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HomeMy WebLinkAboutBuilding Permit #607-2017 - 45 ROSEMONT DRIVE 12/6/2016V /1" BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: _ 2,6q Date Received Date Issued:_ 14 \V all items on this IMPORTANT: LOCATION PROPERTY OWNER rc MAPPARCEL& must i� Print Q� �,�LED 16 •N� it Print 100 Year Structure yes no ZONING DISTRICT: Historic District yes no `Machine Shop Village yes ( no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addi(ion ❑ Two or more family ❑ Industrial ElAlteration No. of units: El Commercial [Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer OWNER: }` Name: A JJ..__... / - 1 llUU1 GJJ Contractor Name: Ka Email: Address: 00 DhbGKIN 11L)N Ur VVUMM 1 V DC rCr-,rvrx1w' ?fication - Please Type or Print Clearly Phone �,1 �� y 616? _ Il 1�1nn m 0,11 Av�- ne Y�1 � 6 i y 114,,n I�c�,� ;� a? '� � Phone: / n �` �,. Supervisor's Construction License: 7 y Home Improvement License: C is f Exp. Date: _ l R I `. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $t FEE: $ Check No.: / 9/ 7% Receipt No.: NOTE: Persons contracting1 with nregistered contractors do not have access to the guaranty fund Signature of Agent/Owne 1 G Signature of contract _. _ - 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 o 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 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 PLANNING & DEVELOPMENT Reviewed On Signature. COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH COMMENTS ti Reviewed on Signature Zomig Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Drivewav Permit DPW Town Engineer: Signature: Located 3.84 Osgood Street FIRE DEPARTMENT -Temp Dumpster on site yes _ no. Located at 124 Main Street - -- Fire Department signature/date COMMENTS i" 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 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 ❑ 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/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. Jol- 2 tq Check # Date !7= ) Q) I I L, f TOWN OF NORTH ANDOVER Certificate of Occupancy $- Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee $- TOTAL Buildind in�pector �.CD —v CL S' = CD CD �. 0 N 0 0 N LU CD CD CD CD 0 0 CDD 0 CD M m ic TTV Cl) Z Z cn O n O mCD N -� cD c • CD n 0 ..►CL0 Oo = S� O O O O •-� O. O n O N O _ CD 0 : CD Q. OCD U) Q O rt U) , O O r+ n c7 rt O �D : S CD •a0 U3 = �: 0 O N ..r O 0 N :� ZCD S. cr .-r n CD .O. 3 0=r- ° Q O — U= 0 CL U) �' O O (D rLUID ) o o O O_ C O CD Co %. CD CD 3N O O DC rt� CD 0 �s CL N 3 (CD (D rt N (D fD p7 C 7 7o M m T 7 N Z7 O C S G7 HC 'G p T 3 y (A O n :;o O C S mM m A T �' Q� xT O C S C p�j S 7 O C S O C O_ O W C Z m f7 3 O O CL S O O T y r > rL cmc v3 ps ^^ it Com'^ � � � 4 '7 � S ►� y ,c, y1 z Cc C- iv - ;71 .r 07 r 14 J - X 1 ^ f = v a Y n a R C ti y N N v co wW �c cn Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers M Name (Business/Organizatioa&&,,ridual): Address: City/State/Zip: P&O _�- 6 J Are you an employer? Check the a p`6 r 1. [1 I am a employer with employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [Vo workers' comp. insurance required_] 3. ❑ I am a homeowner doing all work myself [No workers' comp, insurance required] t Phone #: priate box: 4. % I am a general contractor and I hate hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. incnrance.t 5. F] We are a corporation and its officers have exercised their right of exemption per DvIGL c. 152, § 1(4), and we have no employees. [No workars' comp. insurance required.] _� 1:11 &��� Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. Demolition 9. 0 Building addition 10.❑ Electrical repairs or additions 11 Q Pl , ing repairs or additions 12.❑ of repairs 13. Other �► �' ° ' 'Any applicant that checks box 91 must also fill out the section below sbowing their workers' compensation policy information. t Homeowners who submitthis affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating sash. $ Contractors that check this box must attached an additional sheet showing the name of the sub -contractors aad state whether or not hose entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer tit at- is providing workerscompensation insurance for my employees. Below Is the policy and job site information. . r ; 1 /1 Insurance Company Name: 5 Afr, - Policy # or Self -ins. Lic. #: W Job Site Address: The Commonwealth of Massachusetts OZ 15— Department of Industrial Accidents e ! .Office of ,Investigations ;a I Congress Street, Suite 100 - . Boston, M4 02114-201 ? www nnass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers M Name (Business/Organizatioa&&,,ridual): Address: City/State/Zip: P&O _�- 6 J Are you an employer? Check the a p`6 r 1. [1 I am a employer with employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [Vo workers' comp. insurance required_] 3. ❑ I am a homeowner doing all work myself [No workers' comp, insurance required] t Phone #: priate box: 4. % I am a general contractor and I hate hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. incnrance.t 5. F] We are a corporation and its officers have exercised their right of exemption per DvIGL c. 152, § 1(4), and we have no employees. [No workars' comp. insurance required.] _� 1:11 &��� Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. Demolition 9. 