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HomeMy WebLinkAboutBuilding Permit #291-11 - 350 SUMMER STREET 10/12/2010 I BUILDING PERMIT OF No oT6 A't' TOWN OF NORTH ANDOVER' APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received ,,,E° "° c5 �SSACHUS�� Date Issued: IMPORTANT: Applicant must complete all items on this page ',LOCATION ��� . �'cJ.�►-i�r� �"�. " Print j PROPERTY OWNER , ,... .. .. b .;. , �:.. ZONING DISTRICT: '. Histone Dist"nc es. o MAP 210� P ARCEL. t Machine Shop.Village yes o TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition _ ❑Two or more family ❑ Industrial EI Alteration No. of units: - ❑ Commercial WRepair, replacement ❑Assessory Bldg ❑ Others: - t ❑ Demolition El Other 0 Septic O Well El Floodplain b Wetlar ds ff Watershed District: ❑WaterLSevver. DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: f1)CJJh dtb M UCkuf-, Phone: Address: CONTRACTOR Name: - Phone: iI Address' _ f ,t - I S Construction License: te: ''. .u eisor s p Home Improvement License: Exp. Date:: ARCHITECT/ENGINEER Phone: I 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: $ ,�) FEE: $ �S Check No.: Receipt No.: NOTE: Persons contr eting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owne �//"/ ce�Signature of contractor i 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 ❑ I THE FOLLOWING SECTIONS FOR OFFICE USE ONLY' INTERDEPARTMENTAL SIGN OFF - U FORM _ _ DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ D COMMENTS CONSERVATION Reviewed on - Signature COMMENTS HEALTH Reviewed on Signature COMMENTS { Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments `- Water& Sewer Connection/Signature ®ate Driveway Permit - DPW Town Engineer: Signature: Located. 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street ,Fire Department signature/elate COMMENTS- i Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL ill • ovement of dieter location, avast or service drop requires approval of . Electrical Inspector Yes No DANGER ZONE LITERATURE:, Yes N® MGL Chapter 166 Section 21A—F and G min.$10041000 fine 4 NOTES and DATA— For department use i I it I ® Notified for pickup - Date Doc.Building Permit Revised 2010/October 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 1 Addition Or Decks ❑ Building Permit Application o Certified Surveyed Plot Plan ❑ WorkersComp Affidavit 1 ❑ 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 N 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 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 ❑ Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit i Ian 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:Building Permit Revised 2008 - Location No. Date l v �oRTM TOWN OF NORTH ANDOVER A }�o Certificate of Occupancy $ �ssCHu;Et�' Building/Frame Permit Fee $ '�— Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # Z 2354 Building Inspector The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 IF www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians[Plumberg Applicant Information Please Print Legibly Name(Business/Organization/Individual): ACadA O A&)C Address: 310 Sy,Mw%f-A_ S T City/State/Zip: OU AX)JK _ Phone#: 1 /8 CON.0 -566 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(fall and/or part-time).* have hired the sub-contractors 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 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers' comp.insurance S. ❑ We are a corporation and its ' officers have exercised their 10.❑Electrical repairs or additions required.] 3. I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers'comp. c.152,§1(4),and we have no 12.❑Roof repairs insurance required.]i employees.[No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: 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 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. I do hereby certify 4pder the painnss�jandpenaldes ofperjury that the information provided above is true and correct. Signature• Ax4i,2� Date: Phone#• Cf 7� �O17�a S�p(O 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 CIerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: F NORTH TOWN OF NORTH ANDOVER 2oOFFICE OF o ">. a °� BUILDING DEPARTMENT * 1600 Osgood Street Building 20, Suite 2-36 North Andover,Massachusetts 01845 S"1CHU5� Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Pleasepnnt DATE: 16-f 1 1 L) JOB LOCATION: Number Street Address Map/Lot HOMEOWNER—O&OA60-D hadct q7� �o�� 77 (rI� --c��j� O -Same Home Phone Work Phone PRESENT MAILING ADDRESS _ d �I/v1:► ��,�5�. f'Yt S' City Town Zip Code The