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HomeMy WebLinkAboutBuilding Permit #777-2016 - 50 JOHNNY CAKE STREET 1/4/2016BUILDING PERMIT <avnry q\ o ZSLlD ,67 �Q ✓f 1� L TOWN OF NORTH ANDOVER o '< APPLICATION FOR PLAN EXAMINATION Permit No#: �I Date Received 1 4 1 Ar i) gSSACHUS�� Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION SQ , D hnn�A C.aL`-- L#-#-� Print J PROPERTY OWNER J1't• Ou-tly-w-A Print 100 Year Structure yes no MAP PARCELA ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Resid tial Non- Residential ❑ New Building One family ❑ Addition ❑ Two or more family ❑ Industrial BSI ration No. of units: ❑ Commercial epair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑Other _ -- Septic ❑ Well _ _ ❑ Floodplain ❑Wetlands El Watershed District El Water/Sewer DESCRIPTION OF WORK TO BE PERF K t:U: Mats Lw�' G.�� SrcLt.li�' C�11w1o�.�. +n 0.�►•V ° vrn.1��� r ;ro J} OWNER: Name Jdentification - Please Type or Print Clearly O1%t h�.f-Ir-bQ me:q � ' ZOg • pl cl � Address: `,J� 30y`r%" Contractor Name: r y E, cup i Phone: Email:In3J� 'ova Yv�0.► Y`'� Address: PO govt 444—lnshA 113�l 1 . Supervisor's Construction License: 1�1�10 Z- Exp. Date: S Z -j 1 T Home Improvement License: ARCHITECT/ENGINEER Exp. Date: ld l I11P 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: $ �-t�' �i FEE: $ Check No.: A, Receipt No.:g NOTE: Persons contkaftind with unregistered contractors do not have access to the guaranty fund 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 COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS Reviewed On Signature Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Co Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE�DEPARTWENT Tempp[Rumpster onRsite Ny`es Locatedjaf 1244MainrSti-eet• "9 Pte `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 NOTEb and VAIA — (1 -or clepartment use ❑ Notified for pickup Call Email Date Time Contact Name Doc.BOdin,; Permit Revised 2014 We 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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks 4 Building Permit Application 4, Certified Surveyed Plot Plan Workers Comp Affidavit 4 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 OTE: 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) ;rF Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products TOTE: 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 UVN, "CA lu LN No. Date Check # TOWN OF NORTH ANDOVER Certificate of Occupancy $ _ Building/Frame Permit Fee $,2 t Foundation Permit Fee $ Other Permit Fee 4 TOTAL $ building Inspector = � Q 0 m O L '0to O LL E- .�+ T Q N 00 LLI Z z Z m C O m 7 LL 0� U C LL. 0 z Z C J d bD 7 w C LL. o z Q V W ui ai? 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Ptabbaaadiogaedpddarg6aoatadodai =174.00 Vt0N7D.AM Revtdstnbormadmaedaiatoimffii(2)budmedmdaeasthmowbbaa�amamad4eporvmtmadaast adoftbodaaoomfift SL177.S0 V@NMAIM.Rovidetaborand bmtattallvmtitdmrfiueeio(6D]o>Rerbgamamtmatoe&®oar. t170A0 BASEO►�tR C�.4i4kt4eryldalaboranda000fabmhasetl(98)tbrBPom dB.19wBeadSbeBlms iasdadoomdatpmtowa ddaa tmomaetae@tegatdm Imme a8L 517!.!0 I BBQ AdblIna afT6l"> ;gladft am a-ibdtQ,cmtmrK4OmQtt PAX3394M4W Iids bbft I soJoho4y►Cab Law Nm* Andw►masAoisas• fte" 0aoaa=10 viol Pro aSmm ostas ea aaaa.aor teo0meneaa tto t7a070 CONTRACT pop a PROGRAM CMA4� aHA.M MOM4197 lolZtmis 42MI em sohbecdmLau NodhAodaw,MA018os- JOB TION UmmamommW own gpmm%mm" I I ,rammbmwa. 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Taft i4,86 M Prograa91n $3.110A0 CustonterTataL. =1p67A8 aasAOMMAWTOMaexe •ooaaKutaWOMAN= aunAWAVOMM S.wawswop "'One Thoumd Pour Hundred My4vMen & WM80 Dolce 81 A67A9 aaeaaraamrnaroseaaveeraavieowao aYaaafeoama.e� /0 tb� 30 OAR i9�m�nw+v:meeore M G a�ddw pop a 4 homed =mdhodm I I I Roltori a ,�®ata�arybe�fmab�na g pmdwdlop ftnvwkonnrypnoparQ►. . 