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HomeMy WebLinkAboutBuilding Permit #137-12 - 36 PILGRIM STREET 8/17/2011 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 131 -12-- Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION '301 Print PROPERTY OWNER I/G Gia Unit# Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes o Machine Shop Village yes o 100 year-old structure yes o 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 Well" � �xFloodpla�n; fD Wetlands. ID,� tevft.District } DESCRIPTION OF WORK TO BE PERFORMED: I I (Identification Please Type or Print Clearly) OWNER: Name: Phone: l�� Address: CONTRACTOR Name: Phone: i Address: �s GUl�% w ee f Supervisor's Construction License: d �; 6'/J O Exp. Date: Home Improvement License: �L���a� Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT'$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ 7 FEE: $ Check No.:_J 3 31- N Receipt No.: C9-1411111 NOTE: Persons contracting with unregistered cohlractors do not have access to the guaranty fund Si nature of`A ent/Owrier Signature of contractors i 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 ❑ 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 I Doc: Doc.Building Permit Revised 2008mi 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 ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ 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: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS 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 NOTES and DATA— For department use ❑ Notified for pickup - Date Doc:.Building Permit Revised 2011 June/mi Location ry` No. Date -L- 14ORTil TOWN OF NORTH ANDOVER ��Oo••`•o '•,hOow f s � o Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 2 21 244bl Building Inspector NO`S-30-20'0 "JE 04;05 PM ALLAN INS AGNCY FAX NO, 978+745+5483 N Ul f� CERTIFICATE OF LIABILITY INSURAN EDATE(MWOO I.RODUCE;- 11/30/20. THIS CERTIFICATE IS ISSUED ASP.MATTER OF INFORMA FLL.;41 INSURANCE AGENCY INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATI I 63 1/2 JefPe=u4z1 A anus 2,Aci HOLDER. THIS r-ERTIFICAT(=DOES NOT AMEND,EXTEND g P.O. Box ,^11 ALTER THE COVERAGE AFFQRIJt~ )8Y THE POLICIES BE s SAMEM MA 01970-0511 COMPANIES AFFORDING-COVERAGE # I COMPANY j.....-.._ ,q Seneca Insurance company —- - - -- !,NsuRa_D .....__..._.._ COMPANY TGL -C IWC dha IP-=e-t FOofing B Safety Insurance Group 265 WTNTs+REED ...... I COMPANY I _ i Landmark insurance company � �AV?;R.r,:;:�� YQA 01830— ..�..--•--- _ COMPANY 17 National OniOn Piro Insurance ,COVERAGES THIS iS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BEI_p11 HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIC I INDICATED,NOT-,NI T HSTANOiNGANY REQUi(F(ENT,TEW4IOR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT 70 WHICH Tyf- I CRTIFiCA TE MAY BE ISSUED OR MAY PERYAIN,THE INSURANCE:AFFORDED 13Y THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE fERNIS, k EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN 1A HAVE BEEN REDUCED 6Y PAIO,CLAIM_ S TYP`OPINSURAN`'E YNUM13ER POLICY EFFE{:TIVE POLICY•EXPI RATION LTR; PO1JC, . pA7E(MMrDDfWJ PAYE genMJDDrrY) Lf1AlTs ' GENERAL !ERILI`Y BODILY INJURY UGC $ — ..._ ZO:ftPRc'HENSIVE FOpe4. SGL3000422 / / / / 1100 rOO00 EODIL•(IN.nJRYA3r�- ... ... .. PROPERTY DAJACE OCC 00 i... J EXPLOSION&COLLAPSE PROPER—HAZARD ! .. � 2,AGE AGG $ 2 QQ J PRODUCTS/COMDAM PLETEO OPER BI d Pp COMBIIJED CCI: I``- CONTRACTUAL 31/ 'L/2080 X1/12/2011 $ BI&PO CONI$bV=D AGG r i I'4_EPEfdD£NT CONNTRACTORS $PtHSONAL INJURY AGC $ 1,17O i,X I BROAD FOP,M PROPERTY DAMAGE _ x PERSONA!,INJURY M�t�ical payment _..— P.l:?OM08tlELIAB1LIit • - _. _ I � .ANY AU70 BODILY INJURY f 4X ;ALL oWNrO AUT OS{Privwo Pass; (Por w5on) 5 6203819 ' -v gLLGV✓NEI�AUTOSpT/16/2{�7.1 BU]ILYINJURY t'Ovsts peaBengwl :Per ncciaonr, B �e=l HIRED AU70S i n I NON-O'hINED AUTOS PROPERTY DAMAG€ $ I _I GARAGE LIAid1LI .r Y ._......_ ..... ... BODILY IN-JURYPROP8 COMBEN TY DAMAGE I EXCESS LIAEIUTY _ _.' — —._. _ _ q 4 I UNBRE4A fORis ,EACH OCGJRKENCe 5 r CQ t-- LO54597 I1�12/2010 11/12/2011 AGf fREGATE 5 5,OC _ 1 OTHEF.