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HomeMy WebLinkAboutBuilding Permit #749-2017 - 555 TURNPIKE STREET 5/1/2018 • _P%A,• M e I •• • • • i -12. rn r a�t3 s s w uy Pt,j Ii r S Pias zi d` ti - � stx t Y7x4' xf ..'�"+n',; �:. � 'ttt^n xp }jre�t'r'- + r '�.w��a siv._"y Pp^a u %. .x rct�.c.•% t�"Y.�+1 p` svr� x,� r <'� < z rrr r. a-:?'h�5' � �r ry � .,�� fS�"q _: � '�" r�r'�Yt, �`5sa a x ..s. , fc, f &�y r r.ns� t n,t•tj F "�Vd�"Nrrz` Vit, }�r x t �ti • ��� • • • r .rrrY. a "4 5 i q- r.-Fra .�, f +x cM u,,�u b ss- ' lY x roa�'eap� sr art 77 +fkx r cY� n41 f�UErfxlxa r �.�°n!YF"�t-'f4f hx •. �'S,r{*.. �f�.e � Irb '` ��rod �.�xl°}rC s i»r c E -rfFt � •• - / ' !� i 7ALir � 'J -,_Y r tk1�"`4ip: 3�.,,, [•«� Y .r >;a P.."M' i�.: ,y�Y7 t f, 1 yxir ��kas! r i"J!!YiE� y -3 �.i,.;>.(ka �f1 k{ sL � : .i 'rc ^nL+'y ? t y ,�. ,r`x y-y ..✓7.k .c C' t r ! .v ti o Y t�$Y xr�t E :. lr i,_�£ ✓x ::.<�+� z.t. ti.n „/ry la' +»Yd p� t� eu""Vr?xy°..' p f 3tF ��'G Ya`.,a'� r`"s .!r�y���Y1�,,'����7R4.12.r��`S r,S���Y�i'�`ti��'��,� r�l z� t 4K„v PG .Y i t, x t t-. :h v`.W'1a �,e-� �rs.a. .�r fir, s,Kx � tnvt r .„�r.� x a #t 4.: fat 4 �� .-r•. a roNJ�'§ aY't,1 vy, ,'F ka Y ♦t tz3 °ti........ 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Y t ' u ! 4> ;ate 3 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 - 11 FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zonina�.Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Plarnik Board Decision: Comments Conservation Decision: Comments Water & Severer Connection/Signature& Date Driveway Permit DPW Town ! ]Engineer: Signature: Located 384 Osgood Street FERE'DEPARTMENT - Temp Dumpster on site yes no Located at*124 Mair.,'Street Fire Departmerit signatureldate 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 filo MGL Chapter 166 Section 21A=F and G min.$100-$1000 fine NOTES and DATA— (For department use 13 Notified for pickup - Date Doc.Building Permit Revised 2010 Building Department Tine fonowing is a list of the required forms to be filled out for the appropriate permit to be obtained. F Zoofin1g, 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 40TE: 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 10TE: 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 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 Location No. I���l' 9 017 Date 1/3/t ,'L v/' • • TOWN OF NORTH ANDOVER ��'�- � fir• . . Certificate of Occupancy $ �^ Building/Frame Permit Fee $ � Foundation Permit Fee $ Other Permit Fee $ TOTAL $ i Check# r? `� �1 8 Building inspector Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 159000.00 m $ 180.00 ' Plumbing Fee $ 22.50 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 22.50 Total fees collected $ 325.00 554 Turnpike Street 749-2017 on 1/31/2017 demo for potential tenant %J W V GM r- 1 V � c10RTf•{ � ve- W" , Z. p y S No. zT h ver, Mass, 1 A (7 CoCNICNNWICK ��• �as RATED ►'4�`�q5 U BOARD OF HEALTH Food/Kitchen PERMIT T Septic System THIS CERTIFIES THAT w.WA#..............E.o1mvI BUILDING INSPECTOR has permission to erect .............. buildings on S Y....... .v"h c. Foundation ............ ....... ......... Rough VK 0 tobe occupied as ............... .:.... ... ...0................ ......... ......................................... Chimney provided that the person accep Ing this permit shall in every respect conform t 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. ®� V110*(rC PLUMBING INSPECTOR S � VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO T RTSRough i 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. FUDDRUCKERS r------------------------ - -- ----- --------- ------- 1 -------------------1 1 I I 23'-3- INSIDE COOLER 58'-3 3/4' I 83'-3 3/4' 1 10 1 N Z - I _ � J 1 C 1 64'-4' ❑ o 0 L& ❑ ❑ THE LEASED FLOOR AREA IS 4,335 SF MTHOUT THE COOLER d a (CENIERUNE OF DEMISING WALLS AND TO THE OUTSIDE OF nua m TORET ROOM Q04M 0 EXTERIOR WALLS).ADD 288 SF FOR COOLER. .i d ❑ ❑ �. �.< �• O O 43'-10" 19'-3' HL-- Li i ❑ -------------------------------------- ------=-------=----------- 0 BEST CLEANERS zo'-o' 12'-0' FIRE LANE Z ?Q / PROPOSED ALTERATIONS TO: MACLAREN ASSOCIATES LLC '1"A6 DRAMaO nnE off° oa,.u— THEVINEYARD-AT THE CROSSROADS A R C H I T E C T S P L A N N E R S 556 TURNPIKE STREET.,NORTH ANDOVER,MA 01845 EXISTING FLOOR PLAN 11 MAIN STREET,P.O.B.:606,ATKINSON,NN 03611 +/e• o• IA-11 syse -+'- FUDORUCKERS --------------------------------------- ---------------------------- 1 I I �-------------------T ILI t 1 I :i I i ! i o � I I I I I I 1 0 o THE LEASED FLOOR AREA IS 4,335 SF VATHOUT THE COOLER (CENTTRUNE OF DEMISING WALLS AND TO THE OUTSIDE OF TDLET RM TOM 11000 Lffl£ O EXTERIOR WALLS).ADD 288 SF FOR COOLER. l o -- --_----- - - --- -- - - ------ --------------- -o - - ____ooslNc cu sante[___ BEST CLEANERS o'-0 1'-o' FIRE LANE 2y / PROPOSED ALTERATIORS TO: MACLAREN ASSOCIATES ILC 01"A' A&R cu. �ogm -F,Y65�AN8 FLOOR PIAN THE VINEYARD•AT TEE CROSSROADS A R C H I T E C T S P L A N N E R S 654 TURNPIKE STREET.,NORTH ANDOVER,MA Oi845 11 MAIN STREET,P.O.BO%:606,ATKINSON,NH 03811 1•�•6� �_�• s d n a� �r 1 r � r� t 24 N HIM 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) Notified for pickup- Date Doc.Building Permit Revised 2012 Pians Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimtning Pools 0 Well ❑ - Tobacco Sales ❑ Food Packaging/Sales 0 Private(septic tank,etc. ❑ Permnanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMENTS CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ —❑ COMMENTS 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 Located at 384 Osgood Street AGREEMENT FOR CONTRACTOR SERVICES THIS AGREEMENT for construction services ("Agreement") is made as of the Agreement Date set forth below by and between the North Andover Crossroads LP a Massachsetts limited liability company("Crossroads"), and New England Builders and Contractors, Inc. "CONTRACTOR" In consideration of the Services to be rendered,the sums to be paid, and each and every covenant and condition contained herein,the parties hereto agree as follows: 1. SERVICES. The CONTRACTOR shall provide demolition services in the former Vineyard Liquors space at CrossRoads Plaza in North Andover,MA and ready the space for a new tenant or tenants as the case may be. 2. TERM. J J Commencement Date: t / //�`7 Termination Date:jhi/7 The term of this Agreement shall become effective on2017,and shall continue in force and effect for a period of 2�2 day(s), unless sooner terminated in accordance with the terms of this Agreement. 3. PAYMENT. Crossroads shall pay CONTRACTOR$15,000.00 for services rendered pursuant to this Agreement. CONTRACTOR shall submit detailed billing for said services to Crossroads. 4. FA CII ITII S EQUIPMENT ANPOT HE `MATERIALS AND OBLIGATICINS. CONTRACTOR shall,at its sale cost andexpense,furnish all equipment,and©they materials m4y he reared far fimushing servlces'pursuarit to this Agreement. 5 . ADDITIOI�TAL PI2CIVISIUNS. Those a+dthticnal.provisions uwque'to this Agreement,if anyy,shall be set forth in ;Attachment YA . 6. ATTACHMENTS. .All attachments referred to-I are attached hereto an(f by this reference: ncoxpted herein. 7; TERMINATION.C%ossiaada and,CONTRACTOR shall egch.have the nglt tp terminate this Agreement upon ten ft days written notice to the otherparty IN WITNESS WHEREOF,the parties hereto have executed this Agreement on d 7 PBJ Development Corp,General Partner of New E 'laud Builders and Contractors,.Inc. North Andover Crossroads L.P. DATE(MM/DD/YYYY) A�RV® CERTIFICATE OF LIABILITY INSURANCE 1/30/2017 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 Danielle Rice NAME: THE ROWLEY AGENCY INC. A/CNNo Ext: (603)224-2562 FAX No:(603)224-8012 45 Constitution Avenue E-MAIL DDRESS: enc drice@rowley g y'a com A P.O. BOX 511 INSURER(S)AFFORDING COVERAGE NAIC# Concord NH 03302-0511 INSURERA:Union Insurance Company 25844 INSURED INSURER B Acadia Insurance Company 31325 New England Builders & Contractors, Inc. INSURER C: 464 Merrimack Street INSURERD: INSURER E: Methuen MA 01844 INSURER F: COVERAGES CERTIFICATE NUMBER:16-17 General w/Equip 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. ILICY EXP TR TYPE OF INSURANCE IVSD WVD POLICY NUMBER MMIDDPOLICYNYYY MEFF MIDD/ /YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE a OCCUR DAMAGE TO RENTED 300,000 PREMISES Ea occurrence $ CPA002835530 10/13/2016 10/13/2017 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY F JPROT [:]LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Eaaccident $ 1,000,000 A ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED MAA150042932 10/13/2016 10/13/2017 BODILY INJURY(Per accident) $ AUTOS AUTOS X X NON-OWNED PeOP.ER ent DAMAGE $ HIRED AUTOS AUTOS X UMBRELLA UAB X OCCUR EACH OCCURRENCE $ 10,000,000 B EXCESS LIAB CLAIMS-MADE AGGREGATE $ 10,000,000 DED X I RETENTION$ 0 CUA008438324 10/13/2016 10/13/2017 $ WORKERS COMPENSATIONX PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY OFFICERIMEIMBER PROPREXCLUDED?ETORIPARTNER/ ECUTIVE NIA E.L.EACH ACCIDENT $ 500,000 B (Mandatory In NH) WCA0355905-17 10/13/2016 10/13/2017 E.L.DISEASE-EA EMPLOYE $ 500,000 If yes,describe under 3A States: I9i fi NH DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 A Leased & Rented Equipment CPA002835530 10/13/2016 10/13/2017 Limit: $150,000 Installation Floater pmt: $300,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Covering operations of the named insured during the policy period. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, NH 01845 AUTHORIZED REPRESENTATIVE Danielle Rice/DJR ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 0n`14nn SEE REVERSE SIDE FOR IMPORTANT INFORMATION THE COMMONWEALTH JF€NASSACHUGETTS, TOWN OF:NORTH ANDOVER Bill No. 5. Fiscal Year 2017 3rd Quarter Malo checks PyatIe To Actual Real Estate Tax Bill' Tovult of North Andover' Office of Collector of Taxes: Collector of Taxes Gail Tierney,.,T.reasurer/C6..11ector PO. Box 184 Medford; MA 02155-60012= Office Hours: is 1 Mari � :017-4:36 Tues, 8kOO 6'.00 NORTH ANDOVER CROSSROADS LIMITED PAR1 .TfNERSHIP Wed. £3;00 4,30 Thtirs. :Df3-4'313 861 TURNPIKE:STREET Fri'.8:00-12:00 NORTH ANDOVER MA 01845-6150 TAX.COLLECTOR: 978-688-9550 lll�l��l�111!lllll �'l°Ilrllli�li���llllli ril�lllltll�iir�� l� ASSESSOR: 978-68M.566.. Pay online at; www.townofhorthandover corgi Please use the,enclosed IOckbox envelope to expedite your payment This will assist us in Processing your payments more efficiently:' The Tax,.Collector's Office is located at 120 Main Street. Town of North Andover 3rd Quarter ReCelt Fiscal Year 2017 3rd Quarter Bill No. Actual Real Estate Tax ill: _- 1561 PROPERTY DESCRIPTION Gail Tierney,Collector-of Taxes RE Tax $103677.41 X LOC: 550 TURNPIKE STREET CPA X3110.32 CLASS. CODE: 323 (riterest at the rate a"14°14 per annum will accrue: Betterments NEAP-LOT-PLOT: 210-025.0-0001-0 00.0' $D.00 on cwtirdue pay lents Erdtit the due date until BOOK/PAGE: 8 pm 4366 / 15ayment isacte, Wafer/Sewer Liens $0, 0,0. LAND AREA: 3.82 acres Subtotal $106787.73 TO TAXABLE VAL: 5069800 SPECIAL ASSESMENTB IMP W' � Tax Rate Per$1.000 - 3rd Qtr. 'Due 2-l.1/2D17 $2.6570.82 Betterments $0:00 « Prelim Tax $53446.09 I Res 2 4penSp 3 Comm 4 Indust Liens $0.00 Payments made $53446.09RE 20.45 20.45 20.45 20.45 I Land 1206400 Abatement/Adjustment. $0.00 I Building! . 386.3400 Past Due $0.04}. I Assessed owner as of January 1, 2016 NORTH ANDOVER CROSSROADS TOTAL VALUB sD64sao Interest LZMZTED•PARTNERSHiP: 4th Qtr. ;Due 5/1/2017 $26670.$'2 i 8.61 TURNP,=STREET 5 ,_ AMOUNT.DUE °R -A ER, f ll ll 111111111111111111111111111 �1/2017 $26670.82 Town of North Andover 3rd Quarter Receipt_ Fiscal Year 20173rd Quarter Bill No- ActualReal Estate Tax Bill PROPERTY DESCRIPTION RE' Tax. $103677.41 Gail Tierney,Collector of Taxes CPA $3110.32 1100 550 TURNPIKE STREET E ents made`after 12.,15/201,6' m . I CLASS CODE Betterments $000 3'23- Pdym MAP LOT-,PLOT; 2100-25000.010000 may nct be reflected'on this ni.I:1 Water/Sewer Liens $0.00 �- BOOK/PAGE:; 4365-/ 158 Subtotal $106787.73 >' L ND AREA: 3,82 acres Abatement Applications are due in. --- -- -- - �' TOT TAXABLE VAL. 5b64966, the Assessors Office by 2:..01/2017 3rd Qtr. Due 2%1/2617 $26670.82 Tait,RatePer$1,000 Prelim Tax $53446.09 j 1 Res 1.OpenSp 3 'Comm 4 Indust Payments Made, $53446.09 j t 1 20.45 20.45, ;20.45; 20.45 Abatement/Adjustment $0.00 - Past Due $0.00 ell Interest $D.DD Assessed-owner as of January-1, 2015. IIIIIIIIIIII�IIII[Illllllllllllllllllflll 4th Qtr... Due 5/1/20:19 $266':70.82. NORTH ANDOVER.CROSSROADS . -.. . LIMITED PARTNERSHIP:..... AMOUNT DUE-85 �, i TUMIKE STRUT - FORTH ANDOVER, MTt 2/1[2017 $26670.82 , 01845'-6150 .. 0427,5?3679201'7'C 00:0OaflOd BQ00L00000001000B1,5610110002667082[]32 ,17i�G`o��nattttealtii nf,�'assac�Zelts Department of lndusttial Accidents .up, 1 Congress street,suite 100 Boston,HA 02114.2017 ww.mass g ovIdia Workers'Gompeusation Insurance Affidavit:B;uilelers/Contractors/EIeetrician&Mumbers. TO BE MM 3}'WUR M,PERMITTING AUTHORITY. Anplicant,infortnat tin Please Print LedbI Name(Bnnsiness/orpahmtionikaividua): b)E t? s Address: 4 4 t—\ A C t� -S—\ City/State/Zip: tl �w cvj A o I t4' Phone i#: 9 Are you an employer?deck&aappioprlatebw 'Type of project .Iequired): 1.I am a'employervtith_& .. emptoyees.