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HomeMy WebLinkAboutBuilding Permit #111-11 - 525 TURNPIKE STREET 8/5/2010 i BUILDING PERMIT Of NoRDTH qti TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received A�RArea � � i) �SSHCHUS�� Date Issued: (� IMPORTANT: Applicant must complete all items on this page � ��� ���.. �•..'�'+'�-d �s V YrudP^.+"'.-.` '.Yrs uze'4�� � .-,Thad i'7i � t � '�"t � � � � a3 d�.Y"' ?w r AP2 RCS ON]NGIB�RICTwD�stn � o «oma. TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other '*w ..,>_ oodpir a#eR-0 sf iedI?rs#r+ �.� � s }, DESCRIPTION OF WORK TO BE PREFORMED: Rem a (z e �4 C- T-t o Identificati n Please Type or Print Clearly) OWNER: Name:-2 ,4e- A% Phone(-7/7 )76/-x(.83 Address: % LL p "e9+ �yn'r. 2" t" � i '.t` 4.'r"'�f° �'& s * '' 3�� �# ' Rz rw k4' � °`"ter .3."s., n"° t.�x.'- r t :� ac r. ., w,�„ "3•a, :. .� �. ._F CON, IZA des t`� �A 'Address. h k „T x 'c 53t .:: •-. F Ile, w ARCHITECT/ENGINEER o, , � /`y/?v, 7Phone: 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: $ _ 3 �J� , FEE: $ Check No.: S 3 / Receipt No.: NOTE: Persons contracting with unregistered*contractors do not have access to the guaranty fund i Location No. Date01 NORTH TOWN OF NORTH ANDOVER 4, 9 i • • Certificate of Occupancy $ 's�s',.•o'Eta Building/Frame Permit Fee $ s�GMus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # �J 233uG Building Inspector NORTH -TO" Of _ .. Andover , No. //� - d��/ = - - �`u 0^ o dower, Mass., ID Y Q LAKE ^, COCMIC EWICK V 7,95 RATED P? C:) �l BOARD OF HEALTH Food/Kitchen 'PEKM .1 T T Septic System BUILDING INSPECTOR THIS CERTIFIES THAT .............................................................................................................................. Foundation ..................... buildings on �. ... . ...... . ......... Rough has permission to erect.................. g .�. . ............. to be occupied.as....... .....C�. .... .r-... �...........�C1...... .1°.t ....�...... .........�) !.. Chimney provided that the person ac epting this permit shall in every respect conform to the ter the application on file in Final 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 CONSTRUC STARTS Rough ........ ...... .... .......................................... Service. -----�-� IG INSPECTOR Final Occupancy Permit Required t0 Ocmpy Building GAS INSPECTOR Rough Display in a Conspicuous Place on thel 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. SEE REVERSE SIDE Smoke Det. 07/22/2010 15:41 2078838371 AAA ENERGY SERVICE PAGE 01/01 BUILDING PERMIT a N•aosN,� TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION s � r ParmIt NO* Oat*Received arC i DIPORTA=NT:A licant must cant ae all iterns on this paLoc TYPE OF IMPROWMENT PROPOSED USE 1 Residential + Note-Residential Now Igulk ing One family Adc� on Two or more family Industrial if Alteration i No.of Unlit: Commercial Repair, replacement Aasessory Bldg Others: Demolition Other r DESCRIPTION OF WORK TO BE PREFORMED: !ace Idetui8ea Please Tcpe or Print Cteady) OWWR: Name-2.4c b.. Address: U. �+ YS91yj71q Q. Wb R H - A C ITECT /ENGIN E E R 4 y Address: ZSR- Pv2.1d(PJ_ i'ty LA41" 1 E R No- 3 3 PEE MG VLL BULL PRMW.s11o0 PER ito00.o0 OF t1vE raTAL t TeD�St BASEQ�►fl3S.Od PEIt SF. Total Project goat S 3 �J FEE: S Check No.: Receipt No.: N OTE: Persons emmmSng with unreswered MbwMars donor have acnes to rhe guamnty fund i:�, �'! The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Nrashington Street Boston, M4 02111 www mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Avolicant Information Please Print Legibl Name (Business/Organization/Individual):A A/'x — —CG",( •C� Address: Q i; SC;LLA LN A City/State/Zip:_V b Phone CB • •�g 8 7F01 mployer?Check the appropriate box: m to er with 4. Type.of project(requited): P y _ ❑ I am a general contractor and I ees(full and/or part-time).* have hired 6. ❑New construction the sub-contractors ole proprietor or partner- listed on the attached sheet I Remodeling ship and have no employees These sub=contractors have 8. Demolition working for me in any capacity. workers' comp.insurance. [No workers' comp.insurance 5. 9• [1 Building addition P ❑ We a corporation and its required.) officers have exercised their 10.7 Electrical repairs or additions 3.❑ 1 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 insurance required.]t 12.[J Roof repairs q ) employees. [No workers' comp.insurance required 13.❑ Other C IV `A.ny aPPlicant that ch._cks box-#1 must ) also fill out m_section bei�iv showing taerr v�o:?;ers'comY�;-tion posc} info.:�ation. f 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 their workers'comp policy information, I am an employer that S workers'idi is rovn P compensation ins com P urance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: C Expiration Date: Job Site Address:_5�J City/State/Zip: UOM&\ N (a Ndove Attach a copy of the workers' compensation policy declaration page showing the he ( policy n b P y umber and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 fine up'to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the forad to m off a STOP WORK ORDER and imposition of criminal penalties 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 fhe pains and penalties of perjury at the information provided above is true and correct Si ature: Date.: (� `I Phon #: 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 S.Plumbing Inspector 6. Other Contact Person: Phone#,: Information ann d 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 pe—rson 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 notbecause 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 coxnpliance with the insurance coverage required." Additionally,MGI;chapter 152, §25C(7)states"Neither.the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptableevidence 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),addresses)and phone number(s)along with their certificates)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. