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HomeMy WebLinkAboutBuilding Permit #321 - 40 ROYAL CREST DRIVE 10/29/2007 NORTH BUILDING PERMIT 0It -[Uro 06 Aa 0 TOWN OF NORTH ANDOVER F APPLICATION FOR PLAN EXAMINATION Permit N0:1 Date Received 2x °, ��SSACHUS Date Issued 10 IMPORTANT:Applicant must complete all items on this page y r LOCATION- -'PROPERTY OWNER`:,�A 1 Pnnt MAP NO: PARCEL: ZONING.DISTRICT.. Hist©rc District yes _ 'Machine Shop Village.v.yes fno TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial pe,Repair, replacement Assessory Bldg Others: Demolition Other 'Septic Well . " Floodplain Wetlands, u 1Natershed Dstnc# -:;Water/Seaver DESCRIPTION OF WORK TO BE PREFORMED: Identification Please Type or Print Clearly) OWNER: Name: V,"<'o ~ 5c�.�. �^^� Phone: Address: 7'*7;t CONTRACTOR "Name:- ne.. 'Ad( ress. ..—— .S Supervisor's Cons#ruc#ion;Lxense. . a= ` ` 'Exp Y:Date: t C . ,.. Dome Improvement License Exp.' Date. ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:SULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST B SED ON$125.00 PER S.F. Total Project Cost: $ 1 2.0 00 FEE: $ IL Check No.: A Receipt No.:-2A2r 2 NOTE: Persons contracting m eyed contractors do not have access to the uaranty u signature of Adent/Owner y Signafure of contractor. Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools WellT � obacco 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 DATEAPPROVED OVED PLANNING & DEVELOPMENT COMMENTS DAT JECTED DATE APPROVED CONSERVATION oga COMMENTS DATE REJECTED DAT PROVE HEALTH l� o COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes PlanningB Decision:Board on: Comments Conservation Decision: Comments Water & Sewer Connection/Si-qnature&Date Drivewav Permit Located at 384 Osgood Street FIRE DEPARTMENT -Temp''Durrpster on site; yes y. no ,Located at 1.24Main Street ;Fi "De / p.. ment signauredate, 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 i Doc.Building Permit Revised 2007 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 PP 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations d 600 Washington Street W= Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): 7Cc Address:�.?(f1 City/State/Zip: I�/1% 1.5 Phone. #:-3"C "761_ Are,you an employer?Check the appropriate box: 1.El"I am a employer with L .-- % ' 4• E] I am a general contractor and I Type of project(requiredy employees(full and/or part-time).*`' have hired the sub-contractors 6 ❑New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' g Buildin addition [No workers' comp, insurance comp. insurance.$ ❑ g required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.D—Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other 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-contractors 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: ri e�L,C ��S ^��rC c' c"✓�C �( �� Policy#or Self-ins. Lic.#:',�A7C -7 Expiration Date: Job Site Address: y ltc�:�A\ C.�� �' 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that 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 and penalties ofperjury that the information provided above is true and correct. Signatuie:, 1 �.) Date: lezDVI10, i Phone#' OfficJaI u e 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 Terson: Phone#• ` NORTfq '9 Town of : t over No. • �- - � C',Q =_- LAKE o ower, Mass., i a a g O COCHICHE w ICK y1. SRATED OPP` -`G7 �7 BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT... ............ ..... .../4.. ......Q ... ...........:............ ....................... Foundation has permission to erect......... .............................. buildings on ..... � .......�. .�.. .I¢'..f.�...L�'M..r-.. ......... Rough to be occupied as:.......... ifi.�... ...f.. .�. .......f'�r. .�.h... k.11�1.. ....... !/ Chimney provided that the 'person acce tin this pe d shall in eve respect conform to the tefms of the app li tion on file in P P P P N P 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 Lq4 4000, PERMIT EXPIRES IN ,6 MONTHS ELECTRICAL INSPECTOR UNLESS _CONSTRUC A TS Rough .. Service BUILDING INS R 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. �1tr-%a�rra�zaix�¢a�i r��.'