—,HAN UMBRELLA FORM I L vM f:N5AT10N A.1{p VC STA I U. J7 ._ s cMPIO'ERS`LJABJLJi 009934145 / / / J ,.TORY'uruir ...LY,.1 T d THE PR.JPRIETORf j X IINCL EL E-t,GH ACCIDENT Ig. .. ..._L,OC A ^ARTNERSJFXE:CUTN1E B$/28 GLOISEASE- 1,0C t I OffZE_S ARE: EXCL�" NFI /2010 08/28/2011 POLICY�UvllT S i .. I "+. —•• _„,_ �EL DISEASE-EA EMPI OYES oTHcR .. $_ 1,0C I F I DESCRIP I ION OF OPERA nONSILOCAYIONSIVEMICL.BSfSPECtAL ITEMS E i ' I I f CERT€rICATI-HOLDER 1 1 SHOULD ANYOF THE ABOVE DESCRIBED POLICIES eE CANCELLED BF.FOR I EXPIRATION DATETHERaF,THE ISSUING COMPANY WILL ENOEAVOR TO M, J 30 OATS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO Ti BUT FAILURE TO AWL SUCH NOTICE SHAT-L IMPOSE NO OBLIGATION OR LI. OF AN KIND UPON YHE COMPANY,IT5 AGENTS OR REPRESENTATIVES. I AUTHORIZ D EPRES NTATIVE g _f._ •'-� '— I O CORD CORPORATION Park Plaza m ate 5 170 BostOT4 mas&*,�elts ®L 116 improvement . •tom, -=-�--ate..,.._.____:-- �er�astraf6on:• � i Tyoe: Privafp ;21&12033Coif ins y aL fT `tom raj •rf UFOAtAddr eSSandrB Caa'Q9_N2.rk8 Addrm --I I1 � diad _ Pf�t xrd Vs' Uri";IBU ? JT3 Y453 ; CC construction Supervise? :ear se CS 78930 RICHARD.] iAMat!RT 94 plCenn E v RD HAMPSTEAD, NH (wi. i:�isidS���E:)33Ca T T: 30062 The Commonwealth ojMassachusetts :_4 W.. Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 ir www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ApIpUcant information Please Print Lezibiv Name (Business/OrganizatiorvIndividual): Address: a 6_5 City/State/Zip: ' C/ O/230 Phone Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 4. ❑ 1 am a general contractor and 1 i employees(full and/o part-time).' have hired the sub-contractors 6. ❑New construction 2.Q 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g_ Demolition working for me in any capacity. employees and have workers' j con insurance.' 9. ❑ Building addition req required.) workers'comp. insurance p' 10.❑ Electrical repairs or additions ' required.] 5. (] We are a corporation and its pa 3.❑ 1 am a homeowner doingall work officers have exercised their 11. Plumbing❑ g repairs or additions i myself.(No workers' comp. right of exemption per MGL 1-) c. 152. §1(4) and we have nors' -).C3 Roof repairs , insurance required.] - '13.❑ Other employees. [No worke comp. insurance required.] -Any applecam that cheeks box a 1 must also fill out the section below showing their workers'compensation policy information. *Horneowinn who submit this affidavit indbmhng they are doing all work and then hire outside contractors must submit a new affidavit i»Qicating such. =Convwtots dw ahwA this box mus auached an additional sheet showing the name of the sub-contractors and state whether or not those aMnes have employees. If the sub-wrmactors have employees,they must provide their workers'comp.policy number. I an dw engdoyer AN is providing workers'compensation insurance for my employees. Below is the policy and job'site blRformaatiors Insurance Company Name: &a'r�YJl� Polity#or Self-ins. Lic.e: I-.1 %` _ Expiration Date: Job Site Address. 6 A City/State/Zip: , Attach a eoPY of the workers compensation policy declaration page(showing the Po 'number and expiration date). v as under Section 2 A of MGL c. 1 aiitut to secure coverage aired 5 G 52 can lead to the F crag req tmpostuon of criminal penalties of a fine up to 51.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fide of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DLA for insurance coverage verification. I do hereby certify sawnder-Am pains and penalties of perry that the injonnolon provided above is true and correct Si Date: Phone#: O ieW use only. Do not write in t/rs area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector S. Plumbing Inspector 6.Other Contact Person: Phone#c: NORTH T® oAndover ., 0 -14 I`.; No. 37 aot y 0 = o , over, Mass., T O LAKE �• I� COCKICHEWICK U BOARD OF HEALTH E M IT .. .. T U Food/Kitchen Septic System Vllii�� BUILDING INSPECTOR THIS CERTIFIES THAT.................... ..................................�.�.. ��� .................................................. Foundation y has permission to erect........................................ buildings on ....3(=......... ........rt............... Rough to be occupied as....... ......... .&0 ..........a��................................................................ Chimney provided that the pars n ang this permit shall in every re ect 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 Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MO THS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIOS 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.