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HomeMy WebLinkAboutBuilding Permit #25 - 409 BLUE RIDGE ROAD 7/11/2012 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N04 Date Received Date Issued: , IMPOR NT: Applicant must complete all items on this page LOCATION ® �C/ &26 /g P nt PROPERTY OWNER a,<4 o c ® P t MAP NO: PARCEL:ZONING DISTRICT: Historic District yesGn Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential kNew Building e0ne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other M Septic ❑Well -❑Moodplaii ❑Wetlands) 0 Watershed,D strict ❑.Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: © a. 3o x93- Ze lzrw P,2 74- ah ay« Re M 11A adentificatio Please Type or Print Clearly) OWNER: Name: a,Ca a Phone: 6/7, 7 F(,/—Cao7i7 Address: & 9 l'S All CONTRACTOR Name:lvl e Address: (o CoGZo Supervisor's Construction License: Q (p 0 9 Exp. Date: a7 13 Home Improvement License: A2 Jr %�� Exp. Date: / ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 1-.3 U--0 �. FEE: $ SO -q Check No.: V4 Receipt No.: NOTE: Persons contracting ith unregistered contractors do not have access to the guarantyfund nature of Agent/Owner Sianaturecontractor Location `1 0"c1 No. O��J ^ '� Date • - TOWN OF NORTH ANDOVER j 40F Certificate of Occupancy $= Building/Frame Permit Fee $,32:' j Foundation Permit Fee Other Permit Fee $ TOTAL M� . $ Check# 02 2 25499 /B ilding Inspector 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 ❑ I THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM A ' s 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,Str6et' Fire Department signature/date COMMENTS Dimension Stories: Total square feet of floor area, based on Exterior dimensions.__ Number of _— Total land area, sq. ft.: uires approval of ELECTRICAL: Movement of Meter location, mast or service reodrop q Electrical Inspector Yes 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 2008mi 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 MOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) a 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: Doc.Building Permit Revised 2008mi FR] [3 PC PrPrJprP�PLPE J�d3 E3 JLLPLr�3 .t IMPORTANT DOCUMENT iJ�rJ�rJ�rPrJ�rJ�rJ�rJ�rJ�rlrJ�rJ�rJ�cPr�r� O 5Cortifleate of Flamm Res its s ee 5 5 5 5 REGISTRATION ISSUED BY Date of Shipment 5 Q APPLICATION � m 5 S NUMBER VINISRIE INC ® 8/28/2006 5 5 r EVANSVILLE, INDIANA 47725 Tent Identification 55 5 MANUFACTURERS OF THE FINISHED oa33��,`�� 5 5 1-40.1 TENT PRODUCTS DESCRIBED HEREIN Pj SThis is to certify that the materials described have been flame-retardant treated 5 S (or are inherently noninflammable) and were supplied to: 5 657150 5 SPETERSON PARTY CENTER INC 5 S139 SWANTON ST S S 5 5 WINCHESTER MA 1890 5 5 S 5 S S 5 S 5 S S 5 Certification is hereby made that: 5 5 SThe articles described on this Certificate have been treated with a flame-retardant approved 5 Schemical and that the application of said chemical was done in conformance with California S S Fire Marshal Code. All fabric has been tested and passes NFPA 701-99, CPAI 84, ULC 109. 5 5 5 Serial # 5 8046023(z) 5 5 Description of item certified: 5 5 NAV I-TRAC LITE 1-II13 LND 30WX 15 S VINYL.WI1"I'l:SNYDIR 5 Flame Retardant Process Used Will Not Be Removed By 5 5 Washing Akd Is Effective For The Life Of The Fabric 5 5Signed: - - S Name of Applicator of Flame Resistant Finish ANCHOR INDUSTRIES INC. 5 D cncn�P�n�n�c rrJ��Pcnc!@PrPcP�nrJ��rP�P�rPrP�nrPrPrPcnc Pr rrPrPc n�nrPrJ�cP�P�P�PrP�r�P�nrP�rcl�cPrPu�c rc rrPrJ��PrPrPrPrPcP�PrPrPrPrJ��P�PrPrPu��P�P�P�P L7 � NORTH-{ T'own ondover O No. - �.K. h h ver, Mass, A_ COCHICHtW1[/( .-1. S V BOARD OF HEALTH Food/Kitchen PER T L D Septic System .