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HomeMy WebLinkAboutBuilding Permit #704-15 - 350 WINTHROP AVENUE 3/6/2015BUILDING PERMIT' TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION,— Permit No#: Date ReceiVed Date Issued: IMPORTANT: Applicant must complete all'item& on this. -page I.-Cip Y. LOCATION dV PROPERTY OWNER Print it Print 0. Year Structure , yes 0 MAP PARCEL: ZONING DISTRICT: Ristoric)bi District yes no, Machine Shop Village yes Vno TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential El New Building [] One family D Addition El Two or more family D Industrial El Alteration No. of units: El Commercial D Repair, replacement D Assessory Bldg El Others: 0 Demolition El Other D Septic D W_11 e 0:17lood0lain [TWOtlands Q Water -she d District El Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: _NZ Identification - Please Type or Print Clearly OWNER: Name: 6- CS,7'11 tyrlLr)d C27111( Phone L_f t3)6e)q-7;?66 Address: 3 S_b LJ 'I73 A-V)-yC P )4- VP_ A&V� /611" 08 -4:7 . 7-, LZ 4 Contractor Name: n '71 !3 - _7 ?hone S Address: '6�Cx to, rk? Ahue r 4_ Supervisor's Construction Licen§e:, _._Exp. Home Improvement License: Date. ARCHITECT/ENGINEER Phone-:` Address: No FEE SCHEDULE BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED-COSTBASED ON $125.00 PER S.F=— Total Project Cost: $ EEE ►fib Check No.: Receipt N6.,:; - NOTE: Persons contracting with unregistered contractors do. not have access to the guarantyjra4nd rl Plans Submitted ❑ #\ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYpF.nF SEWERAGE DISPOSAL Pvblic 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 Reviewed On Signature_ 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 & Date Driveway Permit DPW Town Engineer: Signature: -n%L- vcr r%1%I lrqLrr I = rPr,-IN vuiII , OUMNM F Located at 124Main Street Fire Departmentsignature/date., 4 COMMENTS Located 384 Osgood Street - no . Dimension Number of Stories: Total square feet of floor area, based on:Exerior 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 AInTF'C and nATA — Wer dPnartment usel Co Stqo o eLe - ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 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 NOTE: ❑ 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 Secfion/ElevatronTlar�= Of Proposed Work -"With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (SingIc'a' nd,-fv%G 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: Building Permit Revised 2014 Location A/L No. . u Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL Check �",�v f� 2 G 5 4 Builling Inspector � Z CD O CL r- Q �. '> (O -a O 0v CD Q C Cr CD O CL L �• CD CDD O �Wl �G 0 0 y CD CD CD U) O O CCD O CD c o AA) = U) MU� ="• < (D cD,CL o ( n O ,may a 0 � � z p• �' �� N =i OO N r0+ gyp' N T rt o�0 �Q m m CD N W cD m N 0 x � CL 23c cD � N Q ..r • o or•� Cc) :A W ••" M CD S O < U3 �,• ;� CD O C to —� -h co co .� = cCD °, Sr o n CD Cn Q. < o. o co O < 0 — CA Q y 5' o U) CDCD O w C: CD r0 W: N CD O (A V) C T ppT7 r- rn VI .o T x rn;o (7 ;o T Cl) �_ T Y C N0 Orn S y O (D N C 03 C X rn � C � C C -6 O Z O � O � j- z � N 3 n Cl) S Cl) V d n � r z O z c o AA) = U) MU� ="• < (D cD,CL o ( n O ,may a 0 � � z p• �' �� N =i OO N r0+ gyp' N T rt o�0 �Q m m CD N W cD m N 0 x � CL 23c cD � N Q ..r • o or•� Cc) :A W ••" M CD S O < U3 �,• ;� CD O C to —� -h co co .� = cCD °, Sr o n CD Cn Q. < o. o co O < 0 — CA Q y 5' o U) CDCD O w C: CD r0 W: N CD O (A V) co T ppT7 VI .o T x T (7 ;o T Ln T Y C N0 0 S O (D N C 03 C d C 23 C C -6 O j- N 3 n S d n O O � S 70 %i ° n z V r Gl H O -ni D m m O O O _ * 64 Lo 0 C 0 c OP ID: DC CERTIFICATE OF LIABILITY INSURANCE D CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, 0YYY1O 03/105/200512015 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 Platinum Insurance Agency 418 Massachusetts Ave Arlington, MA 02474 Niru hatia Yadav CONTACT NAME: PHONE FAX W. No. Ertl: ac No ADDRESS: PRODUCER CUSTOMER ID a, BOLLY-2 INSURE S AFFORDING COVERAGE NAIC p INSURER A: Safety Indemnity Insurance Co. MalINSURED BolIyWOOd Grill Inc. 350 Ave t Gill 350 WinthropW INSURERS: Peerless InSurnace INSURER C: North Andover, MA 01845 INSURER D : INSURER E: INSURER F: 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 ADDL SUB POLICY NUMBER MNUDDY EFF MNWD EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 B X COMMERCIAL GENERAL LIABILITY BKS55786233 10/01/2014 10101/2015 LNILU PREMISES Ea occurrence $ 100,00 CLAIMS -MADE ElOCCUR MED EXP (Any one person) $ 5,00 PERSONAL & ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ 1,000,00 POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT A X ANY AUTO BBDM21 08/20/2014 08/20/2015 (Ea accident) $ 1,000,00 BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ A X SCHEDULED AUTOS PROPERTY DAMAGE (PER ACCIDENT) $ A X HIREDAUTOS A X NON -OWNED AUTOS $ $ UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WCSTATU- OTH- AND EMPLOYERS, LIABILITY Y / N TORY LIMITS ER E. L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? ❑ N / A Mandatory in under I (f yes, describe un E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS below B Liquor Liability BSK55786233 10/01/2014 10101/2015 Liquor 1,000,00 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Liquor liability is included $1,000,000 limit SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Niru Bhatia Yadav %)I 95113-2UU9 ACORD CORPORATION. All rights reserved. ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 ,.� www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual): Address: City/State/Zip: N014 q] A ey Md 61�4yhone #: 679 $%- 7Fop Are you an employer? Check the appropriate box: 1.❑ I am a employer with employees (full and/or part-time).* 2.❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6. EJIWe are a corporation and its officers have exercised their right of 'exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 7. ❑ New construction 8. ❑ Remodeling 9. ❑ Demolition 10 ❑ Building addition 11. ❑ Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13. ❑ Roof repairs 14:✓Other -Any applicant that cnecks box # 1 must also till out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors th$t 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. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Job Site Address: 2, (,cJ l VI rn a cJ1) i►tJV Ah 6 J61111' City/State/Zip: M 4 Gall.( Attach a copy of the workers' compensation olicy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: � � fl � �–�,' Date: 49—Of— Official 9–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 Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: 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 coritract: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 work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such 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 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 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 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 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, not the 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 number listed below. Self-insured companies should enter their self-insurance license 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 a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where 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 burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: I The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia