HomeMy WebLinkAboutBuilding Permit #539-13 - 544 SHARPNERS POND ROAD 1/28/2013TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit N,�- Date Received
Date Issued:
IMPORTANT: Applicant must complete all items on this page
PROPOSED USE
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. LOCATI ONl
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PROPERtTYP®WNERI�
❑ Two or more family
❑ Industrial
❑ Alteration
Prmt�
RI
-10 ea
iiE
ncRisnNOct
yesj x;
yes nC
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septics DkWellaFloodplam
-
MachmeShopaVillage;
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
6 Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septics DkWellaFloodplam
-
❑iWetlands�
-
_
El, WatershedlDistnct
it ❑Water/hSewerE
DESCRIPTION OF WORK TO BE PERFORMED:
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Please Type or Print Clearly)
OWNER: Name:
IMP 6dldgo�'
Address: N IF MV A N G 1)
C®IVT�RACTOR' :Name �-/� ly l j� .�..Ptone
Address
Supervisorls Constructi dii -dense
-� - - - —
HnmPIrnnrnvPrnent;Ilt G' Exna Date::T J--__�
s/
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ FEE: $Z 03
Check No.: Receipt No.:
NOTE: Persons con ratting with unregistered contractors do not have ac"cess to the guaranty fund
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Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ §tar's, ped Plans ❑
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑Swimming
Tanning/Massage/Body Art ❑
Pools 0
Well ❑
Tobacco Sales ❑
Food Packaging/Sales El
Private (septic tank, etc. ❑
Permanent Dumpster on Site ❑
4g
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMEN
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE REJECTED
11
DATE APPROVED
El -
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Towi! Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Maih`Strdet
Fire Depai-iment-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
NOTES and DATA — (For department use
El Notified for pickup - Date
Doc.Building Permit Revised 2010
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
o Building Permit Application
o Workers Comp Affidavit
o Photo Copy Of H.I.C. And/Or C.S.L. Licenses
o Copy of Contract
o Floor Plan Or Proposed Interior Work
o Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
Li Building Permit Application
Li Certified Surveyed Plot Plan
o Workers Comp Affidavit
o Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
Li Mass check Energy Compliance Report (If Applicable)
o 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)
o Building Permit Application
o Certified Proposed Plot Plan
o Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Copy of Contract
o Mass check Energy Compliance Report
o 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 subm;tted with the building application
Doc: Doc.Building permit Revised 2012
Location/
No Dat
Check # �09-
26121
TOWN OF NORTH ANDOVER
Certificate of Occupancy $ ��
Building/Frame Permit Fee
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Building Inspector
Jan 24 2013 18:43 P.02
�c p® CERTIFICATE OF LIABILITY INSURA
1/•24/..►NCE D/24/ 201IDD/Y3
3
THIS.'CERTIFICATE 19''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 PQLI.CIES :
_. SELOW_THIS. CERTIFICATE -OF INSURANCE DOE8 NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED ••.
REPkt§ENW-IVE.OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL• INSURED, the policy(ie9) must pe endorsed. if SUBROGATION IS WAIVED, subj-Oct tO
' fhe.4er!ns and conditions.of the policy,'certWh polIeW.May .requlna an endorsement. A statement on this c6itificato does not confor rigltt5 to the
certificate holder in lieu of such eridorsemen s '.
-PRODUCER
INstjRANCE SOLUTIONS CORPORATION
60. W®atville Rd
f "
Plaistow. NH 03865
CONTACT Kathleen Miller, CISR, CPIW
N E:
PNONIE (603)382-4600. FAX (609)982-2034
Asn 1�' , kmillar@ iscinaurea . coin
INSURERS AFFORDING COVERAGE NAICl1'
INSURERA:TrBLV Cas & Surety CotR of IL 19046.
JNSURED' • • •.
