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HomeMy WebLinkAboutBuilding Permit #197-14 - 49 ROYAL CREST DRIVE 9/3/2013 O� ttORT11 1 BUILDING PERMIT TOWN OF NORTH ANDOVER F ~ p APPLICATION FOR PLAN EXAMINATION Permit NO: �/ 7—� Date Received Date Issued: �4SS�cHUS IMPORTANT:Applicant must complete all items on this page f ��gCooisl 30 RoyAL- Ci sr y�wG= /Ur�R7({ Au.�F� MQ Print ;'PROPERTY OWNER 41&N /✓o;z-rR Aw)oUi5iL , (-1, Print :�11AAIVO; ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential " ❑ New Building ❑One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑Commercial A Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other q Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District El-WaterlSewer y2(�rGl�tcn Identification Please Type or Print Clearly) OWNER: Name: `� lUp�fr( INvE Phone: Address: o JAL CP-EIvc (( 0/ y CONTRACTOR Name: Phone: '408s Address: %Kw�s%E �zsu� , Uyir Z/- , .SAt6N NY en 3Z'? .Stapervisor's:Construction License: ' Exp. Date: l` � '-il;6 e Im fovement License: / Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. S � FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 3y, qlo. -- FEE: $ Check No.: Receipt No.: Q/ NOTE: Persons contractingwith unre istered contractors do not have access g ss to thef uaran and g ignature of Agent/Owner Signature of contractor --- 1 Plans Submitted ❑ Plans Waived❑ Certified Plot Plan ❑ Stamped Plans TYP&OF-.SEWEPAGE.DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑. . Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ i Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS .CONSERVATION Reviewed on Signature COMMENTS P HEALTH Reviewed on Signature z COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes- .. Planning Board Decision: Comments Conservation Decision: Comments Wates & Sewer Connection/Signature& Date Driveway Permit DPW'I ow2.Engineer: Signature: Located 384 Osgood Street (FIRE-DEPARTW_;'Nt -Temp Dumpster on site yes no ,Located at 124 Mair,. 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 I NOTES and DATA— For department use I I i I I El Notified for pickup - Date i Doc.Building Permit Revised 2010 Building Department The fohovving is a list of the required forms to be filled out for the,appropriate.permit to be obtained. Roofivg, 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 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) a 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 cas<s if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apn-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submAted with the building application Doc: Doc.Building Permit Revised 2012 6i'f " Location � Rd No. 12 Date t r • - TOWN OF NORTH ANDOVER F i. . Certificate of Occupancy $ J t Building/Frame Permit Fee $ 6a i r Foundation Permit Fee $ Other Permit Fee. $ 4 TOTAL $ Check# a 26801 (Building Inspector i .� OORTH Town of .. ' E 'A', n over ,I A 0 No. Iq Z ver, Mass, l COC"KHI ICK SAO PSV S V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT - - BUILDING INSPECTOR ......... ..... .Q......��..:``..�..:...........� ................................................ has permission to erect . buildings on �? �� �.(......Cff'�s� Foundation .......!.....`.i..... .... ............... ............. . ............. to be occupied as � -- , roe Rough .�.�/..�:t.,,1 1.......................�.............�°.........r5�'. ...... Chimney 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 CONSTRUCTION RTS Rough Service ................ ...... .. ..................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. IF SEE REVERSE SIDE it ACC)RV CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 8/28/2013 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 NZTE�CT Diane Hall Alliant Insurance Services, Inc. PHONElA'C 13-443-2472 ac No):213-270-0984 333 South Hope St., Ste. 3750 EMAIL Los Angeles CA 90071 ADDRESS: INSURERS AFFORDING COVERAGE NAIC# INSURER A:The Ins Co of the State of PA 19429 INSURED INSURER B-Chartis Specialtyn r n American Technologies, Inc. INSURERC: 2 Northwestern Dr., Ste.2C INSURER D: Salem, NH 03079 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:2117784703 REVISION NUMBER: 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 TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LTR IN R WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS A GENERAL LIABILITY GIL 5142564 /1/2013 /1/2014 EACH OCCURRENCE $1,000,000 XCOMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $100,000 CLAIMS-MADE ITI OCCUR MED EXP(Any one person) $10,000 X Contr Liab Incl PERSONAL&ADV INJURY $1,000,000 X XCU Included GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 JECT F7 POLICY X PRO- LOC $ A AUTOMOBILE LIABILITY CA 3275235 /1/2013 /1/2014 COMBINED SINGLE LIMIT Ea accident $1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED Pe°rPER DAMAGE $ X HIREDAUTOS X AUTOS UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ A WORKERS COMPENSATION C 015655931(CA) /1/2013 /1/2014 X WC STATU-S I OTH- A AND EMPLOYERS'LIABILITY Y/N C 015655932(AZ) /1/2013 /1/2014LIM A ANY PROPRIETOR/PARTNER/EXECUTIVE C 015655933(TX&OS) /1/2013 /1/2014 E.L.EACH ACCIDENT $1,000,000 A OFFICER/MEMBER EXCLUDED? N/A C 015655934(NH&OS) /1/2013 /1/2014 A (Mandatory In NH) C 015655935(MA&OS) /1/2013 /1/2014 E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 B Contractor's Poll Liab- P01364273 /1/2013 /1/2014 Each Loss $1,000,000 Professional&Mold Liab Aggregate $2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Apartment Investment and Management Company(AIMCO), and any of AIMCO's subsidiaries and affiliates that may directly or indirectly own or manage the property at or for which CONTRACTOR performs any Work, and their respective partners, managers, members, employees,officers,directors,trustees,shareholders,counsel, representatives,agents,successors and assigns are included as Additional Insured as respects Liability arising out of operations(work)performed by or on behalf of the Named Insured as required by written contract. Reference Number: PROPERTY NAME: ROYAL CREST ESTATES(NORTH ANDOVER)CONTRACT NO.: 15739-401064-CP-00001 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN AIMCO NORTH ANDOVER, L.L.C. ACCORDANCE WITH THE POLICY PROVISIONS. 50 Royal Crest Dr. North Andover MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Print For Department of Industrial Accidents Office of Investigations 1 Congress Street,Suite 100 - Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): XfER1eAJ Address: 2I`l�Rr�lw>rs�rR1J !z� 1/,t/�fi ZL City/State/Zip: 6A.1-c-AA , A/At 03©-�j Phone#: 6,03-X39,! 0'0, Are you an employer?Check the appropriate box: Type of project(required): 1.MI am a employer with S'j96 4. F] I am a general contractor and I YU employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.# required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.E] Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no [/ 11, employees. [No workers' 13.% Other dt✓ 0iglt comp. insurance required.] fip t ' *Any applicant that checks box#I 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 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 for my employees. Below is the policy and job site information. Insurance Company Name: 7_4.- TiJ.SLZA>�c C,,, 6F 74 _$rA- or ?A Policy#or Self-ins.Lie.#: 01565S93S Expiration Date: el/17-44y Job Site Address:_ 50 Roya4 6x45 ' 'D'auc City/State/Zip: N 4WbL,6II , ,474 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 gins and enalties o er'u that the information provided above is true and correct. Si afore: " Date f'l 3� )3 Phone#: 603.870 BS` 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#: Massachusetts-Department of Public Safety Board Of Building.Regulations and Standards Construction Su.perl-isor License: CS-093599 BRIAN 558 E LOWELL 1 1�y �_ t,a�a Crnnmissioner Expiration _ 04/20/2014 .. I