HomeMy WebLinkAboutBuilding Permit #854-15 - 45 WINDKIST FARM ROAD 4/27/2015Aw-� �F . NORTH
BUILDING PERMIT o�orytt�EoJOIN
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TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit Noz-154�( Date Received '%sa Q�ZED
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION Ih l11Z
PROPERTY OWNER.
Pnnt� 100 Year Structure yesOno
MAP PARCEL:_/J' L ZONING DISTRICT: Historic District yesMachine Shop Village yes
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
�ne family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septic ❑ Well
❑ Floodplain 0 Wetlands
0 Watershed District
❑ Water/Sewer
RIPTIONF WORK TO BE PERFORMED:
nolo 0 ! etiCts4+w Fb fc o e cx -
Identification - Please Type or Print Clearly
OWNER: Name: /� ���_v1 �a �t ro s� _ Phone: �'�`/�y'��3
Address:MC
Contractor Namj�4 hone: q
Address: 7� 7 W obvfl) _S� . W t l m c
-Uq • 6 s,=23
o (47
Supervisor's Construction License: (9-7 Exp. Date: I lit/
Home Improvement License:._.. 7,T6 ._. Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASELDf ON $125.00 PER S.F.
Total Project Cost: $ , f qZ - 7 5 FEE- $ I �
Check No.: k,205Vi(e90, Receipt No..
NOTE: Persons contracting with unregistered contractors do not have ac to the guaranty fund
Signature of Agent/Owner Sicinature of contractor_
k,
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
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
Signature.
Reviewed on Signature
Reviewed on Signature
-f Zoning Board of Appeals: Variance, Petition No:
Planning Board Decision:
Comments
ning Decision/receipt submitted yes
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 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
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
NU I 11=5 and UA 1 A — (ror a
❑ Notified for pickup Call
rtment use
Email
Date Time Contact Name
Doc.Building Pennit Revised 2014
zM
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. Date
I
TOWN OF NORTH ANDOVER
Certificate of Occupancy
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee
TOTAL $
Check # cl
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Wit-MIWTON, MA 0 -► :
IUDduxt&ttxry I
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
E H` 600 Washington Street
- Boston, MA 02111
-`� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibiy
Name (Business/organizution/In(liv.iduat):
��� '
Address: � liras
City/State/Zin:
Phone #: f-1 � ` 7.2 q - �Y�2
Are you an employer? Check the *propriate box:
I.0 1 am a emplover with
4• ❑ I tint a general contractor and I
employees (full and/or part -tithe)."
have hired the sub -contractors
2.0 1 am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub -contractors have
workingfor me in any capacity.
employees and have workers'
[No workers' comp. insurance
comp. insurance.t
required.]
5. We are a corporation and its
3.0 1 am a homeowner doing all work
officers have exercised their
myself. [No workers' comp.
right of exemption per MGL
insurance required.] '
c. 152, §1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. 0 New construction
7. 0 Rentodelinty
S. 0 Demolition
9. 0 Building addition
10.0 Electrical repairs or additions
11.0 Plunnbino repairs or additions
12.0 Roof repairs
13.0 Other
'An, applicant that checks box #I must also fit out the section below showing their workers' compensation policy information.
' I lonicowners 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 subcontractors 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./or inv employees. Below is the policy and job site
hiformation.
Insurance Company Name: • . U 4 .-SMI S . h iel
Policy # or Self -ins. Lic. #: W CC 500"501 '4 09 aO) %4tt+ Expiration Date: it NIS
loh Site Address: tJJ`^ U)tl. at );rrh �� - City/State/Zip: r ✓1 �o��I G1
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to suture coverage as required under Section 25A of MGL c. 1.52 can lead to the imposition of criminal penalties of a
fine tip to S 1.500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a line
of up to 5250.00 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 certtf,�v�utrder the paints and penalties of perjury that the information provided above is true and correct.
Phone #:- _ _, a 1 - `a 3
Offrcial 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. Hoard of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
--moi 9MCNA01 OP ID: OP
lawrrv� CERTIFICATE OF LIABILITY INSURANCE
7TE
INSR
-F
04/01/2015
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NgGAT(VELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CEIMFICATE 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(les) must be endorsed. If SUBROGATION I5 WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate do" not confer rights to the
certificate holder in lieu of such endorsamant(s).
