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HomeMy WebLinkAboutBuilding Permit #700-12 - 336 CANDLESTICK ROAD 4/2/2012TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: I Do ® �� Date Received 4 r).a{'A IRRIIP.fi' � l/ I I ' . IWORTANT: Applicant must complete all items on this page I �,J� Print PROPERTY OWNER3(-1a MaAden _ __ _ __Unit# _ Print MAP NO: /0)� P.A.RCEL:A 5-0 ZONING DISTRICT: Historic District yes Machine Shop Village yes n�Y 100 year-old structure yes n�o TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ Addition , Alteration 09ne family ❑ Two or more family No. of units: ❑ Industrial ❑ Commercial ❑ Repair, replacement ❑ Demolition ❑ Assessory Bldg ❑ Other ❑ Others: pers'heDd_�Brstnc gglwuomclhli;�fl ®Velanls�� .;t�- OF WORK TO BE PERFORMED: �► CONTRACTOR Name: ���� l(%<<C«9/ Phone: 602'-80/-93a� Address: YY 6?n� —K7)> M, 961 N 4 03 t, SS Supervisor's Construction License: /6) L1271, Exp. Date:. G?f� Home Improvement License:/ 7L,5- 90 Exp. Date: ��G� ARCHITECT/ENGINEER Phone: Address: Reg. No FEE SCHEDULE: BULDING PERMIT: $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cost: $ X30 FEE: $ Check No.: 1 Receipt No.: !� NOTE: Persons contracting with unregistered contractors do not have -IW s ranty fund 3/3�,/ r TOWN OF NORTH ANDOVER. Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee TOTAL $ Check# 25150Building Inspector r Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑' Tanning/Massage/Body.Art ❑ SwunmingPools ❑ 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 PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS DATE REJECTED DATE APPROVED El Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Wafer & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dempster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS 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 Doc:.Building Permit Revised 2011 Tune/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 W Building Permit Application E( Workers Comp Affidavit d Photo Copy of H.I.C. And/Or C.S.L. Licenses V Copy of Contract V 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 o Flo or/Crossecti on/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 IMOTE: 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 a 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 Xn all cases if a variance or special permit was required the Town CIerks 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 A 0 z CL co O c sCD :W C L �� O H z :g C ; i-•7 O vV i� O.0 O A m C A N EQ CL � O y EE .� mo urn CD c E m O N� O � H C _m ZC� H O0 R W . m o U y O m v) CD w cmo c �aC� •� O m C-2 y O. C Z i lV c ' cao c N :d COD LU W CO .O- C= .r. •N Ali d t ct;O C Z 1 y+ LU E V V2 a -Collcc C2 Z COD O� J I co O co ■ L � V Z CD 0. Cl CO) � C w+W � cm I Q CD _ L4 c ■r= mCD Cl co m CLI.—_ CD CD o m ca o Q CL QM Q C o"FLC3 CD � c coo C Z ts co V V2 C C _c CL 25 LU W W 19 W N O O " uCO o w v cn w A as a O w O w c U G w W a O w' C w w W O cw c3i C w" O t7 O w G is. w cQ z cn co z CL co O c sCD :W C L �� O H z :g C ; i-•7 O vV i� O.0 O A m C A N EQ CL � O y EE .� mo urn CD c E m O N� O � H C _m ZC� H O0 R W . m o U y O m v) CD w cmo c �aC� •� O m C-2 y O. C Z i lV c ' cao c N :d COD LU W CO .O- C= .r. •N Ali d t ct;O C Z 1 y+ LU E V V2 a -Collcc C2 Z COD O� J I co O co ■ L � V Z CD 0. Cl CO) � C w+W � cm I Q CD _ L4 c ■r= mCD Cl co m CLI.—_ CD CD o m ca o Q CL QM Q C o"FLC3 CD � c coo C Z ts co V V2 C C _c CL 25 LU W W 19 W N ACORU®DATE CERTIFICATE OF LIABILITY INSURANCE (MMIDD/YYYY) 04/03/2012 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 endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT RICHARD A. FRENCH NAME: PHONE (603) 882-9532 FAC. C No: (603) 882-6137 FRENCH INSURANCE AGENCY, INC. EDDIe .RICKAFRENCH@COMCAST.NET 12 DERRY STREET INSURERS AFFORDING COVERAGE NAIC # CBP1044212 INSURERA:PEERLESS INSURANCE COMPANY HUDSON NH 03051- INSURED INSURER B INSURER C : MATTHEW BRACANI INSURER D: PO BOX 76 INSURER E: / / INSURER F: MILFORD NH 03055- COVERAGES CERTIFICATE NUMBER: 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 LTR TYPE OF INSURANCE ADDLSUBR POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A GENERAL LIABILITY CBP1044212 03/27/2012 3/27/2013 EACH OCCURRENCE $ 500000 X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑X OCCUR / / / / DAMAGE 50000 PREMISES Ea occurrence $ MED EXP (Any one person) $ 5000 PERSONAL & ADV INJURY $ 500000 GENERAL AGGREGATE $ 1000000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 1000000 / / / / X POLICY PRO JECT LOC / / / / $ AUTOMOBILE LIABILITY / / / / accident SINGLE LIMIT (CESM. BODILY INJURY (Per person) $ ANY AUTO / / / / ! ALL OWNEDSCHEDULED AUTOS AUTOS / / / / BODILY INJURY (Per accident) $ HIRED AUTOS NON -OWNED AUTOS / / / / PROPERTY DAMAGE $ Per accident UMBRELLA LIAB HOCCUR / / / / EACH OCCURRENCE $ EXCESS LAB CLAIMS -MADE / / / / AGGREGATE $ DED RETENTION $ $ / / / / WORKERS COMPENSATION / / / / WC STATU- I OTH- ER AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) N / A / / / / E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ If yes, describe under DESCRIPTION OF OPERATIONS below / / / / E.L. DISEASE - POLICY LIMIT 1 $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CARPENTRY CERTIFICATE HOLDER CANCELLATION ACORD 25 (2010/05) INS025 (201005).01 ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are reqistered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. BUILDING DEPT. TOWN OF NORTH ANDOVER, MA AUTHORIZED RESENTATIVE ACORD 25 (2010/05) INS025 (201005).01 ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are reqistered marks of ACORD Information and Instructi®ns 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 ofthe foregoing engaged invioial enterprise, andincludingthelegalrepresentatives of a deceasedemployer, 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 work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an empIoyer." MGL chapter 152, §25C(6) also states that "everystate or local i1censlug agency shall'waithhold the issuance'or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for nny applicant who has not produced acceptable evidence of compliance with the insurance 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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapterhave beenpresented to the contracting authority." Applicants Please fill out the workeis', compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), addresses) and phone number(s) along with their certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, 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 maybe submitted to the Department of Industrial Accidents for c e city tion.of insurance coverage. Also b e 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, not the Department of 1•ndustrial 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 number listedb elow. Self insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure thatthe affidavit is complete andprinted legibly. The Department has provided a space at the bottom PIease be sure to f 11 in the p of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. ezmit/license number which Will be used Rs a reference number. that must submit multiple pemvthiceuse applications in any given year; In addition, an applicant need only submit one affidavit indicating current Policy information (ifnecessary) and under "Job Site Address" the applicant should write "all locations in town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be (city or provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each Year. Where a home owner or citizen is obtaining a license or permit notrelated to any business or commercial v (Le. a dog license or permit to burn leaves etc.) said person is No required to complete enture this affidavit. The Office of 1'nvestigations would like to thank you iu 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: !he COIL Aorcwealth 01 lgassach setts Depattinent Q£Zudustrial Accidents offloe of Invotigattons 600 Washington Street Bastau M , 02111 TeI. # 617=-727-4900 ext 406 or 1,$77-I1�Ik4SSA 1 The Commonwealth ofMassachusetts bepartmentoflndlustr al.Acddents Office oflnvestigations 600 Washington Street Boston, MA 02111 yY www.m0s_,v-gov/d'ia Workers' Compensation Xnsur.InceAffidavit: Builders/Contlractors/lectricialns/�Plumbers plicant Information 'et e ,. Name (Business/organization/Individual): Lr Ak Address: 8 • City/state/zip/Gi/ �� 9�� A.re you an employer? Check the appropriate box: 1• ❑ I am a employer with 4. ❑ I am a general contractor and I Type of project (required): mployees (full and/or part time).* 2• have hired the sub -contractors 6. ❑ New construction a sole proprietor or partner- ship and have no employees listed on the attached she9et. � 7• These sub -contractors have N Remodeling working for me in any capacity, [No workers' comp. insurance workers' comp, insurance. 5. ❑ We are a corporation and its $• 0 Demolition 9. ❑ Building addition required.] 3. ❑ 1 am a homeowner doing all work officers have exercised their right of exemption per MGL 10 0 Electrical repairs or additions 11.[] Plumbing repairs cr additions myself. [No workers' comp. ' insurance required.] i c. 152, §1(4), and wehaveno employees. [No workers' 12.[]Roofrepairs comp insurancere d 13.[] Other , quue .] Any applicant that checks box#1 must also fill out the section below showingtheir workers' compensation policy information. T Homeowners who submit this affidavit indioatingthey are doing all work and then hire outside contractors must submit anew affidavit indicating such. 'tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policinformation. Ir am an employer that isproviding workers' compensation insurance for my eynpZoyees yBelow is Ae policy and job site ir2formation. Insurance Company Name: Policy # or Self -ins. Lic. # J'ob Site Address: Expiration Date: City/State/Zip: 4ttach a copy of the workers' compensation policy declaration page (showing the policy Failure to secure coverage as required under Section 25A ofMGL c.152 can lead to date). number and expiration ation 'no up to $1,500.00 and/or one-year imprisonment, as well as civil eltithe imposition of criminal es of a es in the form of a STOP WORK ORDER and a fine If up to $250.00 a day against the violator. Be advisepna d that a copy ofthis statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. do Hereby Certify uncle theins andpenallies ofperjury thatthe infotmationppovidedabove is true andcorrect. 0 -161$c5 / — O ficial use 04'- -00 not write in tills area, to be completed by city or town official. City or Town: PerniffMcense # Css:umgAuthority (circle one): , (. )Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector �. 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