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Home My WebLink AboutBuilding Permit #640 - 37 CHARLOTTE WAY 5/21/2009Permit NO: Date Issued: BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received IMPORTANT: Applicant must complete all items on this pal LOCATION PROPERTY OWNER-----' f�, Print MAP NO: 5PARCEL: ZONING DISTRICT:K-C-Historic District Machine Shop yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building _.. Addition Alteration famil Two rare famil 7W7of units: Industrial Commercial Repair, replacement Demolition Assessory Bldg Other Others: Septic Well Floodplain Wetlands Watershed District Water/Sewer eVC:- DESCRIPTION OF WORK TO BE PREFORMED: Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: r,�f CONTRACTOR Name: t.<-- l c> ._.. Phone: "�78 a ' a -"t Address: Supervisor's Construction License: L1 Exp. Date: '710 Home Improvement License: Exo. Date: ARCHITECT/ENGINEER' iivq � 'EC4" Q�> Phone: c�75 30 1 71C�0 Address: -3o" t`&T '5T moi : Reg. No. /t �O FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $115.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: /0 tf/r Receipt No.:0-,b� 05)(62 NOTE: Persons contracting withegistered contractors do not have access to the guaranty fund Location ��+33 G+(,A(to l° t1 f• l.'`A4`% No. Gv �0 Date �OR,M TOWN OF NORTH ANDOVER O p VOW ` Certificate of Occupancy $ _= s►s CHU cNu Building/Frame Permit Fee $ Foundation Permit Fee $ I� Other Permit Fee $ TOTAL $ Check it 12056 Building Inspector 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 APP OVED PLANNING & DEVELOPMENT 6b-1 G"� COMMENTS CONSERVATION Reviewed on c-, COMMENTS -1HEALTH COMMENTS re M Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments �-zr-o9 Water & Sewer Connection/Si nature & Date Driveway Permit DPW Town Engineer: Signature: Locatea 384 Usgooa Street FIRE DEPARTMENT - Temp Dumpster on site . yes, no Located at 124 Main Street Fire Department signatureldate� COMMENTS Dimension Number of Stories: Z 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 W I t5 and UA I A — (for department use ❑ Notified for pickup, -,Date Doc.Building Permit Revised 2008 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 ❑ Floor/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 o 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: INSPECTIONAL SERVICES DEPARTMENTMITORM07 Revised 2.2008 l k, 1 1t}� The Commonwealth of Aftasachusetts Department of Industrial Accidents Office of Investigations 600 Wi7shington Street Boston, MA 02111 t ' www_mass govldia . Workers' Compensation insurance Affidavit- Builders/Contractors/Eiectricians/Plumbers Applicant Information Please Print LeQrhiv Naaie(susiness/orgenizadon/individuai):- Address:�� !��C City/State/Zip:_.1 .�_ Phone #:.7 Are you an employer? Check the appropriate box: i. ❑ I am a employer with employees 4. I am a general contractor and I Type of prefect (regnire�: 6. .New construction (full and/or part-time).* 2. ❑ I am.a:sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. i 7. Q Remodeling ship and have no employees These stt&contractors have 8. (] Demolition working for me in any capacity, [No workers' comp, insurance workers' comp. insurance. 5. ❑ We are a corporation and tis 9' ❑ Building addition required.] 3. ❑ I am a homeowner doing officers have exercised their 10. El Electrical repairs or additions all work myself [No -workers' comp, insurance right of exemption per MGL c. 152, § 1(4),'and we have no 11.[] Plumbing repairs or additions 12. Roof ❑ repairs required.)t .employees. [No workers' I3.0.0ther comp, insurance required.] I •Any applicm tbst checks boz #1 roust also fill out the section below showing their workets' Compensation policy in ;Any who submit this affidavit indicating they are doing all work and then hire outside conu=cn must submit a new affidavit indicating such. ZContTactors that check this box mustzrtaehed an additiow) sheer showirrg• the name of the sub-contractan and their workers' ce ,policy infomuuion ! Man employer that is prourdimg.workers I cornpewadon insurance for rrtJ' employees Below is the o ' information p k and job site . Insurance Company Name: Policy # or Self -ins. Lic. #:1'�7��j I,�i f�c l „ Expiration Date: Job Site Address; >_ �] �- E City/stat,-Zip:- L) . yQ �IJ��^� i► , Attach a copy a the workers' Failure to secure compensation policy declaration page (showing the policy number and expiration dat4. 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 5250.00 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 cert! ujrder the pains and penalties olperlwy that the information provided o is true and correct Si tie: + ✓J Date. "bone 6t q F.