1�,- IMF.-. / Do The Common weafthof Maswhusetts Depw*nent of Industrial Accidents Q.Tice of Investigations I Congress Street, Suite 10,0 Boston, MA 02114-2017 wwwjnass.gov1dia Workers" Compensation Insurance Affidavit.- Builders/Contractors/Electtivians/Plumbers Applicant Information Please Print Legibly Name (Brasier ewownizwiomndiv uaw, lh�l'c IYN' &V&Al�n Adidxss: 66 Box 314 Are you an Check the appropriate box., 1.0 1 am a employer with S employees (full and/or parl-time).* 2. C3 I am a plc proprietor or partner- ship and have no employees "rking for Tric in any capacity. [No UVActs, comp. imsurante required-] a.0 1 am a homeowner doing all work myself, NN workers' comp. it umnee required.] t 4. [3 1 am a general contractor and I have hired the sub -contractors listed on the attached sheet Thesesub-contractors have employees and have workers' comp- insuranceJ S. we are a corporation and its officers have exercised their right of exemption Per MGL c. 152, k I(4), and we. have no employees. [No workers' comp, insurance required] Type or projM (required), 6, [3Nr-w construction 7. Retrad ling 8. Demolition 9. [32luilding addition 10.[] Electrical repairs or additions 11.[3PIunibing repairs or additions 12,[3R.00f repairs 1313father *Any aWficamural chcOks box 41 wk4aW fill mt tine ftaionb&w sWmgftgr workem'campmaim policy irzlbmwim, they are doingatl %vkxW*m him a new *C,NIMCTM that cbmithis box must attach ! al 24ftWW Sbml shownig, +-cwme of the ail slam uix#w, ornmOwscontitirshave unplwfm. ff the sub-contrartm- ba -.v vrpk�, they am a proNidt thtr arc Vis' a ey clamber. lam an employerdrat ispray Jiding wwrken'contpemation insuroarefat msyemployre& Below is the policy and job site informadon. Insurance Company Natw--AuL&t#—Anui(-,o,^— Policy # or Se -its. Lic. ...K `3 Job Site Address., \n (W `aka L&AL- Citylstatcaip: 0 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to seem coverage as required under Section 25A of MGL c� 152 can lead to the imposition of criminal penalties of a fiw up to $1,5M.00 andior one-year imprjw�nmcnt' as well as civil penalties in the form ofa STOP WORK ORDER and a fine of up to $250,00 a day against the violator. F—k advised that a copy of this statetrient may be forwarded to the Office of Investigations of the DIA 4.bT insurance coverage verification. I do horby cv*fy under Ow pains and ptnathes of perjury MW the infer rm•wn pro rded above is trwe and corred, Date, phme#— Ala U'AJ!"311 Officid we onto. Do nM write in &is arca, to be completed by ch or town afficiat Ctq or Town: Perladt/1.1cense # issuing Authority (drde one); 1. Board of Htalth 2. Bwlftg DepaM"I 3. CityfTown 0erk 4. Electrical Inspector 5. Plumbing Inspector 61. Other Contact Person: Phone #, A U' CERTIFICATE OF LIABILITY INSURANCE TT IS CERTMUM FS ISS #Es? AS A MATTER OF INFOR#44TION ONLY AND CDNcERS W RIGHTS ttKm THE LAR tTFTCAiE HDIXER. TH35 CERTIFICATE DOES Wt Af'a"IR?4ATtMY OR NIGAT VELY AMEND, eXTEND OR ALTER THE COVERAGE +f?t"tR. E43 P THE POLICIES snow, Tms mini ATE Of INStiT NCE D0tS NgTCONST'ITUTE A C T4TRACT BETWEEN IKE ISSUING I IRERCSa. AL(r4GRIZE? RMESEN TATIVE 9R PRCIWC£R, ANO THE CERTIFICATE HOLD", IM TAHT NOW Mghi hrstder An AT1 i IRSTJ E isr ; ,'Mug tw eQOFW It at TIC N IS' AVIED,OH EP t4mt &)d of potcy, Berta+n pow" my mqu is fm eoftoserarnt, A. statern a cm ttsfT 0"ft ob" not awdrT rNic to the cmtTcm hokw in fteu of € mt(s). Ckyton trarOn J Its AVnW km "fey AR npd Risk ;Z;; 1618 mcr"npion St Po a" so we t. (800) 6344M A�.