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Home My WebLink AboutBuilding Permit #069-2016 - 4 High Street Suite 205 7/15/2015 BUILDING PERMIT` TOWN OF NORTH ANDOVER: APPLICATION FOR PLAN EXAMINATION. =` Q _ b Permit No#: 1� Date ReceivedAD � 1e 7q ADHATED PPP,`•(5 SSACHUS� Date Issued: I I_ IMPORTANT: Applicant must complet6 all items'on:this page LOCATION fit' R l_� `� Print _ PROPERTY OWNER - Print 100.Year Structure yes no MAP PARCEL-:_ ZONING DISTRICT: Historic District s n. - -__ 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 ii Septic ❑ Well ❑ Floodplain ❑Wetlands ❑ Watershed'District ❑Water/Sewer DESCRIPTION OF WORK TO BE.PERFORMED: i Identificatio - Please Type or Print Clearly _ OWNER: Name: �.C'* Phone: leo l'1 —b L X31 i Address: `L. %I A I J�l 4D Pt 6r-U 6- 0 2-14-? `:Y.t . /.rte u1^1 Contractor Name:.. .({c rZ4, W#4 ws - Phone:. L Address: �_l (L C_h n om " "fru 1, tl } 0-t ye i Supervisor's Construction License- Exp. Date: J-6 Home Improvement License: _-_- Exp. Date' 1 ARCHITECT/ENGINEER A c r^CcN<Phorte:. CJ' i Address: o 5 pt �- Q b.z.iUYN '..Reg.,No.e ` f Q 0 0 . FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST'BASED ON$125 0 PER S.F. Total Project Cost: $ Lt- FEE: Check No.: M y Receipt No:: 29 NOTE: Persons contracting with unregistered contractors.do.not,have.access t the guaranty fund Signature of Agent/Owner Sig nature,.af.con.tractor —i ~ I Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ i I TypF-6F 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 I INTERDEPARTMENTAL - SIGN OFF U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS � i CONSERVATION Reviewed on Siqnature COMMENTS HEALTH Reviewed on Signature COMMENTS r Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments I P Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp DumpsAr on site Ips 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.$10041000 fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 I r Building Department ,h The following is a list of the required forms to be filled out for the appropriate permit to be obtained. i Roofing, Siding, Interior Rehabilitation Permits fr ❑ 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 j ❑ 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 ' 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 Doc:Building Permit Revised 2014 Location No. D(Ipol— ZO Date • - TOWN OF NORTH ANDOVER I Certificate of Occupancy $ Building/Frame Permit Fee $C9 --, Foundation Permit Fee $ -a- r Other Permit Fee $ TOTAL Check# Jr 13 ,fding Inspector / � NORTIy Town o E •n over No. - aa1�5 oh , ver, Mass, Li COC LAKII NIc Kl WICK ��• �d A04ATED S U BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System THIS CERTIFIES THAT AI t BUILDING INSPECTOR ..................C........ .. A..wc ...!K ...Lt. ............ .. .. SeA*f has permission to erect buildings on ..SW 9�SFoundation ................... ... ..............� ... Rough tobe occupied as ..........� .).&A.... .... .............�.............................................................. Chimney provided that the person accepting this permit I in every respect conform to the terms of the application Final on file in 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 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION S. S Rough Service .................... .... ....................... BUILDING INSPECTOR Final GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. Smoke Det. i 26'-5 114" 8'-5 5/8" 17'-6 5/8" j r r ti 1 M/ f SUITE 2 1 205 w 0 mill f The Commonwealth of Massa chusetts z . Department oflndustrialAccidents 1 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. Applicant Information Please Print Legibly Name (Business/Organization/Individual): 0—X efl \`N L' -s---' C-- Address: 3 t C—M n Ni? C , c5 �/ U � ►� 0 L I �� •- City/State/Zip:1,1 X YrAG 47.0 r1 O Z-r� Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.011"Z a employer with �,, employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition IFI I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 E]Building addition 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 11.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.FJ Roof repairs These sub-contractors have employees and have workers'comp.insurance.# 6.Q We are a corporation and its officers have exercised their right of'exemption per MGL c. 14.Q Other 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] *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 a new 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-conlraciors 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: t Q s � y V V t- -{ Policy#or Self-ins,Lie.