Jean `:Morin dba '
Jean Morin' Construction -
143 SUNT ROAD
FAST...HA'MP.STEAD 'NH 03826
INSURER B'>VG Insurarice Com an 15 997 -
INSURER C-. -
INsuRERD_
INSURER E:
--IT 1,2-1,12A n 641 G IMUMMM NI rMRFFR•. '
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THIS'IS:TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR;THE POLICY PERIOD
',.NTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WiTH•RESF?ECT TO WHICH THIS;'
.INDICAT,ED:OTWI
'CERTIFICATE • MAY. BE: ISSUED OR MAY PERTAIN, THE INSURANCE. AFFORDED BY THE POLICIES• DESCRIBED HEREIN IS SUBJECT TO ALL ,THE TERMS,
. xdLyg16NS`ANn.. CONDITIONS OF SUCH P.OLI.CIES.,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID.CLAIMS. ,
1NSRADDL
'LTR
• • '' TYPE OF.INSURANC£
Town of No. Andover
9U9R
vivni
POLICY NUMBER
POLICY EFF
M/DD[MM/DD,
POUGY EXP
LIMITS
'. •
GENERAL LIABILITY'
EACH OCCURRENCE S i•, 000, 00.0
DAMAGE TO RENTE
PREMISES Esoccliffe S 30,'000
'
X. COMMFRCIALGENERAL.LWBILITY
MED EXP An one reon $ 5, 00
A'.
CLAIMS -MADE n 9000R
6808577X065
/19/2012
/19/2013
PERSONAL a ADV INJURY $ • 1, 00'0 ; 000
GENERAL AGGREGATE $ 2',000,b00
GEN'LAGGREGATf LIMIT APPLIES PER:PRODUCTS-COMPlOP
AGG $ 21000'.1000
$
X `POLICY PRO- LOC
AUTOMOBILE LIABILITY '•
Me 110001.000
BODILY INJURY (Par Pemorn S
$
ANY AUTO
ALLOWNEDX SCHEDULED
0116034
8/10/2012
8/10/2013
BODILY INJURY (Per eccldeht) S
08
' ' X• NOWOWNED
P0AUTOS 0acc TY DAMAGE $
X HIRED AUTOS AUTOS
UNnsured motorist combined $ .1 000,000
UMBRELLA UABOCCUR
EACH OCCURRENCE $
AGGREGATE $
EXCE58,LIAa CLAIMS -MADE
DED •RETENTIONSS
WCBYATU- OTH- "
C
,WORKER&'COMPENSATION
E.L EACH ACCIDENT $
AND'EMPLOYERS',LIABWTY YIN
ANY. PROPRIETOR/PARTNER/E(ECUTIVE
*SEE BELOW •
ELDI3FJ+SE-EA EMPLOYEE S '
'OFFICER/MEMBER Li
-(Mandatoryln'NN),
N/A
E.LDISEASE- POLICY LIMIT S.
Ir• * daed"be,under
DESCRIPTION OF OPERATIONS blow
of OPERATIONS i LOCATIONS /'VEHICLES (Attach•ACORD 101, Additional_Reiva&A Schedule, If more apace 18 required)
,DESCRIPTION
Re.; .5dd sharpners. Towyn Rd,_ . No Andover MA 01845 ;
*The ;insured has purchase. d• Workers, Compensation coverage through the MA Worker's Compensation Assigned
Rick Pool.. No 'have requeated'the servicing carrier iQaue a Certificate of Insurance on your'behalf:' ,
ates of:InsranOG'for Workers' Compensation -coverage on
.Agents are'.not permitted to•isBue Certificti
polic ea•issua.d.through the MA Workers. Compensation Aesigned:Risk Pool.
I,.GK11C1{rHIG•I7VGVGK
�----""----
(978) 688=95x2
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE;.
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED AN '
ACCORDANCE WITH THE POLICY PROVISIONS.
Town of No. Andover
1;600 OBgood St
NO AI3dOveJ: / MA 01845'
AUTHORIZED REPRESENTATIVE
K Miller, CISR, CPIW/
INS025 (201 o66:di
'.nnfnrf Parenn-
TIIe.ACORD name•and.log'o are registered marks OtACORD. ;
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House: 1-603-974-1193
Cell: 1-978-360-4796
jean Noel -Morin
CARPENTRY CONTRACTOR
143 Hunt Rd. • East Hampstead, NH 03826 ;.
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