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HomeMy WebLinkAboutBuilding Permit #916-15 - 350 WINTHROP AVENUE 5/14/2015045- —Fo t- BUILDING PERMIT NORTH\ ct`eD. X61 �C TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION w 1• Permit No#: Date Received ,TE° gSSACHUs�� Date Issued: ORTANT: Applicant must complete all items on this page LOCATION 3-z5-6 w k- n p 4ve-n ur- Print PROPERTY OWNER M rr4-�- Gaskz+ Print 100 Year Structure yes no MAP OPARCEL:� ZONING DISTRICT: Historic District yes o Machine Shop Village yes. no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial Alteration No. of units: Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic q Well ❑ Floodplain 0`Wetlands ❑`''Watershed District ❑ Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: AO(ol Z. Galas ►\ow ba (c�p 4v aoW 54 � j -1-1 6,kenl, A.(a( Zsitnlcs An Ing Lav 4-c.6s6op, 0t JPryrmh k +t-focAij!jj +1 r- news,A�r Identification - Please Type or Print Clearly OWNER: Name: n/l arlc,y-t- Phone: -FW-D Address: ?-IS- C=ad+ 54, Tevksb.ry MA 0►$ -74, Contractor Name: S ,tea I G Cohs4yv4,m. Phone: 463 ?9 g 3 c) i Email: Address:_ _ I I I (Zd. tZ 1'0-45e, ,�/ 4 0 3 9 1 Supervisor's Construction License: C S - l v` 5 0 `l Exp. Date:IT2 1 Za !L Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Address: Phon IM FEE SCHEDULE. BOLDING PERMIT.• $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ 16 1 0 0 C) FEE: $ I Check No.: -)- . Receipt No.: a Llr—>m I NOTE: Persons contracting with unregistered contractors do not have access to the guary� ht fund Plans Submitteda Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer X Tanning/Massage/Body Art ❑ Swinuning Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Pennanent 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 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 P DPW Town Engineer: Signature: Located 384 Osgood Street _ "FIRE DEPAR�T[MENT .TernpDu pst ��O.�._ -SII = m eros site; N es no �1Locateci at�1�24i,MaigtStr`;eet, "`.� - �. Faire Departmentsignature/dated x�C.®M IVI E N(TtSx . a ,, 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 DANCER ZONE LITERATURE; Yes No MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine NU 11:5 and UA I A — (I -or clepartment use ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Pennit 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 4, 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 E: 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/Cross Section/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 E: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ,,6 Building Permit Application 4. Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit 4, Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 2012 IECC Energy code 4, Engineering Affidavits for Engineered products TOTE: 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 A)jA L,/) Fj Locatior�a No. Date lit t - Check#") ---- 7 1 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee Other Permit Fee TOTAL $ Building Inspector L 13 n 5M �1 :v5 O 0 M0 v, Q Q. 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O. 0 U O W IL cn z C9 z 0 J IM rM1 L.: d CL C a �_ Y 4 /4 3K 1 17[ C M May 4, 2015 To Whom It May Concern: EXECUTIVE OFFICES 875 EAST STREET TEWKSBURY, MASSACHUSETTS 01876-1495 978-851-8000 Seppala Construction Inc. is authorized to provide construction services to add a sandwhich/salad case in the Market Basket store located at 350 Winthrop Ave., North Andover, MA. This job will be issued to Seppala Construction on a time and material basis, If you have any questions I can be reached at 978- 640-8117. Normand Martin Facilities Manager Planning & Development The Commonwealth of Massachusetts J Department of IndustrialAccidents m 1 Congress Strec>y Suite 100 Boston, MA 021.14-2017 WMmars.govIefia NA-vrkers' Compensation Insurance AMdavit: Builder s/Contractors/Electriclans/Plnmbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Api lcantlnformatirn iease)E'rint I;e iy Name (Business/OrgenizadoWIndividuai):, Seppela Construction Co., Inc. Address: 153 Hunt Hill Road City/Statelip: Rindge, NH 03461 Phone #: 603-$99-3011 Are you an employer? Check the appropriate box: 1. I am a employer with l 'S employees (full and/or part-time).* 2. [:]1 am a sole proprietor or partnership and have no employees working forme in any capacity. (No workers' oomp. 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. Twill ensure that all contractors either have workers' compensation insurance or are sole proprietors with no a nployees. S. 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.* 6.E] We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have noemployees. [No workers' comp. insurance required.] Type ofproject (required): 7. [] New construction 8. [947,emodeling 9. ❑ Demolition 10 [] Building addition 11.❑ Electrical repairs or additions 12.E] Plumbing repairs or additions 13. QRoof repairs 14. []Cather *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 anew affidavit indicating such. (Contractors 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. Ianaaemploy erthat 4vpro vid9tVworkers'compensadonbitwanceformyemploy ees Belowisthe,polkyWit djobslte wormattom Insurance Company Name: Ohio Security insurance Co. Policy # or Self -ins, Lie. #: AWS55358735 Expiration Date: 01/oiao16 Job Site Address:. 350 Winthrop Avenue . Gity/State/Zip:North Andover, MA Attach a copy of the workers' compensation policy 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. Ido hereby ce,rl fy under the pains and penalties of perjury that ihe Wermation provided above tar true and correct; 603-899-3011 O,,(j'iciat use only. Do notwrtte in tuts wa to tie comp%ted by city or town q, pad City or Town: Permit/License # Issuing Authority (circle ane): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: AC40REr CERTIFICATE OF LIABILITY INSURANCE `-� DATE(MMIDDIMY) F 5/5/2015 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(les) 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 Infantine Insurance P. 0. Box 5125 Manchester NH 03108 CONTACT NAME: Yvette Fanaras PHONE(603)669-0704 AIS Not 603-669-6031 EMAI Yvette@infantine.com INSURER Sl AFFORDING COVERAGE NAIC # INSURERA:American Fire & Casualty 066 INSURED Seppala Construction Co., Inc. 153 Hunt Hill Road Rindge NH 03461 INSURERB:West American Ins Co 393 14082 INSURERC;Peerless Ins CO 198 INSURERD:Ohio SecurityIns Co INSURER E : INSURERF: 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, EXCLUSIONSAND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCEINSR AUVIL !RJBR POLICY NUMBER -POLICY EFF .MMIDDNM PO EXP MMA)DNYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE. $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES a occurrence $ 300,000 A CLAIMS -MADE 5_1 OCCUR X BkA55358785 /1/2015 1/1/2016 MED EXP (Any one person) $ 5,()00 PERSONAL &ADV INJURY $ 1,000,000 GENERALAOGREGATE $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS- COMP/OP AGG $ 2,000,000 POLICY PRO-. X I LOC I X I $ AUTOMOBILE LIABILITY COM D NED SINGLE LIMIT _T11 to accident 1,000,000 B ANY AUTO BODILY INJURY (Per person) $ ALL OWNEDSCHEDULED AUTOS AUTOS AW55350735 /1/2015 1/1/2016 BODILY INJURY (Per accidentl $ X HIRED AUTOS X NON -OWNED PROPERTY DAMAGE .,(PerAUTOS accident)$ $ X UMBRELILA LIAB X OCCUR EACH OCCURRENCE $ 