOBILE LIABILITYOMBBI9tDS NGLE LIMIT accident) G $ 11000,000 X ANY AUTO BODILY INJURY(Per person) $ A �UToAOSWidED SCHEDULE V0716909 /1/2011 /1/2012 BODILY INJURY(Per accident) $ AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Pena Unftxedmotorist comWned $ 11000,000 X UMBRELLA LrAS OCCUR EACH OCCURRENCE $ 4,000,000 BP EXCESS LIAB CLAIMS-MADE AGGREGATE $ 4,000,000 DED X RETENTIO 10,00 0844365 9/1/2011 /1/2012 $ C RKERS COMPENSATION X WC STATU- X OTH EMPLOYERS'LIABILITY PROPRIETOR/PARTNERJEXECUTIVE YIN E.L.EACH ACCIDENT $ 1,000,000 ICERIMEMBER EXCLUDED? NIA 0009870539 /1/2012 /1/2012 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,0001000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1 000 000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remaft Schedule,If more space is required) CERTIFICATE HOLDER 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. AUTHORIZED REPRESENTATIVE Seth Tebbetts/LUCI r! � rsrsa ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025/9ninnsi nt TIw At tWr)nama enrl 1~m ere ranlctamrf marlre of A(W112171