-IT-4:11,71, ly. Do not write in this area, to be comtple ed by city or town ofciaL Town: Permit/License # ority (circle one): I. Board of Health 2. Building Department 3. City/Towu Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other N Contact Person: Phone #• 44 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, 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 receiver or trustee 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 occupant of the dwelling house of another who employs persons to do maintenance, construction or repair wdrk on such dwelling house or on the grounds or building appurtenant thereto shall not because of sucb 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 buildings in the commonwealth for any applicant who has not produced acceptable evidence.of compliance with the insuranee'coverage required." Additionally, MGL chapter 152, §25C(7) 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-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members orpartners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage., Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for.the permit or license is being requested, notthe Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please -call the Department at the nurnber listed below. Self-insured companies should enter their self-insurance"liceme number on the'appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the 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 permit/license 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 been officially stamped or marked by the city or town may be provided to the applicant as proof that valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. When 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 permit to bum leaves etc.) said person is NOT,required to complete this affidavit. The Office of Investipations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Indrastdal Accidents Office of imvestibations 600 Washington Street Boston, MA 02111 TeL # 617-7274900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax # 617-727-7744 www.mass.gov/dia CORD CERTIFICATE OF LIABILITY INSURANCE OP ID BDATE(MMIDD/YYYY) S1 ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR WINDO-4 03/18/09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION TYPE OF INSURANCE ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE McLaughlin Insurance Agency HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 828 Lynn Fells Parkway ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. N. Andover MA 01845 Melrose MA 02176 Phone:781-665-2775 Fax:781-665-0295 INSURERS AFFORDING COVERAGE NAIC# INSURED _ INSURER A: United Specialty Insurance Co. INSURER B: Ohio Casualty Group M. Justin Belliveau rConstruction, Inc. Mr. Justin INSURERC: American intemat'l Companies INSURER O: 13 Elm Street Manchester MA 01944 INSURER E: 1A "A PREMItFS(Eaoccur1,nce) $50,000 COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSR TYPE OF INSURANCE POLICY NUMBER LI Y E TIVE DATE MMIDD POLICY EXPIRAN DATE MMIDDIYY LIMITS IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR N. Andover MA 01845 GENERAL LIABILITY ACORD 25 (2001!08) EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY CR0946109 01/01/09 01/01/10 1A "A PREMItFS(Eaoccur1,nce) $50,000 CLAIMS MADE FX -1 OCCUR MED EXP (Any one person) $ EXCLUDED PERSONAL &ADV INJURY $1,000,000 GENERAL AGGREGATE $ 2, 000, 000 GEN'L AGGREGATE LIMIT APPLIES PER* PRODUCTS - COMP/OPAGG $ 2,000,000 POLICY X PROECT LOC J AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 ANY AUTO (Ea accident) BODILY INJURY $ ALL OWNED AUTOS B SCHEDULED AUTOS BA00953558225 11/01/08 11/01/09 (Per person) BODILY INJURY $ X HIRED AUTOS X NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY -EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO AUTO ONLY: AGG $ EXCESS/UMBRELLALIABILITY - EACH OCCURRENCE $ 5000000 A X OCCUR 7 CLAIMSMADE CXA4GS709 01/01/09 01/01/10 AGGREGATE $ 5000000 $ DEDUCTIBLE $ X RETENTION $ 10000 WORKERS COMPENSATION AND X TORY LIMITS I I ER C EMPLOYERS' LIABILITY WC6967012 03/20/08 03/20/09 E.L. EACH ACCIDENT $500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. DISEASE - EA EMPLOYEE $ 500, 000 C OFFICER/MEMBEREXCLUDED? WC009399316 03/20/09 03/20/10 If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE -POLICY LIMIT $500,000 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS RE: Edgewood Retirement Community Renovation and Expansion, North Andover, MA Edgewood Retirement Community, Inc. and Trident Building,LLC; Bank of America, N.A. their subsidiaries, affiliates and parent companies; and their respective officers, directors, trustees, managers, members,building committee members and employees are additional insureds on all policies CERTIFICATE HOLDER CANCELLATION EDGEW- 2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN Edgewood Retirement Community NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Inc 575 Osgood Street IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR N. Andover MA 01845 REPRESENTATIVES. 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