10,000,000 C EXCESS LIAB CLAIMS -MADE -AGGREGATE $ 10,000,000 DED I X RETENTION$ 10,000 X 5055358735 /1/2015 1/1/2016 D WORKERS COMPENSATION- rrcS .AT, t1 N- X X AND EMPLOYERS' LIABILITY YIN T lM it E.L. EACHACCIDENT $ 500,000 ANY PRO PRI ETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? F NIA (Mandatory In NH) If yes, describe under S55358735 /1/2015 1/1/2016 E.L. DISEASE - EA EMPLOYE $ 500,000 E.L. DISEASE -POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below tate: NH LKA,9T ,NY,OC DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Various Work It is agreed and understood Market Basket Store #12 and DSM II LLC are named as additional insureds with respects to General Liability and Umbrella when required by written contract. rrn.nr c nvA.AJ= C rArdf'PI 1 OTIMI Market Basket Store #12 350 Winthrop Avenue North Andover, MA 01845 ACORD 25 (2010/05) 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 Harrison/BYM ©1988-2010 ACORD CORPORATION- All riehtr racarvarl INSU25 (201005),01 The ACORD name and logo are registered marks of ACORD .4coRi ® CERTIFICATE OF LIABILITY INSURANCE kk.. /5/,MIDDIYYYY) 5/5/2015 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(les) 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 Infantine Insurance P. 0. Box 5125 Manchester NH 03108 NAME: Yvette Fanaras PHONE (603) 669-0704 603-669-6631 AIG No. AIL ,Yvette@infantine.com anDHE SS. INSURER(S) AFFORDING COVERAGE NAIC p INSURERA:American Fire & Casualty— 4066 INSURED Seppala Construction Co., Inc. 153 Hunt Hill Road Rindge NH 034 61 INSURERB:West American Ins Co 44393 INSURERC:Peerless Ins Co 24198 INSURERD:Ohio Security Ins Co 24082 INSURE R E : 1 INSURER COVERAGES CERTIFICATE NUMBER:2015/2016 Master Qt ►nslnm MIJUIRIM-Q• 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 WTH 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, EXCLUSIONSAND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCEY INSR WdD POLICY NUMBER .MMIDDIYYYY EXP MMrDDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 -MMAX COMMERCIAL GENERAL LIABILITY T 300 00 PREMISES a occurrence $ � 0 A CLAIMS -MADE OCCUR RA55358735 /1/2015 1/1/2016 _ _ ' MED EXP (Anyone person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AOOREOATE E 2,000,000 GENLAGGREGATE LIMIT APPUES PER: PRODUCTS- COMP/OP AGG $ 2,000,000 POLICY "X .PRO-, X. LOC $ AUTOMOBILE LIABILITY COMB N�D$INGLE LIMIT E9 accident' S 1,000,000 B X ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS W55358735 /1/2015 1/1/2016 BODILY INJURY (Per accident) $ X HIRED AUTOS X NON -OWNED AUTOS PROPERTYDAMA0E Per accident $ S X UMBRELLA LI AS X OCCUR EACH OCCURRENCE $ 10,000,000 C EXCESS LIAB CLAIMS-MADEAGOREOATE $ 10,000,000 $ DED I X RETENTION$ 10,000 USO55358735 /1/2015 1/1/2016 D 1NORKERS COMPENSATION AWSTA I I.. QTµ XTORY LIMITS AND EMPLOYERS' LIABILITY YIN E.L. EACHACCIDENT $ 500,000 ANY PRO PRI ETORIPARTNERIEXECUTIVE NIA OFFICERIMEMBER EXCLUDED? (Mandatory in NH) S55358735 /1/2015 1/1/2016 If yes, describe under E.L. DISEASE - EA EMPLOYE $ 500 000 E.L. DISEASE-.POLICYL.IMIT $ 500,000 DESCRIPTION OF OPERATIONS below tate: NH,1fA .VT ,NY,SC DESCRIPTION OF OPERATIONS I LOCATIONS IVEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) RE: Permit - Market Basket Store #12, Horth Andover MA --MI IVI �I�- nyr.yGR GANGCLLAIION The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 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 Jim Harrison/BYM � _ M..Vmw Za Icv caval U 1988-2010 ACORD CORPORATION. All rights reserved. INS025 (201ou).Ot The ACORD name and logo are registered marks of ACORD 0 c CO >, y O o CD - N O Co X U - l!J O a c O Iz i d E Q d V7 r O Y y G 'O �IA U O J M U z