current exemption for"homeowners"was extended to include owner-occupied dwellings to two units or less and to allow such homeowners to engage an individual for hire who does.not possess a license,provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned"homeowner"assumes responsibility for compliances with the State Building Code and other Applicable codes,by-laws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. , HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 ORTM Town of Andover v#..err. �i. y:y�•I'` No. 2 9/ -,2o /l __ KIt. dover, Mass.,LA 1 Z • O C, CMICME WICK V 7�AORA TED S U ` BOARD OF HEALTH Food/Kitchen Septic System PEI�iMIT T D BUILDING INSPECTOR THIS CERTIFIES THAT............ ..fir... i .................. ........................................................................................... ..... • Foundation ' a ' has permission to erect ...................................... buildings on 1�......3jM..I.��.......�..... .................... Rough ,, tt to be occupied as...... `r.. l. �rr........1' 1.y �:....................................................................................... Chimney ' e provided that the per on accepting this permit shall in every respect conform to the terms of the application on file in Final 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. PLUMBING INSPECTOR VIOLATION of-the Zoning or Building RegulationsVoids this Permit. Rough Final PERMIT EXPIRES IN--f.1,MONTHS ELECTRICAL INSPECTOR UNLESS CONS TS Rough ......................................................................................................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. SEE REVERSE SIDE Smoke Det. I iVlassachusetts- Department of Public Slit(tt Board of Building;Regulations and Standards Construction Supervisor License I License: cs 42023 Rastricted.to: 00 RICHARD A MUCKLE i c I 433 MARKET ST LAWRENCE; MA 01843 Expiration: Crnmi�siancr 2/19/2012 Tr#: 16148 J r t ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDPrM) 09/24/2010 PRODUCER (508)651-7700 FAX (508)655-8853 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Eastern Insurance Group LLC - Commercial ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 233 West Central Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. ick, MA 01760 INSURERS AFFORDING COVERAGE NAIC# INSURED M & A Architectural Preservation Inc. INSURERA: Peerless Ins Co 24198 433 Market Street INSURERB: AmGuard Lawrence, MA 01843 INSURERc: Hartford Fire Insurance Co. 19682 INSURER D: INSURER E: 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. POLICY EFFIE POLICY SR kDD'L EXPIRATION 1N R NSR TYPE OF INSURANCE POLICY NUMBER DATE MMIDDIYYYY DATE MM/DDIYYYY LIMITS GENERAL LIABILITY CCP8344422 11/01/2009 11/01/2010 EACH OCCURRENCE $ 1,000,000 DAMAUL R.)HEN 11715— X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 50,000 CLAIMS MADE M OCCUR MED EXP(Any one person) $ 5,000 A PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEML AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY X PRO LOC JECT AUTOMOBILE LIABILITY BA8344971 11/01/2009 11/01/2010 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 1,000,000 X ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) A X HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT '$ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY CU8346371 11/01/2009 11/01/2010 EACH OCCURRENCE $ 5,000,000 X OCCUR 0 CLAIMS MADE AGGREGATE $ 5,000,000 A $ DEDUCTIBLE $ X RETENTION $ 10,000 $ WORKERS COMPENSATION MAVICO22196 11/01/2009 11/01/2010 X I TORY LIMITS I I ER AND EMPLOYERS'LIABILITYYIN E.L.EACH ACCIDENT $ 1,ANY 000,000 B OFFICER/MEMBER EXCLUDED?ECUTIVEH , (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 THERATION FLOATER/ 08MSUF4752 11/01/2009 11/01/2010 $250,000. PER LOCATION INSTALLC STORED MATERIAL DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS E: ALL OPERATIONS PERFORMED UNDER ENABLING WORK - 32 QUINCY STREET PROJECT - CAMBRIDGE, MA SKANSKA USA BUILDING INC. PROJECT #138020-000-011 HE FOLLOWING ARE INCLUDED AS ADDITIONAL INSURED (CG2010 10/01 & CG2037 10/01) FOR ALL COVERAGES EXCEPT ORKERS' COMPENSATION: THE PRESIDENT & FELLOWS OF HARVARD COLLEGE ACTING BY AND THROUGH THE HARVARD APITAL PLANNING AND PROJECT MANAGEMENT HCPPM SKANSKA USA BUILDING INC. SKANSKA USA INC. AND THEIR CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR SKANSKA USA BUILDING INC. REPRESENTATIVES. 253 SUMMER STREET AUTHORIZED REPRESENTATIVE BO TON, MA 02210 Rosemary Fulham/PMA ACORD 25(2009101) ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD