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Home My WebLink AboutBuilding Permit #1280-2016 - 40 ROYAL CREST DRIVE 6/8/2016 BUILDING PERMIT �gOrdYp� A• /b 46-r TOWN OF NORTH ANDOVER ,,. APPLICATION FOR PLAN EXAMINATION * _ A. h �� `ocriiCiw. Oy <x 1` Permit N®#. Date Received �RAoRATEO'pep`�5 �SSAC14 SSR Date Issued: �WipoiT NT: Applicant must complete all items on this page LOCATION *OWNER a Print PROPERTY Print 100 Year Structure yes Fno MAP PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ommercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other btiSeptc ❑�VVell: ❑{Flo'odplain 0`Wetlands: D Watershedt'District i - DESCRIPTION OF W RK TO BE PERF RMED: v I t rJ Identification- Please Type or Print Clearly OWNER: Name: Phone: 2 k Address: c1 �0 1 Ue Contractor Na Gc mac✓ / V Phone: q.3-011 Z--- Email: Address: k A144, Supervisor's Construction License: If Exp. Date: `1j Z� 7 Home Improvement License: Exp. Date: i 6 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ uw•c,`' FEE:-$ � Check No.: 6 o Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund �-�v . 0 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ nuning 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 d 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 Fngineer: Signature: Located 384 Osgood Street FIRE DEPA - R4TMEIT mpi r Te" Dumpster onsite yes.. �, not �. Locatedat�124yMaintStreet {` } FireiDepartment�signafia` e/date r u _�.. - COMMEIVTS , Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ff.: ELECTRICAL: Movement of Deter 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 MOTES and DATA— (For department use) ® 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 Er,nineering Affidavits for Engineered products OTE, All durnpster 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 OTE: All durnpster 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 2012 IECC Energy code 4- Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit Irn 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 OO R TH own of �? ndover O " to a d ?,0 kh ver, Mass, -0 6 M c0c«1cn1_1Cx 11. �l,9S RATED 1►Pa�,(� U BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT .. .PI.C.Q...................................................................................................... BUILDING INSPECTOR •• has permission to erect .......................... buildings on .Efi �. .. too.•' ice'' . Foundation Rough 47 to be occupied as ...�� ... ... .... ...0�1A& �................................................................ Chimney provided that the person accepting t Is permit shall 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 CONST ION Rough da ervice .. ..... ..... ....... Final BUILDING ECT 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. The Commonwealth of Massachusetts Department of IndustrialAccidents f 1 Congress Street,Suite 100 Boston,MA.02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE MED WITH THE PERMITTING AUTHORITY. A licant Information Please Print Legib Name(Business/Organization/tudividual): City/State/Zip: rz r 0o- Phone Are you an employer?Check. ajppropriate box: Type of project()required): 1.01amaemployer with�_employees(fall and/or part-tune).* 7. El New construction 2.�I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.F1 I am a homeowner doing all work myself[No workers'comp..insuranco required.], 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.[1 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurances 6.❑We are a corpozation and rfs officers have exercised their right of'exemption per MGL c. 14, they D 152,§1(4),and we have no,employees.[No workers'comp.insurance required.] ". *Any applicant that checks Box4l must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit#his 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-contractors have employees,1hey must provide their woilteis'camp.policy number. lain, an employer that is pi'ovidirzg workers'compensation insurance for my employees.'Below is the policy and job site information. //�� D �7 Insurance Company Name: /a e G v[ r In 41 �. �f��•a+.�e� — Policy#or Self-ins,Lic.#: � if1/�U �' 1 Z Expiration Date.__/ i Job Site Address: - rz �V l " '�L7 "" Lf 0 City/State/Zip: Attach a copy of the wor rs'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 Eno 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. X do hereby cert' nderliepai s nd penalties ofperjury that the information provided above is true and correct. Si nature: Date: G Phone#- I', 7 g t 7 2 2— Official use only. Do not write in this area,to he 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 Instruction 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 contrddt 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. Hovtdver 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 thegrounds or building appurtenant thereto shall not because of such employment be deemed to be anemployer." 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.iiisurance 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. LimitedLiability 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 ifyou'are required to obtain a workers' compensatioil 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. Ia.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 proofthat 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 wwvv.mass.gov/dia { Massachusi'tts Department of Public safety., Board of Building Regulations and Standards r License: CS-065281 Construction Supervisor PAUL BRUNO 4't4 109 CHESTNUT STREET "i Rte= LYNNFIELD MAp01940 S 3f 4i1 i� . Expiration: Commissioner.: _.._. 09/28/2017 j .r i � 1 DATE(MWD AcoRU CERTIFICATE OF LIABILITY INSURANCE °"YYY' `,,,/ �+ �+ 4/4/2016 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 REPROENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WANED,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 certifigate holder in lieu of such endorsement(s). PRopucEel CO NAME, Jean Sullivan, CIC, AIS Burgin, Platner, Hurley Insurance Agency, LLC PHONE (617)472-3000 FAX (617)472-7248 14 Frfinklin St. AIM:&n.jas@bphins.com INSURERS AFFORDING COVERAGE NAIL S Quincy MA 02169 INSURERA:Hanover Insurance Company 2292 INSURED INsuRERB.Safety Indeninity Insurance Co 33618 B & M Restoration & Contracting, Inc. INSURERCAcadia Insurance Company 218 Paris St INSURER D: UMBER E: East Boston MA 02128 INSURER F: COVERAGES CERTIFICATE NUMBER:Iaster Cert 2016-17 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. ILTRR TYPE OF INSURANCE POLICY NUMBER POLICY EFFMIEXP POLICY LIMITS GENERAL LIABILITY y N EACH OCCURRENCE $ 2,000,000UAPPM TO RENTED , S COMMERCIAL GENERAL LIABILITY PREMISES Me occurrence $ 500,000 A CLAIMS-MADE ®OCCUR ZHN8997647 /17/2016 /17/2017 MED EXP one $ 10,0001 PERSONAL&ADV INJURY $ 2,000,0001 GENERAL AGGREGATE $ 4,000,096 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 4,000,000 B POLICY PRO- LOC $ AUTOMOBILE LIABRM y y EaMxiderBINED SINGLE LIMIT 1,000,090 B ANY AUTO BODILY INJURY(Per person) $ ALL OWNED g SCHEDULED 6208157 1/6/2015 1/6/2016 BODILY INJURY(Per accident) $ % AUTOS AUTOS x NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS PIP-Basic $ 81000 X ,UMBRELLA LBLB x OCCUR y N EACH OCCURRENCE $ 5,000,090 A LAI EXCESS LIAB C MS.MADE AGGREGATE $ 5,000,090 DED g RETENTIONS 9055121 /17/2016 /17/2017 $ L' W tERS COMPENSATION 11 $ WC STATU- OTH- AND EMPLOYERS'LIABILITYANY PROPRIETORIPARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT $ 11000,000 OFFICERIMEMBER EXCLUDED? a NIA _20-20-003740-03 /10/2015 /10/2016 (Mar'darory in NH) EL DISEASE-EA EMPLOYE $ 1,000 O O B � �r DES RIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMITJ$ 1,000,090 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Addidonal Remarks Schedul%if more space is required) Contract @ 18122-422094-CPe-00002; Property Name- Royal Crest Estates(North Andover); AINCO North Andovgr LLC is additional insured per written contract CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN AINCO North Andover LLC ACCORDANCE WITH THE POLICY PROVISIONS. 50 Royal Crest Drive North Andover, MA 01845 AUTHOR�DREPRESENTATIVE A Ell ail r� :21 P P F R r � P T- •� ®®pppp