�,� BUILDING INSPECTOR THIS CERTIFIES THAT ..................... ............ ............ ..:N........... ....... ............. .. has permission to erect .... buildings on a 10, ....r/. Foundation to be occupied as .t3a..leqr....:... . .......... . 414'?....... .'. .. r..� a Chimney Rough provided that the person accepting this 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 CONSTRUCT T Rough Service ............... .... ..................................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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. SEE REVERSE SIDE cPr�rJ�rJ�r�cPrJ�rJ�rJ�cP�rJ�r PrJ�rJ�r��1i I P O T N T D O C U {�V�/� E r��T r�Pr 2012 cJ�r�cJ�L l�rJ�EMMOMMOu 5 Certi�a•c f FlaiW Res � li SII p a „- d e 5 REGISTRATION ISSUED BY 5 5 5 Date of Shipment 5 APPLICATION 5 NUMBERVMICHIRE05/28/04 } INDUSTRIE INC. J EVANSVILLE, INDIANA 47725 Tent Identification 5 5 [=140.t MANUFACTURERS OF THE FINISHED o�sso2s4 5 STENT PRODUCTS DESCRIBED HEREIN 5 5 5 This is to certify that the materials described have been flame-retardant treated 5 (or are inherently noninflammable) and were supplied to: 5 S 657150 0 PETERSON PARTY CENTER INC 5 139 SWANSON ST S 5 WINCHESTER MA 01890 S S 5 r 5 5 5 5 5 5 S Certification is hereby made that: 5 5 The articles described on this Certificate have been treated with a flame-retardant approved 5 Schemical and that the application of said chemical was done in conformance with California 5 S Fire Marshal Code. All fabric has been tested and passes NEPA 701-99, CPAI 84, ULC 109. 5 SSerial # 8046024(4) 5 5 5 Description of item LITE MIDDLE 30wx15 55 5 VINYL WHITE SNYDER 5 Flame Retardant Process Used Will Not Be Removed By 5 5 5 Washing And Is Effective For The Life Of The Fabric 5 Cj SNYDER MFG NEW PHILAD}LPHIA,OH Signed: `� 5 5 "SPECIAL EVENTS DIVISION•ANCHOR INDUSTRIES INC. Cj J�rlrJ�r�r�[PrJ�r�cPcP�Pr J�[J�[1rJ�rJ�rJ�rJ�[1�r P[P[n[JCnr�[1�r�rJ�rJ�[Pr�CPr�r J�rJ�[1cPCJ�r�rJ�[J�rJ�[!�[Pr�r�C P[1[PI[�rJrJ�[fr��P[l�r�rJ�[1�r�r�rJ�[1 airJ�[J�cf[P[P[J�c1�f�r J�cP t The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information // Please Print Le ibl Name (Business/Organization/Individual): C er'?s 0' -) Q _ Address: ,j C �� City/State/Zip: 1 b)rti % 0l FO/ Phone #: 76�` �� _)0y Are you an employer?Check the appropriate box: Type of project(required): L N I am a employer withv7cpi� 4. ❑ I am a general contractor and I employees(full and/or part-time).'` have hired the sub-contractors 6. E]New construction 2.❑ I 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' 9. ❑Building addition [No workers' comp.insurance comp.insurance.1 b required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. o work ' . right of exemption per MGL y � workers' comp. 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.®Othereln , , comp.insurance required.] *Any applicant that checks box#1 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. $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. p ant an employer ilaat is pt•ovidirag worlrers'conipeazsation insiarance for my employees. Below is the policy and job site information. f / Insurance Company Name: �U�'/Firs S v a °� [�/I � Policy#or Self-ins.Lic. �,�4 C.> Expiration Date: 9' � Job Site Address: 7U /U 4 City/State/Zip: Attach a copy of the workers' compensation 070licy 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 lander thepai�ndpenalties ofpeijuiy that the information provided above is trace and correct. Signature: Date: Z Phone 4: �07 �/O c173 Official use only. Ito 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#: ffnfoir floe Rnd hsttirue ons 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 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 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 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 Df 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 Site Address"the applicant should write"all locations in (city or .own)."