HomeMy WebLinkAboutBuilding Permit #897 - 345 RALEIGH TAVERN LANE 6/24/2011TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: 7 Date Received
Date Issued:
IMPORTANT: Applicant must complete all items on this page
Print
MAP NO./ PARCEL: ZONING DISTRICT:
Historic District yes
Machine Shop Village yes!
100 year-old structure yes
TYPE OF IMPROVEMENT
PROPOSED
Reside -
Non- Residential
❑ New Building
ne family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Al ion
No. of units:
❑ Commercial
epair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septic ❑ Well
❑Floodplain ❑ Wetlands
❑ Watershed District
❑ Water/Sewer
Type or Print Clearly)
OWNER: Name:
Address:
CONTRACTOR Name: ml. f Phone:
Address: C Cr (4N,1I16�aZu l�
Supervisor's Construction License: Exp. Date:
Home Improvement License: ��j Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ FEE: $ (� S --
Check No.: Receipt No.:%_
NOTE: Persons contracting with unregistered contractors do not have access to e g ara fund
Signature of Agent/Owner, �,o �-,Afi'��. Signature of contracto 1
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
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
r
Reviewed
DATE REJECTED DATE APPROVED
❑ ❑
nature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comments
Conservation Decision: Comme
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes
Located at 124 Main Street
Fire Department signature/date
COMMENTS
no
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
NU I tb and UA I A - (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
o 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
❑ 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
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The Commonwealth of Massachusetts
" Department of Industrial Accidents
Office of Investigations
a I Congress Street, Suite 100
--- Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
.ter-•^:" r�.�
Name (Business/Organization/Individual):�
Address:
city/state/zip: tneq&
(!,-Y r 4Y-1 Phone #:
Are u an employer? Check the appropriate box:
1. I am a employer with
4. E]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 partfier-
listed on the attached sheet.
ship and have no employees
These sub -contractors have
working for me in any capacity.
employees and have workers'
[No workers' comp. insurance
comp. insurance.$
required.]
5. ❑ We are a corporation and its
3. ❑ I am a homeowner doing all work
officers have exercised their
myself. [No workers' comp.
right of exemption per MGL
insurance required.] t
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.l
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. E] Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11. E] Plu repairs or additions
12. oof repairs
13.0 Other
*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 state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their -workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site
information. % k i A f
Insurance Company Name:`
Policy # or Self -ins. Lica #: �'i�� Expiration Date:
Job Site Address. �`7Ll l aeJn �A pity/State/Zip: ! N
Attach a copy of the workers' compensation policy cfeclaration 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 maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ido hereby certify under thep7tins ofdpenalties ofperjury that the information provided above is true�Cnd correct
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 #:
A� CERTi.FICATE OF LIABILITY INSURANCE
DATE(MM100IYYYY)
02/21/2011
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 -
THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
BELOW.
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
and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
the terms
certificate holder in lieu of such endorsement(s).
PRODUCER - 1-404-945-3000
CONTACT _ --_ _--
NAME:
Marsh USA, Inc.
PHONE 1(L
(A1E-MAILhOmedepot.Cettrequest@marsi:l.COm
_
DAMAGE TO RENTED 1,000,000
S
Xoccurrence)~
COMMERCIAL GENERAL LIABILITY
-
ADDRESS:
TwAllianceCenter, 3560 Lenox Road, Suite 2400
NSURERS AFFORDING COVERAGE NAIC11Atlanta,GA30326
Lt.
PERSONAL & ADV INJURY 59.000,000 —
dfast Ins Co
26387
Fax (212) 948-0902INSURERA:__
PRODUCTS - COMP/OP AGG $ 9,000,000
---
INSURED
INSURER 8: Zurich American Ins Co_
16535 -
INSURERC: New Hampshire Ins Co
23841 -
The Home Depot, Inc.
INSURER o: Illinois Natl Ins Co �-
Rome Depot U.S.A., Inc.
23817 `
2455 Paces Ferry Road NW
Buildin^. C-20
19445
INSURER E: NATIONAL UNION FIRE INS CO OF PITTS --�
F Illinois Union Ins Co
1•�rt„f-1I'1l1 \1111111 ['lCA.
