HomeMy WebLinkAboutBuilding Permit #534-11 - 45 HIGH STREET 1/10/2011TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: 6-3
Date Issued: -/G —U
IMPORTANT:
Ens- H
Date Received
nt must complete all items on this
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Print
PROPERTY OWNER C . G
Print
MAP NO: % PARCEL: 109 ZONING DISTRICT: Historic District (0 no
Machine Shop Village 0) no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
0 One family
0 Addition
0 Two or more family
❑ Industrial
)<Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
0 Assessory Bldg
❑ Others:
❑ Demolition
0 Other
- C .1 .,.... , W. s.y'.ys S ,- ., ,.. -.,
Septic � Well
.Y � � ..,{ , ,,.:. _ .:. '
❑ Floodplam ❑Wetlands -
� F< � ,• , , ;,roti :.
❑ Watershed District;
0 Water /SewerMAI
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OWNER: N,
DESCRIPTION OF WORK TO BE PERFORMED:
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ifi tion Please Type or Print Clearly)
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AddressJv 1-j-6 (d L) 1 17 1 vow (014, �G-, 3Jn J-1'`^"
IL M #9 0 z..r 4-.?
CONTRACTOR Name:
6
Address: l I
l R. #,-i rJ WK iE- L- n vim► Phone:
C,tH Mcg"6
L5
Supervisor's Construction License: GS (, 3 fit— Exp. Date
Home Improvement License: I O $ tt— Q L) Exp. Date:
vigs. dzti �/ a
12,b(ZcsI1
ARCHITECT/ENGINEER t5 yr -'I c ` Phone: L IJ 13
0Lq iC
Address: 3 0'� (f4 N S 1(V-1 1?y-f'o of t1A. Reg. No. 0 �' D
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ 0 o k FEE: $ -':1-2 A X
Check No.: n O'IS Receipt No.: 6p3e5 b
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner Signature of contractor
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
PLANNING & DEVELOPMENT ❑
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE APPROVED
Reviewed on Signature
Reviewed on Signature
4oning Board of Appeals: Variance, Petition No:
Zoning Decision/receipt submitted yes
Planning Board Decision:
Comments
Conservation Decision: Commen
Wafer & Sewer Connection/Signature Date
Driveway Permit
DPW Town -Engineer: Signature:
FIRE DEPARTMENT - Temp Dumpster on Si yes Located384Osgood Street
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 2008
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
o Certified Surveyed Plot Plan
o 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)
o 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
13 Certified Proposed Plot Plan
o 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
o 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
Chat 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
Location
No. 5" 3 Date %
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $ F.
Other Permit Fee $
TOTAL $
Check #
23850 Building Inspector
ujfice of investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeEibly
Name (Business/Organization/individual): �~ 6— (r L <�_
Address: 1 g1 %t A %.o 0 -C,=t _- V I I& ( D 0
City/State/Zip: So h\S� I 1 L "4"t 0 -Li 4-? Phone #: � li — 6 LJ
Are you an employer? Check the appropriate box:
1.Ef I am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet. +
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp, insurance.
[No workers' comp. insurance
5. [:1 We are a corporation and its
required.]
officers have exercised their
3. ❑ I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
1 l.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
*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 their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Q
Policy # or Self -ins. Lie. #: W 0 C' 3 D 1 0 9 :9 3 -Expiration Date: �tJ ' Z-
�, l Ri, O 41 l�. `9W0 JJ� 1 ,-, � � r
Job Site Address: r 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 andpenalties ofperjury that the information provided above is true and correct.
/ I
Si ature: rk Date: 6
Phone #:
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 #:
dirt la- loxcq
ACORD. CERTIFICATE OF LIABILITY L.ITY INSURANCEDATE
(MMIDDtYYYY)
N
1102/2010
PRODUCER
INSURANCE MARKETING AGENCIES
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
306 MAIN STREET
WORCESTER, MA 01608
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
508 753-7233
INSURERS AFFORDING COVERAGE NAIC #t
INSURED RCG LLC
INSURER II Wesco Insurance Company 25011
INSURER B.
17 IValoo Street, Suite 100
INSURER C
Somerville, MA 021413-3656
INSURER D:
INSURER E
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
N
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
POLICY EXPIRATI NDATE IMMI'DDIM
llMfiS
GENERAL LIABILITY
EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY
CLAIMS MADE M OCCUR
DAMAGE TO RENTED
$
MED EXP (/4ry one per=m) $
PERSONAL & ADV INJURY $
GENERAL AGGREGATE $
GEN'L AGGREGATE LIMIT APPLIES PER
POLICY M jE Q LOC
PRODUCTS - COMPIOP AGG $
AUTOMOBILE
LIABILITY
ANY AUTO
COMBINED SINGLE LIMIT $
( t)
ALL OWNED AUTOS
SCHEDULED AUTOS
BODILY INJURY $
(Per Person)
HIRED AUTOS
NON -OWNED AUTOS
BODILY INJURY $
acadent)
PERTY DAMAGE $
attident)
rAUTO
GARAGE LIABILITY
ONLY - EA ACCIDENT $
1
ANY AUTO
HAUTO
OTHER THAN EA ACC $
ONLY: AGG $
EXCESS/UMBRELLA LIABILITY
EACH OCCURRENCE $
AGGREGATE $
OCCUR ❑ CLAIMS MADE
$
DEDUCTIBLE
$
RETENTION $
$
A
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
WWC3010833
05/15/10
05/15/11
X We LIMIT orH-
EL. EACH ACCIDENT $500,000
ANY PROPRIETORIPARTNERIEXECUTIVE
OFFICERINAIEMBER EXCLUDED?
If yes, describe under
YES
E.L. DISEASE - EA EMPLOYEE $500 ,000
E.L. DISEASE -POLICY LIMIT 1 $500,000
SPECIAL PROVISIONS bemw
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT SPECIAL PROVISIONS
ncorrrnwrr un..�r..
FOR INFORMATIONAL PURPOSES
LD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL _2n DAYS WRITTEN
* TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
iE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVE
ACORD 25 (2001/08) 1 Of 2 #S188839/M188838 GCE 0 ACORD CORPORATION 1988
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