�la'sffll4E� � ` BOARD OF BUILDING REGUAT10NS € r ` License: CONSTRUCTION SUPERVISOR mss, Number. CS 077853 Birthdate 71/18/1957 Expires: 1111&2007 Tr.no: 9499.0 i2esWia Wd: 00. KENNETH E SAL-$N AN 2 ADAMS STREET WESTBORO, MA 01581 Commissioner Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 149914 Ecpiratlon - 2/21/2008 Type: Private Corporation TREELINE CONSTRUCTION,INC. - KENNETH SALSMAN 130 WESTBOROUGH STREET ,_, MILLBURY,MA 01527 Administrator I I AGO-RD. CERTIFICATE OF LIABILITY INSURANCE TRECSR? X►ATE(IMM7DDNYYY) .10/07 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER t=F INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Kittredge Insurance Agency Inc HOLDER,THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 155B Otis St. , F.O, Box 1129 ALTER THE COVERAGE AFFORDED 5Y THE POLICIES SELOW. Northboro NA 01532 Phone:508-393-7744 Fax:508-393-6983 _ INSURERS AFFORDING COYERAOE NAIL 0 INSURED INSUKRA: 14AUTILUS INSURANCE COMPANY INSURER B: Hanover SnSurance Group 22292 Troaline Construction Trio, INSUR.ERC: Aryrieatn Home:usnranao Ca. I, 130 WostbQzo Street 'INSURER O: Millbury MA 01527 - s INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUCO Tp THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.N0TYN•fH87ANDING ANY REQUIREMENT,TEM OR CONDITION OF ANY,_ONTRACT OR OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE 04SURMCE AFFORDED BY THE POLICIES OESCRIBEO HEREIN IS SUBJECT TC ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLIOG8.A[, kWA'TE LIMITS ZWOVIN MAY HAVE BEEN REDUCED BY*AID CLAMS. ppL I LTR NSR YYF6 F 1 RAN�CE POLICY NUMBER DATE? IAM DOJYYE pA f MtD LII7IT9 OcntElwl 1,lA81lJTY I EACH OCCURRENCE $ 1000000 A X cOIAMERCIALGENERAL LIABILITY 170659999 104/21/07 04/21/08 PREM 6ES( j s 100000 CLAIMS MACE SC OCCUR rMIED Ei(P(Any one PCrFon) $rjOOb ;ERSONAL s ADV IWURY $10 00000 I 3ENERALAGGREGAYE ^� _ I IGEN`LA3GREGATEUMITAPPLIES PER:I i PRODUCTS•COMPlOPAt^i 52000A 00 POLICY r7 SRO- n LOC AUTCMOQLG LIA(tluYY i COMBINED SINGLE LIMIT $1000000 $ ANY AUTO ' AFN838702401 07/27/07 i 07/27,08 1 (Easxsaem) Ali OWNED AUTOS SOOTILY INJURY ( X SCHEDULEDAUTOS I IPmpft fln) S X HIRED AUTOS I Pe1etRYX NON-OUJNEDALUS ( �n` I$ j PROPERTY DAMAGE I$ -._.-. {Per scciCenl GARAGE LIABILITY I , AUTO ONLY•EA ACCIDENT ¢ ANY AU70 OTHER THAN EAACC $ I P.UTG ONLY: ARG 3 EXCESWUMBRELLA LIABILITY EACh.OCCURRENCE $ —j OCCUR CWIh76 MADE } ,AGGREGATE $ -:w $ 0EDUCTI3LE i $ P.ETEN'TION $ 3 WORKERS COMPENSATION AND X TORY LIMIT ER SMPLOY&RV'LUkSIU',Y O ANY PROPPVEYORJPARTNeRJEXECLfrIVE. 1708979703 12/24,08 16^/24/07 E.L EACH ACCIDENT $1000000 Oyes,da orbeLmR EXCLUDED? i E.L.DISEASE. EA EMI-LOYEE S 1000QQ.0 IP Yea,CBe(YIDe ufltlef SPECIAL PROVISIONS below E.L DISEASE-POLICYLIMIT $1000000 OTHER DESCR!PX16N OF OPEItAYION3 J LOCATIONS!VEHICLES!EXCLUSIONS ADDED BY ENDORSEMENT,'SPECIAL PROVISIONS ' i I CERTIFICATE HOLDER CANCELLATION NOANDOV SHOULD ANY OF THE ABOVE DESCRIBED POLICES BS CANFELLED BEFOR$THE EXPIRATION DATE THEREOF,THE ISBUINO INSURERWILL ENbeAvOR TD MAIL 2 0_DAYS WRITTEN N0710E TO THE CERTIFICATE HOLDER NAMED TO YHF 4EPT,BUT FZLIm.TO 00 50 SHALL Town of North Andover IMPOSE NO OBLIGATION OK UABILITY OF ANY KIND UPON THE INSURER,I-M AGENTS OR REpItj3WAT1VQS. North Andover MA AUTH (�D/REPRES9K T!VE ({ )J ACORD 25(20D1108) @ACORD CORPORATION 1988 IMPORTANT If the certificate holder is an ADDITIONAL_INSURED, the policy(fes) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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 lies, of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing Insurer(s),authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage affordw fay the policies listed thereon. ACORO 25(2001/08) Location � � No. Date r HORTN TOWN OF NORTH ANDOVER 0 10 9 Certificate of Occupancy $ Building/Frame Permit Fee $ � Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check#0/ o 0 20761 Building Inspector