Loading...
HomeMy WebLinkAboutBuilding Permit #1321-2016 - 33 PILGRIM STREET 6/21/2016 BUILDING PERMIT %10RTy OF�t�en 6q� TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION _ 7D Permit No#: Date Received �Ssgcr+us���y Date Issued: k ORTANT: Applicant must complete all items on this page LOCATION 3 Print PROPERTY OWNER 7rtSo ✓I 5-7-c h r n5 Print 100 Year Structure yeQno MAP PARCEL: 7�f ZONING DISTRICT: Historic District yMachine Shop.Village y 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 a Others: j ❑ Demolition ❑ Other 'J- ' -v 1A no h 0 Septic 0 Well ❑ Floodplain D Wetlands 0 'Watershed¢District 0 Water/Sewer -- - - -- _ ----— DESCRIPTION OF WORK TO BE PERFORMED: �X7rt` (' t.✓9 /� zySd/STiny Q . ►'ti 7- L-'J L-'J �lr <<;lr✓�9 Identification- Please Type or Print Clearly OWNER: Name: Sc-,5o✓i S'TrPk tvi S Phone: /f 9V--Ll,>a> Address: 33 P% 16 r wi 57- Y7_ oH'/o vrr Peter LMaine Contractor Name. �,�-� n Street Phone: *i Email; Address: 15-W-7638 Supervisor's Construction License: /b Ge, I > Exp:- Date: . Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: e Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. ��Db_ �� FEE: $ Cost: $ I Total Project Check No.: ` l Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 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 OTE: 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) Engineering Affidavits for Engineered products OTE: 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 Iu 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 getthis recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art El 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 m U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS in'R♦s'lle `J`` pyyy l+ (+ 5( y - 'L N :.-. . ]. Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments a � Wafter& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: FIRE DEI'ARTME, NTT mp ®wmpste-r on site dyes' °ca 3n4o0 ;�b 4 e sgood Street ii * # Located at 1p24 Main Street , �— Fire Department Qi } _ Q ' gnature/to , 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 Call Email Date Time Contact Name Doc.Building Pennit Revised 2014 Location -✓. +� y2� esr- "" I No. � � 7 CA Date • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ 5 # " Foundation Permit Fee $ Other Permit Fee $ TOTAL $ ` l s Check#�l ��� r 30 -028 v Builcll g Inspector rl/ NORTH Town of 32 _ O "" �► h ver, Mass,jud!, L 20 O coc"Ic"t WICK pD4ATED S l] BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System Z;;k& THIS CERTIFIES THAT ... BUILDING INSPECTOR ........ ............... ......................................................... Foundation has permission to erect buildings on ....... ..1.1. Ill�.l. LT Rough to be occupied as .. ... ... 1 .1� -�....... Chimney provided that the person accepting this permit shall in every respect...co nX to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. C �� ct l, PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONST ION Rough Service ... .. .......... .... ......... ...... ...... Final BUILDING SPEC OR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. fill � e lugs toy 6 - Inr i 00 AdiWfm Ro 688t�dtfRiC�4iNA�1 CoffmcT XW40m FAX386S i M Pqp _ PROGRAM CKA ffi h=s&Vbws (0 5044707 09ASaA1S 400157 00005 33 POfft Skeet 33 Pifgdm Sheet Na&AndeA4NA018U Nu&Andr^NdA0IUS JOB DB�CR�TIOPT Taft 83.664AZ Pmw= cr RJR to 8648.88 e�aeaeBer�oaaeaexaee .eo�aae�oomma�as�aex�orana�e.