Atlanta, GA 30339INSt1RER
--
- ___ _ ___
21960
COVERAGESTHIS OF INSURANCE LISTED BELOW HAVE BEEN
ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
IS TO CERTIFY THAT THE POLICIES
TERMOR CONDITION OF ANY
CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
INDICATED.' NOI.-JITHSTANDING ANY.REOUIREMENT,
THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN;
SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED
BY PAID CLAIMS.-
EXCLUSIONS AND CONDITIONS OF ��
A0OL UOR
TYPE OF INSURANCE Ip, POLICY NUMBER
POLICY EFF POLICY EXP LIMITS
MMIDOIYYYY MMIDOIYYYY
L�INSR
GL04887714-01
03/01/1 03/01/12 EACH OCCURRENCE S 9,000,000
A GENERALLIAGIIITY
_
DAMAGE TO RENTED 1,000,000
S
Xoccurrence)~
COMMERCIAL GENERAL LIABILITY
PREMISES Ea -
U
MED EXP (Any one person) S EXCLUDED --
CLAIMS -MAGE. OCCUR
X LIMITS OF POLICY XS
PERSONAL & ADV INJURY 59.000,000 —
X OF SIR: $1M PER OCC
GENE RAL AGGREGATE S 9,000,000_ -_
PRODUCTS - COMP/OP AGG $ 9,000,000
GEN'LAGGREGATE LIMIT APPLIES PER:
�_—
X POLICY JECT PRO- LOCS.
BAP 2938863-08
.
03 O1 1 03/_01112 COMBidentINED INGLE LIMIT .1,000,000
B AUTOMOBILELtABILITY
a acddenl _ -
BODILY INJURY (Per person) S
X ANY AUTO,
ALL OWNED SCHEDULED
BODILY INJURY (Per accidenl) S
--M- -
AUTOS NON OWNED
PROPERTY DAMAGE S
Per accident
HIRED AUTOS AUTOS
S
X SIR AUTO P Y
UMBRELLA LIAR
OCCUR
EACH OCCURRENCE S __-_ •_�• __ —
EXCESSLIAB
CLAIMS -MADE
AGGREGATE S _— w-,_,•
S
OED RETENTIONS
WORKERS COMPENSATION
WC061967352 (ADS)
03/01/1
03/01/12
WC STATU• 0TH -
X TORY LIMITS R
C
AND EMPLOYERS' LIABILITY03
Y❑
WC061967359 (FL)
03/01/1
/ 01 12
/
E.L. EACH ACCIDENT $ 1,000,000
D
ANY PROPRIETORIPARTNERIEXECUTIVE
N fA.
OFFICERMIEMBER EXCLUDED? N
WC061967353 (CA)
03/01/1
03/01/12
E.L. DISEASE -EAEMPLOYEE S 1,000,000
E
(Mandatory in NH)
If yes, descnbe under
E.L. DISEASE - POLICY LIMIT S 1,00” 000
C
DESCRIPTION OF OPERATIONS below
Workers Compensation
WC061967355(KY;MO,NY,WI,
p3 /O1/1
03/01/12
F
TX Employers XS Indemnity
TNSC46244151 (TX)
03/01/1
03/01/12
Occurrence/SIR 30M/1M
E
Workers Compensation
WC1192376 (QSI)
03/01/1
03/01/12
SIR 1M
DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (Attach ACORD 101, AdditionaLRemarks Schedule,
if more space is required)
RE: EVIDENCE OF COVERAGE
CERTIFICATE HOLDER
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE'
THE HOME DEPOT, INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
HOME DEPOT U.S.A., INC. ACCORDANCE WITH THE POLICY PROVISIONS.
2455 PACES FERRY ROAD NW - AUTHORIZED REPRESENTATIVE
BUILDING C-20 / USA
�-
ATLANTA, GA 30339
., The ACORD name and loco are registered marks of ACORD
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authorize The Home Depot to pull permits using my
CS License J2 ! and my
HIC Registration #
Any questions please call me at V6
Installer Signature
Company Name ti` `�'�' �'� PTA V t�r�'/�/
M1
,y� �,//Ly�/J09J1/I7269ZCU6CLGLIL O�✓vGC��"`�'�"`6 ,
�\ Office of Consumer Affairs & Business Regulation
OME IMPROVEMENT CONTRACTOR
.;..... '
Registration;i'-'k�26893 .. Type
ExpiraGon 813(20.12_. Supplement: '
The HomeDepoti Aik(omeSennces
RICHARD FALLONN_•__
2690 CUMBERLANl7 PAE2M S
A'(� RlcrA, GA 30339'` `4. `%
Undersecretary .
I
Location
No. D= Date
40RTOI
TOWN OF NORTH ANDOVER
Certificate of Occupancy
$
Building/Frame Permit Fee
$
Foundation Permit Fee
$
Other Permit Fee
$
TOTAL
$
Check #
2 4 6 18 Building Inspector