PRODUCER
John J Walsh Ins Agency, Inc
P b Box 4407
Salam,MA O01970-W7ADOR6ss.
David C Bruett
CMTA --
NAME. cT David C Bruett
PHONE . 978.7115.3300 ; No ; 978-745-9557
�aishi
dbruett@waishirisurance.com
INSURERS) AFFORDING COVERAGE NAIL c
0210912016'
INSURER A; Traveler's i
PrrEs 300,00
INSURED McNary Construction
Joseph McNary
767 Wobum Street
iNsuRma A.I.M. Mutual ins. Companies
INSURER C:
Wilmington, MA 81887
INSUReRRD:
�uaER c
rNSURER F '
GENERAL AOORE ATE $ 2,000,0
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOp
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT '0 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 CLA!►Y.S.
TYPE Of INSURANCEALIUL
INSR
-F
THE EXPIRATION DATE THEREOF, NOTICE NULL BE DELIVERED IN
POLICY NUMBER
MWo LICY EFFLMTS
POLICY EXP �
GENERAL lJABA.ti'Y
A COM IJERR W�LGEN ERA L I-1AeUTY
I CL4jM -- OCCUR
in Om Owners
AUTHORIZED R6PftE$ENTAnve
PO Box 1111
��r} 6621P22A-1642
02108/2015
0210912016'
EACH OCCURRENCE S 1,000,00
PrrEs 300,00
KED EXPAry o-* s 5,00
PERS'Ot� &ADViNJURY s 1,000,00
—
I
#
GENERAL AOORE ATE $ 2,000,0
GEN'L AGGREGATE UMIT APPLIES PER:
POLICY PRD. LOC
AUT010011ILE LIA9LrrY
ANY AUTO
ALL OWNED ^ SCHEDULED
AUTOS
NONOOr1I
M_
V1D
HIKOAUTOS AUTO&
PROpLiCT$-COMP/OPAGG S 2,000,00
�
jS
CdA181ar N Si #
S
� SOCILY INJURY
i B� ; Y INJURY (P(Per&cci0om) 5
PftOPERTYDArAAf,E S
f ER ACCt9EN _
�
UMBREI I A i.IAA OCCUR
I
EACH OCCURRENCE 15
D(CESS UAa CLAIrw& MADE
II
AGGREGATE b
I DED ! j RErENmcws
S
i LYORIUM COMPENSATION
# AND EMPLOYERS' LIABkITY
S ANY PROP.Rie7ORpARTNERlE]tECI.mVtY1N
OFRCEP4JEMBER ExUWDED?
(Mandatory in NN)
If pis desc+ibc ka+der
Df .R�PT10 J OF OPERATIONS below
N/A
CC60(iS014O81-2014A
111fM2014
i
V4C 5Tr�TU- N.
ITS
1111412016; ELL EACH ACCIDENT $ 500,00
FEL
E.J„ DISEASE - EA EMAL6 S 500,00
S.P.L. O;SEASE - K)L.#CY LIMIT S 500,00
E
,PROPERTY S,84
111
DESCRIPTION OF OPERATIONS 1 LOCATIONS I vr;HrAfs (Atlath ACORD dila Adarponal RunaAta Sthedu*, P marc space it required)
Lowe's Companies, Inc and any and all subsidiaries arp additional insured
with r*"Ct to commercial gcnoral liabilty. waiver of subrogation applios
per written contract.
CERTIFICATE IFICATE HOLDER C.ANCE 1 ATlruu
01988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010105) The ACORD name and 1090 are registered marks of ACORD
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Lowe's Companies Inc
THE EXPIRATION DATE THEREOF, NOTICE NULL BE DELIVERED IN
and any and all Subsidiaries
ACCORDANCE WITH THE POLICY PROVISIONS,
Attn: Vendor insurance
AUTHORIZED R6PftE$ENTAnve
PO Box 1111
N Wilkesboro, NC 28M
David C Bruett
01988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010105) The ACORD name and 1090 are registered marks of ACORD