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HomeMy WebLinkAboutBuilding Permit #680-2017 36 - 36 & 38 Hepatica 12/29/20141 V TOWN OF NORTH ANDOVER LM— SAI APPLICATION FOR PLAN EXAMINATION Permit NO: ' t �._ A- �Y Date Received Date Issued: I PORTANT: Applicant must complete all items on this page LOCATION j��,2ZO� 61p�! Kd/ilrC )o/-36% Print PROPERTY OWNER I_,eV 1;we ^ c • Unit # 3!0 37 Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes 100 year-old structure yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building ❑ 0 e family El Addition ]'Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: El -Demolition ❑ Other ` 1� Septie ❑ Well 0. Floodplain ❑ W.etlands. ❑ Watershed'Distr ct ❑ Water/Sewer DESCRIPTION OF WORK Tq BE PERFO # 3(08 - .20/7 �. L `eevive.: 5, 1w �entificoUon Please Type or Print Clearly) OWNER: Name: ire KA,,,of!C d-srG- Phone: Address: /o /f kepi¢ ��i ell BiJ.Ji�rllr ol �. v o yloao CONTRACTOR Name: G� Phone: Address: Supervisor's Construction License: C&;t4-la 2- Exp. Date: /,� A11.1y/�l Home Improvement License: /84, IA; Exp. Date: ?/o/, ARCHITECT/ENGINEER Phon Address: Reg. No. FEE SCHEDULE. BULDING PERMIT. • $12.00 PER $1000.0 THE TOT L ESTIMAT OST BASED ON $925.00 PER S.F. Total Project Cost: $ Z FEE: $ 11-4 Check No.: Receipt No.: NOTE: Persons contracting -th unregistere contractors do not have access to the guarani/y7fund 'Signature ofAgent/Ow gnature of cont racto F i J Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL/ Public Sewer Lv�j/ Tanning/Massage/Body Art ❑ Swimming Pools El 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 DATE REJECTED El PLANNING & DEVELOPMENT COMMENTS DATE APPROVED X t TION Reviewed on !oZ (-o Signature -1 �4 S l HEALTH' ' °Reviewed on Sionature COMMENTS _ r = Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision:• Conservation Decision: Water & Sewer Connecti DPW Town Engineer:. Signa Comments FIRE DEPARTMENT - Temp Dumpster on site yes. Located at 124 Main Street Fire Department signature/date COMMENTS Located 384 Osgood Street no N� v aot-'b Dimension L 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 servicedroprequires approval of Electrical Inspector Yes DANGER ZONE LITERATURE: Yes No, MGL Chapter 166 Section 21A—F and G min.$10041000 fine 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 Li Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses j ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract o Mass check Energy Compliance Report a 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 r, Location ! t No. In �b— 2c,�j Date C- -Z f^ I I (,o TOWN OF NORTH ANDOVER I Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee TOTAL Check # " E' Building lnspector Location a NSA{{ i 4 -2 L t� Date Z� Check # & 9 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee p��'�� Foundation Permit Fee ;$ Other Permit Fee TOTAL $ _v vi• C � n O CD CD O -0 ice= >cQ ma O CD 0 v� CD CD O o _ CD/ CL CD C ' 5 v 0 mz 0P-I'�- O O CD z m 0 z O D O Z O h rr CD N O O O to O W S.Q cm CD to 0 U) 0 U) s U) .a CD 3 Ov�O 2 N='<CD CD 0 -0CD, (D 5 M O rt Q. n i l l C =r =, Z �. CD T O O a m ID N m. 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'%0 O �' 32 oL oe o�2 32 a2 rr N 3 Do rt (D a 7 7 ty m (D trct n O M. 0 o m �c o phi r = ml< m M z v m a 3 o v O tp tD Ln -tk.. x an Ln o 0 UO a z m W _ Q) m w w v v°i � m ff P) uQ � a 3 m 0 3 CD rD UO (D m d e Go 00 < --no v CD m a The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plunabers. TO BE FILED WITH THE PERMITTING AUTHORITY. APP lll:all6 iiuv, u+ -------- Name (Business/Organization/individual):� Address: City/State/Zip: �0 /i��'1�0!/G`L` Are you an employer? Check the appropriate box: Phone #: 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 £or 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 empl `ogees. 5. QI 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.❑ We 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] Ty;N�Paw'donstr&HO`n roje¢t (required): '7. 8. [] Remodeling 9. ❑ Demolition 10 [] Building addition 11.