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Building Permit #730 - 46-48 MAIN STREET 4/17/2012
Permit N0: Date Issued: BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received —+" ft' Z IMPORTANT: Applicant must complete all items on this 7 �6• ryO\ ,x \�4 tee.lrt Ivncw � 7` T/ DESCRIPTION OF WORK TO BE PREFORMED: �J Identifica 'on Please Type Qr Print Clearly) Vi ®vY mi Phone: Cli- 8� ` 3 OWNER: Name: ARCHITECT/ENGINEER Phone: Address: �^ Reg. No. FEE SCHEDULE: BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ 110 FEE: $ I 451 Check No.: 1 U Receipt No.: g� NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund If L - I Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Seng Pools ❑ Well ❑ Private (septic tank, etc. ❑ Tobacco Sales ❑ I Food Packaging/Sales ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS I Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/signature date Located at 384 Osgood Street Driveway Permit OT1 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 2007 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 - Li 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 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 Location "/' H Q, —NtL° e No. t � Date 17 1 Z' s'= TOWN OF NORTH ANDOVER 46 Certificate of Occupancy $ Building/Frame Permit Fee $ 4 Z— Foundation Permit Fee $ `� Other Permit Fee $ TOTAL $ Check #- 25183 25183 Building Inspector 4/13/2012 10:24 AM FROM: MTM Insurance MTM Insurance Associates LLC TO: 978-688-9542 PAGE: 001 OF 001 L'� CERTIFICATE OF LIABILITY INSURANCEF4/13/2012 DATE Y) 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(les) 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 MTM Insurance Associates 1320 Osgood Street North Andover MA 01845 CONTACT Linda MurrayNAME: AIC No Ex (978) 681-5700 AIC No: (978)681-5777 E-MAIL ADDRESS. 1lndam@mtmin5ure.COm INSURERS AFFORDING COVERAGE NAIC S INSURER A.Decoti s Insurance Assoc of MA INSURED Verdeco Designs 28 Andover Street Andover MA 01810 INSURER Atlantic Charter Ins Group INSURERC: INSURERD: INSURER E: INSURER F COVERAGES CERTIFICATE NUMRER-12-13 RFVISlnm Nt1MRFR• THIS IS TO CERTIFYTHAT 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 MMIDDIYYYY POLICY EXP MMIDDfYYYY LIMITS A GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR CIP127898 /17/2012 /17/2013 EACH OCCURRENCE $ 1,000,000 DAAX REMM S TO RENTED PREMISES Ea occurrence $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER : FX -]POLICY .P Coi LOCI PRODUCTS - COMP/OPAGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNEDSCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS COMBINED SINGLE LIMIT Ea accident BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROt PROPERTYDAMAGE $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PRO PR I ETOR/PARTNERIEXECUTI VE 0 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A 00951301 /4/2012 /4/2013 WC STATU-OTH- TOR LIMITS ER E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE, $ 500,000 E.L. DISEASE - POLICY LIMIT 1 $ 500,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Certificate holder as listed below CFRTIFICATF 41n1 nFR rANrri I ATInKi (978)688-9542 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. Building Department AUTHORIZED REPRESENTATIVE 1600 Osgood St. N Andover, MA 01845 M Laorenza/LINDA ACORD 25 (2010/05) © 1988-2010 ACORD CORPORATION. All rights reserved. INS025 (201005).01 The ACORD name and logo are registered marks of ACORD W W y as c c:~ Ots N •`f0.1 V VCR= C R O m C ;= O O N ct E Q mCE O a E.S :60 CD cc . c+ :mcmCL.E N la m O : L L c :m3 c ' J � m -p mc m 'O wa`i L ym; N d C t i 02 'C V N O. C O C m F- (a c Q m :ora :a W C OrC-.'flt C my... Cr H CO)•at . C °C E Ca � v H LU CD ® oma= y a ma O;a = ca W i H �O 1-- Z � a_. m O j M�1 L: Lm u O C/) � z . CO c W U CD CD C Cf) 32 m � � b O cm C �C N m r _ O Z 0 Cl 0 0 L 0 � Z CL O CO) 0 Q! 02 C ._ .CO2 CD F mCD CD CD m CL H� _ cc CA CD OL d CL a 0 � Cc v J •p CD .0O3 z ts CD CL C.± y c C C■_ a _cc 0. CO2 0 W U) C4 19 W W U) w2 U) O w2 w a O U w O W a�' W 4 O a w w cn y as c c:~ Ots N •`f0.1 V VCR= C R O m C ;= O O N ct E Q mCE O a E.S :60 CD cc . c+ :mcmCL.E N la m O : L L c :m3 c ' J � m -p mc m 'O wa`i L ym; N d C t i 02 'C V N O. C O C m F- (a c Q m :ora :a W C OrC-.'flt C my... Cr H CO)•at . 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CO2 0 W U) C4 19 W W U) Nlassachuset>?s - Department of Public Safety Board of Buildinl- Re!-ulations and Standards Construction Supervisor License license: CS 105187 MARK YANOWITZ 20 WILD ROSE DR ANDOVER, MA 01810 Expiration: 7/11/2013 t',unmi.�f uicr Tr#: 105187 Office of eo�mer airs iuess egu an r HOME IMPROVEMENT CONTRACTOR Registration: s?168762 Type:- ;: Expiration: ,`4/5%2013 LLC V CO DESIGNS, LLG j =- ,> MARK : YANOWITZI`= _� =.1 ,-:; "•' ' 20 WiLD.ROSE ANDOVER, MA 61810:-"i -= Undcrsec'ret y The Commonwealth of Massachusetts - Department of IndustriglAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/OrganizatiorAndividual): Address: City/State/Zip:_ k�,ove,-- Phone #: Are you an employer? Check the appropriate box: Type of project (required): L ❑ I am a employer with 4. I9 T am a general contractor and 1 6. ❑ New construction employees (full and/or -part-time).* have lured the sub -contractors 2. V 1 am a sole proprietor or partner- listed on the attached sheet. �• E] Remodeling tr ` ship and'have no employees These sub -contractors have 8. b4 Demolition working for mein any capacity. workers' comp. insurance.g, [] Building addition [No workers' comp. insurance 5. El We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] t employees. [No workers' comp. insurance required.] 13.❑Other *Any applicant that checks box#1 must also fill outthe section bel6w 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 anew affidavit indicating such. tContractors 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:. kaw�c caeva� Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address:_ `1 II Y ► al VI 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 requiredunder 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 DTA for insurance coverage verification. I do hereby certIfy under the pains andpenalties ofperjury that the information provided above is true and correct. LZ og I 2V 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 #: Informati®n and Instructions 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 ofpublic 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. I£ an LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents fox 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 of 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 town)" 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. Anew 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 bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone anal fax number: The Commonw.ealth of M0ss0,rhvsefts De-parhxtent of Industrial Accidents Office ofhivcstigatlons 6.00 Wa.sb ngtoa Street Boston} MA. 02111 Tel, # 61.7-727,4900 ext 406 or 1-877:MASSAFR Revised 5-26-05 Bax # 617"727-7749 www-wass,govfdza