+�,a. IBb6 2I5-8118 Na*oke MA 01"1 u>x >A�IN�:G4a�FR?3E: trut.r.:. �iBSSthf6t Ittrttl:10T4 R'YG a,�aaw�ea. Vmid�, MA Q'i"S o: ThIS IS TV CERM TFAUT TZE FX= OF WWRANCE LISTED 8El 0w;X llru! 3T#xYR IR Fm NAT , t46iiA7liSYAND3 Ah'Y RE€R?41SMEtiT. TEW COW41*N AW CSTIIt TOFt OTf*R D=Mfr4T WOH TIS A T14is G ATW40ATE MAY SE €.SUED t WyPA-9tAW, TKE WWJRAMF, APPORDED RY IKE PWUZS MSCRUD HEREW Is Se w=-cT To Acl Ti+s TERM EX t ANO COWMO OF SUCH POLCTS. LOSTS SKMVN MAY HAVE EtiF` k JCE0 S"f PAM VV TYKE t*4A : 00 003 Dov wowltrrVtt s ; c4ummIaim. t ,�a'r $_.. $ll :,53 ,. .. A415t.5P+�i!4A'.4 �. ¢Jt�A;,Ya';�'Rt Jmva'„st3 F�T3—�''+cs3i4 is�1PT�st�DF:�*'..i"t'p.i9M8�A.MKiEiS%�! — O crc.. S km -p* "qqqS t,rr,rszf�t+^a��s ll�� Kamm ExC zaCa:�esE6.c;� $ armr",a s A W0K%MV se►d*AT4m ain vTptt a� �� r £x E t ... mat rE Y�4. ''sa1AA4 '. MAARP300327 1415=15 t€af3T o% t i , s...1 r t rare "t _ El EACA ACCOW ., E L b65F.A* • r'^ilf,C*," tAe . R?"ii ts�'p ftAFN kez�a orate �9K'*,r;�aA #'-ft ,A9 tifi5r.:. wr.A.wws.a.vw aysw A4w OFTHE .AA%° Ofscke Re Pa mEsKCAxCEi.3.$:"oaao42r_ c4jatastit WE EXPPAT TATE Tom OF. No TICIE WLL K =Tam I4 Comme Svcs AWORPANUE VAN TME POLCV VP0VtS*Wo, Wosfor<att! k MA 01541 ACORD 25 (201011/ 3139 ACORbr CERTIFICATE OF LIABILITY INSURANCE F DATE(MWDDNYYY) CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, 1 7/7/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR 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 CONTACT Nancy Usher WAMEMartin J Clayton Insurance Agency, Inc. PHONE (413)536-0804 FAX (413)534-7874 AIC N -o, ExtJ;_ . -- (AIC . No):_ 1649 Northampton Street _. E-MAIL ADDRESS: P. 0. BOX 989 _ INSURER(S) AFFOR )ING COVERAGE NAIC# Holyoke MA 01041-0989 _ _ _ INSURERA:Nationwide Mutual -Harleysville INSURED INSURERB:Allie_dWorld Natl As_su_ra_nce_C_o_____ _NAT_IO Gauthier Insulation INSURERC: OX 44 ESSEX ROAD _ INSURER D: INSURER E : _ PREMISES (Ea occurrence $ IPSWICH MA 01938 1 INSURER F: COVERAGES CERTIFICATE NUMBER-CL157701379 RFVICInN NI IMRFR• 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 POLICY EXP 1 - -- - --- LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS -MADE OCCUR DAMAGE TO RENTED 50,000 OX PREMISES (Ea occurrence $ _ EXP (Any one person) $ 5,0(10 X GL43487F 7/6/2015 7/6/2016MED PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- r -- - -- JECT L—J LOC PRODUCTS - COMP/OP _ AG_G $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY (Per person)) $ ALL OWNED SCHEDULED _ J AUTOS _ AUTOS I — BODILY INJURY Per accident ' $ ( ) I NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE Per accident _$ $ X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1, 009,000_ B EXCESS LIAB CLAIMS -MADE AGGREGATE $ ___ 1 000 000 1 DED RETENTION BE020792125-194985 ;10/18/2014 10/18/2015 $ WORKERS COMPENSATION IPER OTH- 1_ AND EMPLOYERS' LIABILITYYIN 1 STATUTE ER_ r ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N / A E.L. EACH ACCIDENT $ (Mandatory in NH) E.L. DISEASE - EA EMPLOYE $ If yes, describe under--- �- E.L. DISEASE - POLICY LIMIT ; $ DESCRIPTION OF OPERATIONS below I i DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CSG, NSTAR AND NATIONAL GRID ARE LISTED AS ADDITIONAL INSURED CERTIFICATE HOLDER CANCELLATION ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD MPIdb5tLad with pdfFactory trial version www.pdffacto[y.com SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE MASS SAVE PROGRAM THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CONSERVATION SERVICES GROUP, INC. ACCORDANCE WITH THE POLICY PROVISIONS. 50 WASHINGTON STREET AUTHORIZED REPRESENTATIVE WESTBOROUGH, MA 01581 Daniel Sullivan/MEG ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD MPIdb5tLad with pdfFactory trial version www.pdffacto[y.com -A I t"1111 p v :2 c 0) c 0 p >n° � w 0) w w —0 < c) < X O(Doo CD How � R C: CL i so- '�k 'z *3 W� ,.a z 0 Cfi P > gw w C 0. 0 a! 09 iW x 3f w 0) w w —0 < c) < X O(Doo CD How � R C: CL so- '�k 'z ,.a z i IF w C 0. 0 a! 09 x 3f so- '�k 'z ,.a z w C 0. 0 a! 09 x 3f