❑um Electrical repairs or additions 12_Q.Plbing repairs or additions 110 R06f repairs 14. [] Other *Any applicant that checks bbic #i, must also fill out the section below showing their workers' compensation policy information: Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such 1Contractors 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. pensation insurance for my employees. X am an employer that is providing workers' comBelow is the policy and job site information. Insurance Company Name: /-'�� , Expiration Date: Policy # or Self -ins. Lie. #: r f Job Site Address: �� S' G City/State/Zip: d/0 copolicy declaraixon page (showing the policy number and e7cpiraiion date). Attach a copy of the workers' c 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 fox insurance coverage verification. Ido Hereby certify under thepains andpen� 'es of per' that the information provided abo�e is true and correct. Official use only. Do not write in this area, to be completed by city or town of fzciaL 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 Phone Contact Person- 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 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 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 r'equiired." 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 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 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 IndustrialAccidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensatiori policy, please call the Department at the number Listed below. Self-insured companies should enter their self --insura'nc'e license number on the appropriate line. - City or Town Officials PIease 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 thai 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 burnt leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: 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 wwwmass.gov/dia AC R CERTIFICATE nm.--� OF LIABILITY INSURANCEDATE(MM/DD/YYY/) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS N/16 O RIGHTS UPON THE CERTIRCATE HOLDER THIS BELOW. THIS CERTIFICATE INSURANCE DOES NOT CONS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES E TITUTE A CONTRACT BETW THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policyf esj 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 Ices not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NTACT M.P. Roberts Insurance Agency NAO PHON. AMY ROBERTS 1060 Osgood Street (978 683-8073 FAX N (978) 683-3147 North Andover, MA 01845 ADDRESS: AMSC@mproberts�r,c„rte,,.,,. ___ INSURED KEY LIME INC 10 HEPACTICA DRIVE NORTH ANDOVER, MA 01845 C: COVERAGES INSURER F CERTIFICATE NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSUREDENAMION ED ABOVE EOR 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 POUCIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NSR^ — TR TYPE OF INSURANCE ADDL SUBR -- — -- PC)LICY EFF POLICY IXPT js, GENERAL LIABILITY 1 POLICY NUMBER M/DD/Y I POUG YYYY -- — — MERCIAL GENE RAL LIABILITY CLAIMS -MADE [j] OCCUR GENT AGGREGATE LIMIT APP LIES PER AUTOMOBILE LIABILITY ANY A UTO ALLOWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS UMBMLLALIAB OCCUR EXCESS LIAB CLAIMS -MADE B I"URKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNERIEXECUTNE Y / N OFFICERIMEMBER EXCLUDED? N/A (Mandatory in NH) 3EE0820 6/15/16 6/15/17 WCC50050075812016A 1 9/15/16 9/15/17 IDESCRIPTION OF OPERATIONS 1 LOCATIONS /VEHICLES (Attach ACORD 101. Additional Remarks Schedule, if more space is required) CER N �n"n'J""U"'tNCE $ ] 000 DAMAGE TO RENTED P I Ea $ 5 0 MED EXP (Anyone person) $ EXCLU PERSONAL&ADV INJURY $. 1 000 GENERAL AGGREGATE $ 2 000 PRODUCT'S - COMP/OP AGG $ EXCLU COMBINED SINGLE LIMIT Ea accidant $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident — $ $ !ACH OCCURRENCE $ >GGREGATE $ WC STATU- OTH- $ L. EACH ACCIDENT .L. DISEASE -EA EMPL E S 1, 000, 0 L. DISEASE -POLIO IMIT $ 1 000,0 SHOULD ANY OF THE ABOVE DESCRIBED SAMPLE CERTIFICATE THE EXPIRATION DATE THEREOF, NC ACCORDANCE WITH THE POLICY PROVISIi AUTHORED RE-PRESENTATIVE P ROBERTS ACORD 25 (2010/05) The AC ORD name and logo arere8istered marks 8- 010 ACORD C6—F;Phone: Fax: E -Mail: BE CANCELLED B OR A._BE DELIVMD IN All rights reserved. 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