(full andfor part-time)." 7. D New construction :2.rl lam a sole proprietoror partnership and haw rio.emgloyecs watkiiil;forme in 8. E]Remodeling any.capacity.[No workers'comp:insurance rerlitim j Demolition IF-1 I am a homeowner doingallwork mYsel£�onvorkers'comp.iruwancezeguired.]} 4.❑'I am a bameowaei and will ba h'sing contrsrkcrs to couduot aii work on rry property.I wiil 10E]Building addition casirrethat all contracture e,'the;have worms'compensation insurance or see sole I1:[]Electrical repaixs or additions. propiietars.airinno ranpioyc es. 12:�Plutnlaing repairs or additions 5.[j lam c ageaeral contractor and I have hiredthe sutrdontmctors listed on tho attached sheet. I3.[ Raofrepaixs es®sub caatraaors have erapioyecs and bavevrakers'comp.insntzace r S.QIL'eareacoraorafimamdi'sof'icershavecx=isacltheirrightofexemptionper,MGl.c. � er 152,§t(4),and we have no cmployees.tNo workers'comp.insolence requirtii j 4Any applicardfhat ch+xks box;rl must also fill out thesectien below showingtheir%vilws'compdasationpolicyinfomiation. t Iiomeowndrs who.submitis itaffidavit indicating they are doing all work and t1kn1ire outside contractors must submit a nervi affidavit indicating styli. tConhactors Ami cheek thio 6oxmustattached an additional sbeat showing the naive ofthe sub-contrectors and state Ahethor or not those entities have employees. If the,sub•caatractirsfive empicyees,t4 must pravide.theirworkeieeomppolicyuumber. I'=an employer that is provid ng workers'comperr.sation Insurance-for my employees.'Be[&is thepolicy andjob site information. Insurance Company Name: A CA ) .A �,jy(--A- Policy#or Self-ins. ic.#: -t'+ 3 G — Ex iraian bate: Job Site Address: City/State/ ip Attach a copy of the workers'compensation pokey declaration:page(showing the policy number and expiration date). Failure to secure coverage asrequired underMGL c.152,§25A is--a criminal violation punishable by& ine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and n fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Offfce of Investigations of the DIA for insurance coverage verification. X do hereby'certify U der th ai andperraUk9 of perjury Hurt the information provided above is true and correct Si attire• Date• � 1 � Phone#: t - - 3 11 Official use only. Do notwMe in this area;to be co»rpleted lby.elty or towit official. City or Town: Penzut/Licensa## Issuing Authority(circle ones ; 1.Board.o. calth 2.BuildingDepartment 3.City/Town Clerk 4,ti lectricalllaspector 5.Plumbing Inspector 6.Other Contact Person: Phone 9: i i i f Massachusetts Department of Public Safety j •Board'of Building Regulations and Standards { License: CS-047600 Construction Supervisor WADiH E RAMEY I 25 GOLDEN OAKS DR.. . SALEM NH 03078 ;'•3y:'= I Expiration: j Commissioner 0910112018' 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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application a Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract L3 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 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 submitted with the building application Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007