0 Building addition 10.❑ Electrical repairs or additions 11 Q Pl , ing repairs or additions 12.❑ of repairs 13. Other �► �' ° ' 'Any applicant that checks box 91 must also fill out the section below sbowing their workers' compensation policy information. t Homeowners who submitthis affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating sash. $ Contractors that check this box must attached an additional sheet showing the name of the sub -contractors aad state whether or not hose entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer tit at- is providing workerscompensation insurance for my employees. Below Is the policy and job site information. . r ; 1 /1 Insurance Company Name: 5 Afr, - Policy # or Self -ins. Lic. #: W Job Site Address: C, ©I � � OZ 15— Expiration Date: f' City/State/Zip: Ma V `D'- r�- 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 MGI, e. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisomnent, as well as civil penalties in the form of a STOP WORK ORDER and a fm -e 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. Ido hereby c77rwi the pains an enalties of perp" mat the nyormarton prowaea aoove is true ana curl-- 9 7 liv J,-L,Date: cam_ C � / C O/Z Phone #: Ofj7clal 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/Towu Clerk J. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: ACC)R V CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDNYYY) 02/242016 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 MARSH USA, INC. TWO ALLIANCE CENTER 3560 LENOX ROAD, SUITE 2400 ATLANTA, GA 30326 CONTACT NAME: PHONEo FAX No): E-MAIL ADDRESS: X COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR INSURERS AFFORDING COVERAGE NAIC # INSURER A: Steadfast Insurance Company 26387 100492-HomeD-GAW'-16-17 INSURED THE HOME DEPOT, INC. INSURER B: Zurich American Insurance Co 16535 INSURER C : New Hampshire Ins Co 23841 HOME DEPOT U.S.A., INC. 2455 PACES FERRY ROAD, NW BUILDING G-20 INSURER D: Illinois National Insurance Company 23817 INSURER E: ATLANTA, GA 30339 INSURER F: COVERAGES CERTIFICATE NUMBER: ATL -003741310-08 REVISION NUMBER:o 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. INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MM/DDNYYY POLICY EXP MM/DDNYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR GL04887714-06 03/01/2016 03/01/2017 EACH OCCURRENCE $ 9,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $ 1,000,000 MED EXP (Anyone person) $ EXCLUDED LIMITS OF POLICY XS PERSONAL 8 ADV INJURY $ 9,000,000 OF SIR: $1 M PER OCC GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY ❑ JECOT- [7] LOC GENERAL AGGREGATE $ 9,000,000 PRODUCTS - COMP/OP AGG $ 9,000,000 $ OTHER: B AUTOMOBILE LIABILITY BAP 2938863-13 03/01/2016 03/01/2017 COMBINED SINGLE LIMIT $ 1,000,000 Ea accident BODILY INJURY (Per person) $ X ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS SELF INSURED AUTO PHY DMG BODILY INJURY Per accident) $ HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE $ Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION$ $ C C D WORKERS COMPENSATION AND EMPLOYERS' LIABILITYSTATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Ya OFFICER/MEMBER EXCLUDED? (Mandatory In NH) N 1 A WC015519215(AOS) WC015519217 (AK,KY,NH,NJ,VT) WC015519216 (FL) 03/01/2016 0310112016 03/01/2016 03/01/2017 0310112017 03/01/2017 X PER OTH- ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE- EA EMPLOYE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below Continued on Additional Page 9 E.L. DISEASE - POLICY LIMIT I $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) V Crc l Iri%,m 1 C n%i LUCK GANGtLLA I IUN TOWN OF NORTH ANDOVER 1600 OSGOOD ST. NORTH ANDOVER, MA 01845 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 REPRESENTATIVE of Marsh USA Inc. Manashi Mukheriee TKauuaa`-L ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD `'�1e ��%)t771fJItt!/C(Yl(f1 Q�n (�7:t,rtc%uJc(�d ftice of Consumer Affairs-& BusinewRegulation l� OME IMPROVEMENTCOiVTRACTOR Registration ,126893 Type: Expire#ion:=gj3F2618 Supplement Card THD AT HOME SERVICES; INCL THE HOME DEPOT AT#10ME SERVICES MARK NIADNA 2455 PACES FERRY ROAD.;;.HSC < ATLANTA, GA 30339 t fn Undersecretary .l i,� ns and to rld'a Hoard of Suading _ u License, CS -097174 Construction SuperWsor t{APLLAN KAPC) 38 HERRICK ROAM PEABODY MA 0196