#: W Z "3 S 0 l W/ Expiration Date: Z- 11 Job Site Address: ti- Fi l r" ti v� 1 " ND ot/- -• 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 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 andpenalties ofpeijury that the information provided above is tr a and correct. Si afore: dz_ i(� Date: S J Phone# ( 47 9 i— — G 7-V7,4 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 contract o£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 busines's or to construct buildings in the comrnonv wealth 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=contractors)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 Iindustrial 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 Sitio Address"the applicadshould 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: 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 s .. Aco CERTIFICATE OF LIABILITY INSURANCE °�'�`" °°""�"' 3215 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 POLIaES BELOW. THIS CERnFICATE 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). IRIDDucER T Maria Dupont Insurance Agency, Inc. P Le 18 Copeland Street 17 376-0795 ; (617) 479-9121 Quincy, MA 02169 15me@ dupontinsuranceagency.com INSURE S AFFORDING COVERAGE MAIC• INSUREtA:Main Street America INSURED INSURER B: JK Contracting, LLC INSURERC: 31 Richmond Street INSURE 0: Weymouth, MA 02188 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED 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. LTR TYPE OF INSURANCE POLICY NUMBER EFF P MIIDWLIMITS A OENERALIIABBftY MPT7794M 2/10/15 2/10/16 EACH OCCURRENCE E 1,000,000 )( COMM ERCIALGENERALLLABIUTY DAMAGE TO RENTED 9 500,000 CLAIMS-MADE 7XI OCCUR MED E)F(Any one Person) $ 10,000 PERSONALBADV INJURY $ 1,000.00 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATELIMITAPPUESPER PRODUCTS-ODMPIOPAGG $ 2,000,000 POLICY F1 P LOC I$ AUTOMOBILE LIABILITY a 3INECISINGLELMITdertS ANYAUTO BODILY INJURY(Per pemm) $ ALTOWNED SCHEDULED BODILY INJURY(Per aeddent) $ AUTOS NON-OWNED PROPERTY DAMAGE $ HIREDAUTOS _AUTOS Peraodoem S UNBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS Luke CLAIMS-MADE AGGREGATE $ DED RETENTION WORKERS CGIVENSATION I WC STATU OTH- AND EMPLOYERS'LIABILITY Y I N TfHzY I WIN FIR ANY PROPRIET0WARTNERIE)ECUTNE E.L.EACH ACO DENT OFFICE RAE MBER E)aCLLOED? N I A prandelory In NH) E.L.DI -EA EMPLOYEE Wdescribe under KyeB dRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DI:SCRIP'nONOFOPERAnONS/LOC4TIMIVEHICLES(Mach ACORD1101,AdffdonelRerrarksSolte h,If mon spabregdred) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORED REPRESE NTATNE Bridget McGowan 01988.2010 ACORD CORPORATION. All rights reserved. ACORD 25(201 OW) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: apedranti@crowninshield.com ',3/j/2015 7:22:03 AM PST (CHIT-8) FROM: 100005-TO: 1-6174799121 Page: 2 of 2 ` G0 DATE perloolrYY� CERTIFICATE OF LIABILITY INSURANCE 3131'2015 THIS CERTIFICATE 18 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 SUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the cot! cots holder is an ADDITIONAL INSURED,the poliMisa)must be endorsed. K SUBROGATION IS WAIVED,subject to the to.. and Condition of the policy,certain policies may require an andoesement. A ata' nt on this cartlficate does not confer rights to the certificate holder In lieu of such andoresme s. PRODUCER DUPONT INSURANCE AGENCY INC ZT- 18 COPELAND ST PHONE QUINCY,MA 02169 &K IML Elft ffin Not AFFOR}>a10 cave11A6E NAIL e Na A: Libeft Mutual Fire Insurance 23035 X CONTRACTING LLC 31 RICHMOND STREET e1e1c' WEYMOUTH MA 02188 D rINSi.o�P: UMME: COVERAGES CERTIFICATE NUMBER: 23 7 622 REVISION NUMBER: 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. POLICY EFF POLLY LTR TYPE OF W43UPANCE POLICY WINNERLeare COMMERC"GENERAL.LIABILITY EACH OO1OI iENCE s CLAIMS-MADE F�OCCUR rweal — MED EXP tAny one S PERSONAL s ADV INJURY s GENt.AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s POLICY❑PRO- JECT M LOC PRODUCTS-COMP/OP AGG s OTHER: $ AUTOMOBILE LIABILITY MULE LMFrs ANYAUTO BODILY INJURY(Per pftsw) S COs°ED �DAUTOS BODILY INJURY(Per eodderd) s HIRED AUTOS AUTOSs s OCCl1ItEACH OCCURRENCE s OCCEee I" HCLAIMS-MADE AGGREGATE MO RETENTION S $ A wWC2.3115 7 15 712016 AM ENaOrERs1 uAsanY ANY PROPRIETORIPARTNEWE IEM VE YIN E.L.EACH ACCIDENT s 100000 OFFICERINEMSEREXCLUDED? NIA (Mendelwy in 00 E.L.018EAN.EA EMPLOYEE f 100000 H�rs deoabe under DEBGIR-TION OF OPERATIONS bebw E.L.DISEA -POLICY LIMIT 500000 I DESCRIP OF OPEMTiONS I LOCATIONS I VBA(ACORD 1011,Add)e IN ed.mde,my be.a.rhed Irroan epw Ie nq:dre* Workers compensation Insurame cava 9 soles only to the workers Compensation Isws Of the stab of MA This conifiicate cancele and supersedes all previously Issued(ar6ticates,only as they relate to workers compansalion coverage. i CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 113E CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN MEOW ACCORDANCE WITH THE POLICY PROVISIONS. AInIroIGM PO4UMMATNE Mutual FIn3 InsLnanrx `r P w( A•f/]� 01888.2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are mglaWmd marks of ACORD CERT a0.: 23677622 CLIENT CODS: 1644469 Lucy Oasiiold 3/3/2015 10:19:07 An (EST) Page 1 of 1 J L 1, Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Super-visor License: CS-066334 KIERAN T WHEW - 31 RICHMOND S.T WEYMOUTH MA Expiration Commissioner 09/26/2015