�men�aoaaP -Iyx Hued"Fob&Mae Doom8846.63 m�"°°�' tea° °�°' ea�ri► 01111 3 T i 1 i OWNER AUTHORIZATION FORM ` Jay Stephens (Owners Blame) owner of the property looted at { 33 Pilgrim Street tA (Property Address)North Andover, llflA 01845 (Property Address) I R hereby authorize `�� l� 10`I (Subcontractor) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property. Owners Signature 03/20/2015 Date signaa,re: mi��20.205) Eman: rgim@thMsch.com The Commonwealth ofMassachusetts Department oflndusiWalAccidents Ofjtce of Investigations 600 Washington Street Boston,MA 02111 www.mas_vgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors)EIectricians/Plumbers Applicant Tnfoxmation .'lease Print Legibly Name(Business/Ozganization/Tndividual): Address: PO BOX 958 MA Mio -City/State/Zip: Phone#: Agon an employer?Check the appropriate box: _ I. am a employer with____ 4. ❑I am a general contractor and I Type of prof eet(required): employees(full and/or part time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7. ❑Remodeling ship and have no employees These sub-contractors have S. []Demblition working forme in any capacity, workers'comp,insurance. [No workers comp. .insurance 5. 9• ❑Building addition ' p ❑ We ate a corporation and its required.] offiicers have exercised their 10.E]Electrical repairs or additions 3.011 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c.152 1 4 p ,§ ( ),and we have no insurance re i' 12.[]Roof repairs quired.] employees.ees. o P Y workers COMP,insurance required] 13.❑Other *Any applicant that checks box#1 must also fill out the section > below showing their Homeowners who submitthis affidavit indicating they are do' all work g workers compensationpolicyiuformation: - k and thenicating such n hire outside contractors mus tractors that check this box must attached an additional sheet showing the name ofthe sub-contractors and their workers,comp. olicw affidavit ydinformation. tam an employer that is providing workers'compensation znsurance or m em f y to ees. Belo information. r y w is thep�licy and job site Tusurance Company Name: ODr Policy#or Self-ins.Lie.#: ?Qwe 7� f�f ExpiratlonDate: A, a p j Job Sitedress:d Cj j � / A City/State/Zip: �� n dl o r{r 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 ofMGL c.152 can lead to the imposition sztion of criminal flue up to$1,500.00 and/or one-year imprisonmentas ppenalties of well as civil penalties ofup to$250.00 a day against the violator. Be advised that a co p m the form of a STOP WORK ORDER and a fine Investigations of the DIA for insurance coverage verification.copy of flus statement may be forwarded to the Office of Ido Hereby ce .y uder flee airs and enalties o P P fperjury flzat the Inforzzzation provided above is true and carred Signature- Date- ?hone#: � � y��—;>fio 3 Ojfzcial use only. Do nvf Write in flus area,to be completed by city or town offrciai: • City or Town: Permit cense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electri 6.Other cal Inspector 5 PIumbing Inspector Contact Person: Phone#: DATE(MWDD/YYYY) AC40Ro® CERTIFICATE OF LIABILITY INSURANCEF 6/10/2016 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(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 endorsemen s. PRODUCER CONTACT Linda Bo danowicz NAME: 9 Insurance Solutions CorporationPHONE (603)382-4600 AX No:(603)382-2034 60 Westville Rd E-MAIL ADDRESS:lindab@isc-insuraace.com INSURERS AFFORDING COVERAGE NAIC# Plaistow NB 03865 INSURER A:Western World INSURED INSURERB:Nauti.lus Insurance Group Polar Bear Insulation Company Inc INSURER C: PO BOX 958 INSURER D: INSURER E: Andover MA 01810 INSURER F: COVERAGES CERTIFICATE NUMBER-CL1632326134 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS L POLICY NUMBER MIWD Y MWDD/YYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 GE A CLAIMS-MADE �OCCUR PREMSES Eaoccu encs $ 100,000 NPP8274967 3/24/2016 3/24/2017 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY❑JERT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Peraccident X UMBRELLA LIAR OCCUR EACH OCCURRENCE $ 1,000,000 B EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED I I RETENTION AN026107 3/24/2016 3/24/2017 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVEE.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDE[ F—] N/A (Mandatory In NN E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more apace Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood St, Ste 2032 ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE �A Keith Maglia/SJA �'�� ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 r9m4m) 6110/2016 Preview:Certificates of Insurance A�O CERTIFICATE OF LIABILITY INSURANCE F°"E"°` ' ' 0&1012016 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 WANED,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 NAME: PHONE FAX Automatic Data Processing insurance Agency,Inc. A C No.F. : (AC.Nek 1 Adp Boulevard ADDRESS: Roseland,NJ 07068 INSURER(S)AFFORDING COVERAGE MAIC a INSURER A: NorGUARDInsuranceCompany 31470 INSURED INSURER 8: POLAR BEAR INSULATION CO INC INSURER C: PO BOX 958 Andover,MA 01810 INSURER D: t} INSURER E: { INSURER F: COVERAGES CERTIFICATE NUMBER: 503587 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 REOUIREMENT.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. LTR TYPE OF W SURANCE01 yyyp POLICY NUMBER MM(DDI blYk POLICY XP LIMA COMMERCIAL GENERAL LIABILITY INSD EACH OCCURRENCE S CLAIMS-MADE D OCCUR PREMISES(Eaoccurmnce) S MED EXP(Anyone person) S PERSONAL 6 ADV INJURY S GEHL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S POLICY❑JE T ❑LOC PRODUCTS-COI'P'OP AEG OTFI R: 5 AUTOMOBILE LIABILITY CO MBI tlenl"S I LUJIT S ANY AUTO BODILY INJURY(Per person) 5 ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per atic'eh) S rl HIRED AUTOS UI` WNED c r S AUTOS (Per acadarU El 5 UMBRELLALIAB HOrCUR EACH OCCURRENCE s EXCESS UAB CLAIMS-MADE AGGREGATE Is DED I I RETENTIONS S WORKERS COMPENSATION X H ANDEMPLOYERS'LIABILIY T./N STATUTE ER A ANY PROPMETORlPARTI IER•'EXECUTIVE El.EACH ACCIDENT S 1,000.000 OFF(CEPMEMBER EXCLUDED? Y❑NIA N POWC772258 01/0112016 01/01/2017 (Mandatory in NH) EL DISEASE-EA EMPLOYEE S 1,000,000 II yyes.describe undo DESCRIPTION OF OPERATIONS be— E.L.DISEASE-POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS!VEMCLES(ACORD 101.Additional Remarks Schedule,may be attached K more spam is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE - THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood st I suite 2035 North Andover,MA 01845 AUTHORIZED REPRESENTATIVE A©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD https://adpia.adp.comlicertcf/#/run/preview/503587/900012975 111 /32 c97,e Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home g Improvement C ntractor Registration p Registration: 102726 l Type: DBA Expiration: 7/2/2018 Tr# 419291 POLAR BEAR INSULATION CO. Vincent LeBlanc P.O. BOX 958 ANDOVER, MA 01810 Q '' Update Address and return card.Mark reason for change. Address E] Renewal F1 Employment Lost Card SCA t G 204/-05/11 Vfre�oo�ro�re�nrue«l!�-o��/�a�ac�r�dn, Office of Consumer Affairs&Business Regulation License or registration valid for individual use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration:%.�"102726 Type: Office of Consumer Affairs and Business Regulation Expiration:-1-1 01.8 DBA 10 Park Plaza-Suite 5170 MRM /2l2 Boston,MA 02116 POLAR BEAR INSULATION CO- `r Vincent LeBlanc ; 51 SO.CANAL ST. LAWRENCE,MA 01841 / Undersecretary VV Not valid without signature t Massachusetts -'Department of Public Safety Board of Building Regulations and Standards Construction Supervisor Specialtc ` License: CSSL-106017 PETER A LEBLOC ." 2 EAST PINE STREET,3 �a s Plaistow IVH 03865 t y Expiration Commissioner 04/28/2018