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for 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 amlication.for the permit or license is being req•tes+„ed,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. A new 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. . T1ae 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 and fax number. .The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-72.7-4900 ext-406 or 1-877-MAS.SAFF- Revised 5-26-05 Fax#r 617-727-7749 vvvk=v,.mass._o ov/dia .R- AORDM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 10/01/2009 PRODUCER (603)224-2562 FAX (603)224-8012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION The Rowley Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 139 Loudon Road ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 511 Concord, NH 03302-0511 INSURERS AFFORDING COVERAGE NAIC# INSURED AAA Energy Service Co INSURERA: Charter Oak Fire Ins Co 001109 PO Box 908 INSURER B: Travelers Prop Cas Co of Amer Scarborough, ME 04070 INSURERC: Maine Employers Mutual Ins Co 0008 INSURER D: INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LTR NSR DATE MM/DD DATE MM/DDIYYYY LIMITS GENERAL LIABILITY DT-CO-7093M995-COF-09 10/05/2009 10/05/2010 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAG ETO R occurrence $ 300,000 CLAIMS MADE OCCUR MED EXP(Any one person) $ 5,000 A • PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY X PRO- LOC JECT AUTOMOBILE LIABILITY T-810-7426M235-COF-09 10/05/209 10/05/2010 COMBINED SINGLE LIMIT X ANY AUTO (Ea accident) $ 1,000,000 ALL OW NED AUTOS BODILY INJURY A SCHEDULED AUTOS (Per person) $ HIREDAUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY - AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY DT M-CUP-7426M260-TIL-09 10/05/2009 10/05/2010 EACH OCCURRENCE $ 3,0000000 X OCCUR F1 CLAIMS MADE AGGREGATE $ 3,000,000 B $ DEDUCTIBLE $ X RETENTION $ 10,00 $ WORKERS COMPENSATION ME / 1810079281 10/05/2009 10/05/2010X ORY L MITS ER AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N 3102800842 E.L.EACH ACCIDENT $ 500,000 C OFFICER/MEMBER EXCLUDED? �� (Mandatory In NH) 3A: NH,CT,VT,NY,PA E.L.DISEASE-EA EMPLOYE $ 500,000 If yes,describe under E.L.DISEASE-POLICY LIMIT $ 500 000 SPECIAL PROVISIONS below eased/Rented T-660-6976M014-COF-09 10/05/2009 10/05/2010 Limit: $50,000 A Equipment Deductible: $500 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS overing operations performed by the insured during the policy period. ite Aid Corp. is additional insured with respects the GL coverage as required by written contract. Lexce ering all locations the name insured does work at. 10 days for nonpayment of premium CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30* DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Rite Aid Corp. IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR 30 Hunter Ln. REPRESENTATIVES. Camp Hill , PA 17011 AUTHORIZED REPRESENTATIVE dJ Karen Stapley/KS ACORD 25(2009/01) ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER This Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25(2009/01) Department of Public Safety , f ' One Ashburton Place, Rm 1301 t Boston, Ma 02108-1618 { License: Refrigeration Contractor License ' Number: RC 018340 Expires:05/11/2010 Restricted To: 00 t WARREN P WEATHERBEE 1' 213 DLTNRO13IN RD 'a MASHPEE, MA 02649 Tr.no: 3172.0 Keep top for receipt and change of address notification. DPS-CAI G 5OM-07/07-PC8490 ✓/ie TDo vw.. 4.14 n�/ aaaad��wek2 DEPARTMENT OF PUBLIC SAFETY Refrigeration Contractor License Number: RC 018340 Expires:0511112010 Tr.no: 3172.0 Restricted: AAA ENERGY SERVICE CO WARREN P WEATHERBEE 213 DUNROBIN RD G— MASHPEE, MA 02849 DIG SAFE CALL CENTER: (888)344-7233 Commissioner f_J ✓!ee fn'amr�,aoncueal,Db o�',..Glaa�.rc�ie..aeG ', DEPARTMENT OF PUBLIC SAFETY f Refrigeration Contractor License Number:, RC 018340 Expires: 05/11/2012 Tr, no: 3059.(. Restricted: AAA ENERGY SERVICE CO WARREN P WEATHERSEE i 100 OAKVILLE AVE OSTERVILLE, MA 02655 Commissioner `1 i Awy I i ��ce 1°aninw�u� �,/�o,�oac�ivaelta DEPARTMENT OF UBLIC SAFETY Refrigeration Technician License Number: RT 132498 Expires: 04/09/2012 Tr.no: 2711.0 Restricted: GEORGE W BLANCHARD 14 HILLS RD HOOKSETT, NH 03106 G' Commissioner i NORT Iy ® O _ Andover . O ,N No. ` }� o dover, Mass., Y` D " LAKE It. COCMICMEWICK V BOARD OF HEALTH Food/Kitchen Septic System .PERMIT T D BUILDING INSPECTOR THIS CERTIFIES THAT ............ ..... ................................................................................................................................ Foundation has permission to erect. ........................ buildings on . .. � it. ..... �.. .. ......... Rough ............... ............. .................. to be occupied.as....... ...... ..... ,l,lj.e ........... ........3.)�....� .......... Chimney provided that the person ac epting this permit shall in every respect conform to the ter the application on file in Final 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 CONSTRUCSTARTS Rough Service m- IZ� LD7NG INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. SEE REVERSE SIDE smoke Det.