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. Fhe Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, .3lease do not hesitate to give us a call. 'he Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 61.7-727-4900 ext 406 or 1-877-MASSAFE •ised 4-24-07 Fax#617-727-7749 www.mass.gov/dia re -ation valid for individul use only .111css tegulatioll License or gistr v/i"" Office of 611 Fu I a I rs& 3 1" HOME IMPROVEMENT CONTRACTOR before the expiration date. 11"found return to: -1CC Of COuSLUner Affairs and Business Regulation Off 1� W Type: R i Registration: 69922 10 Park Plaza-Suite 5170 Q W Expiration: 8/18/2013 Individual J Boston, MA 02116 NAR "R TRIANA MARK TRAINA 33 HANFORD RD. STONEHAM, MA 02180 Undersecrelary Not valid without signature nl� r i U D 02 ! E,*Plf-2 !on: 4;;27/2C)i_- TF:7: ACORD CERTIFICATE OF LIABILITY INSURANCE FDATEIrAiA/DDIfYrY1 0/4/2011 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 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). PRODUCER CONTACT NAME: T Michae_ IBonacors0 Bonacorso Insurance Agency, Inc. PHONE ----�FAX . (781)273-3200 A;c.No t�sllz-,-osoo ADDRESS: 83 Cambridge Street E-MAIL mike@bonacorsoins.com P.O. BOX 1502 INSURERS AFFORDING COVERAGE Burlington MA 01803 INSURER A.-Republic Franklin Ins. Co INSURED INSURERB:Travelers Cas & Sur of Illinio _ Peterson Party Center, Inc. INSUR_ERCutica National. Insurance Co 139 Swanton Street INSURER D:Travelers Casualty and Surety INSURER E: _ Winchester MA 01890 INSURER F: COVERAGES CERTIFICATENUMBER:2011 I-LnSTER REVISION NUMBER: � THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLIC`i DEFicDCI INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONtRACT OR OTHER DOCUMENT WITH RESPECT TO V,'HICH Ti-,S CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE T=FMS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR A DL UBR' POLJCY EFF POLICY EXP -- LTR TYPE OF INSURANCE INSR WVDi POLICY NUMBERMM/DOPYYYY fMMIDD/YYYYI LIMITS GENERAL LIABILITY I EACH CURR }{ ENCE 1 1,000,000 DEOCTO RENTED cCOMMERCIAL GENERAL LIABILITY PREMISES Ea OCCurrenc=�� co,00c A CLAIMS-MADE a OCCUR X X CPP4361629 10/9/2011 110/9/2012 M ED EXP(Any one person) Is 10,000 _ I PERSONAL&A.DV INJURY_I 5-- 1,000,000 i GENERH AGGPEG TE 2,OOG 000 j�GGEE�N'LAGGREGATE LIMIT APPLIES PER: i ROD'JC7S-COI ?h0?.=.GG - - O''JG 0001 l X j POLICY 1.7 P 0_ I LO I --- - - AUTOMOBILE LIABILITY i (Ea acIIJ IED SINGLE L.^d,T -- IEaa-cid=<?I� �l'.3rJ zuCO ANY AUTO BODILY INJURY(Per person) ! S ALLOVvAIED X SCHEDULED A-9296A836-11-SEL 10/9/2011 10/9/2012 enl)I AUTOS AUTO }{ }{ BODILY INJURY 1?er acad I X X NON3WNED PROPERTY D.MAGE -— HIRED AUTOS AUTOS IPer accident I 1 Uninsured molorts,BI solit limit S 1 000,000 X UMBRELLA LIAB HOCCUR X X EACH OCCURRENCE 1 g 10,000,00 C EXCESS LIAB CLAIMS-MADE AGGREGATE ; :, 10,000,000 DED RETENTIONS 4361631 10/9/2011 10/9/2012 is D WORKERS COMPENSATION I X i I WC STAIN ACTH- AND EMPLOYERS'LIABILITY YIN' X 1 T �I- I i ER ANY PROPRIETOR/PARTNER/EXECUTIVE E L EACH ACCIDEIJT -. S SOO�JOO OFFICERWEMBER EXCLUDED? N❑ NIA __:__._-_.- (Mandatory in NH) C 4361630 10/9/2011 10/9/2012 I E L.DISEASE-EA EMPLOYEE S SOCi000 If yyes,describe under -- - DESCR!PTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT! S 5.00,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESE14TATIVE Michael J. Bonacorso ACORD 25(2010/05) ©1988;2010 ACORD CORPORATION. All rights reserved. INS025igninns'.n: Tho Ar npn name—H Inns nro ronicforo i—lrc of arnrr) ♦\,.