HomeMy WebLinkAboutBuilding Permit #834 - 565 TURNPIKE STREET 5/21/2012BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued: d
IMPORTANT: $ Applicant must complete all items on this page
4_ z-'Hi§t&ic',As�f' "A4
r ::Machine; y e Shop f, i ag6k,- ,
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One family
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial k'
Others:
Repair, replacement
Assessory Bldg
Demolition
Other
x' : Will
b et q_nqs,'7�,:;'
'W' 'tet8'h-k Dis-g
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i ivi,4 ur vitumn i u tit I-r%t1-UXMF=L):
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Identification Please Type or Print Clearly)
OWNER: Name: Phone: 9'76Y75--6+3,1Jj
V
ARCH ITECT/ENG I NEERJOe .SGTR D L,,q6iAQ1s-5' AIA, Phone:. 27RY,7o_.3-G70
Address: 1 Z ztti- A,,ozvv, ,41,4 n i —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: $ X7600 _-.1 FEEQ_
: $
Check No.: Receipt No.: c 3 Z_ 2—
NOTE: Persons contracting nregistered contractors do not have access to the guarantyfund
9
,8ignpture of A ent/Ownc; 6 i gnature of contractor/e-5-F&I
F7'
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
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH
i
COIOMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No:
Planning Board Decision:
Conservation Decision:
Comments
Comments
Zoning Decision/receipt submitted yes
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE,'DEPARTMENT - Temp Dumpster on site yes f no
r
Located at 924 Main Street -�` F
1 x t :-`x f^ ':rs`�i ir..; s �3.;,,
FirejjDe artment-signature/date-
- �� 6 ��» Z 4� r f •� }fit,,,( 'k * t
COMMENTS
Dimension
Number of Stories:
Total land area, sq. ft.:
Total square feet of floor area, based on Exterior dimensions.
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
NOTES and DATA —
ent use
Ll Notified for pickup - Date
Doc.Building Permit Revised 2008
No
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
❑ 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)
❑ 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 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 2.2008
Location &
No. e�A�- Date A7,a
Check# L:� ��
25322
TOWN OF NORTH ANDOVER
.4
Certificate of Occupancy
Building/Frame Permit Fee $
Foundation Permit Fee
Other Permit Fee $
TOTAL $-
Building Inspector
Location ILA- + (03
No.- D at e
I
Check #
25422
TOWN OF NORTH ANDOVER
Certificate of Occupancy $ jw '—
Building/Frame Permit Fee,
Foundation Permit Fee
Other Permit Fee
TOTAL $
Building Inspector
�SSACHUSEI
CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
Building Permit Number 834-12 on 5/21/2012 Date: June 15, 2012
THIS CERTIFIES THAT
Frank Coppola
THE BUILDING LOCATED ON 565 Turnpike Street
MAY BE OCCUPIED AS Office Space Unit 63 B-1 in Chestnut Green IN
ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING
CODE AND SUCH OTHER REGULATIONS AS MAY APPLY.
Certificate Issued to: Robert J. Gorman
Converge Diagnostic Service
565 Turnpike Street
North Andover, MA 01845
Building Inspector
Fee: 100.00
Receipt: 25422
Check :5376
r
Date .... 1�7..
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that .......... M ... :� ................................
has permission to perform ....... .......... .......
wiring in the building of
......... . . ............ Morth Andover, Mass.
Fee.... Lic. No . .... .............. . . ......... .. .. . ...... .....
ELE ICAL INSPECMR 0
Check # t
. i
.1,11� �O8�57
fl\
Coininonwea[th o� �!'lal,c Official Use Only
c� cc77
Permit No. 0 EL
Apt�rt—,d 43".e sewicee
myBOARD OF FIRE PREVENTION REGULATIONS [Rev. Occupancy and Fee Checked 1/07] leaveblank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFO VTION) Date: - --
City or Town'of: n LI -0-4 To the Inspector, of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) 's— �, I— �',� V�, A i 1C.4r, < �. 1 S L" �,. 1w -� (-� I
Owner or Tenant
Owner's Address
Is this permit in conjunction with a buil ing permit? Yes C
Purpose of Building 71 ey —1 'im P p .
Telephone No.
No ❑ (Check Appropriate Box)
Utility Authorization No.
Existing Service _/!20 Amps /oQ/ aZ 6 Volts Overhead ❑ Undgrd Q�
New Service Amps / Volts Overhead ❑ Undgrd ❑
Number of Feeders and Ampacity
Location and Nature of Proposed i
No. of Meters
No. of Meters
I/ ,e L
1 On L4 L i
Com letion o the &M-4ing table m be wai,,,,A b the r "r o Wires
No. of Recessed Luminaires
No. of Ceil: Susp. (Paddle) Fans
o. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑n- ❑
Lyrnd. d.
o. o mergency Lighting
Baffery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
Mo -. —of etection an
Initiating Devices
No. of Ranges
No. of Air Cond. Tota
ns
No. of Alerting Devices
No. of Waste Disposers
Heat PumpNumber
Totals:
Tons
..
No. o el -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ElConnectumect.cipaEl other
ion
No. of Dryers
Heating Appliances KW
Security ystems:
No. of Devices or E uivalent
No. of ater KW
Heaters
No. o No. o
Signs Ballasts
Data Wiring:
Na of Devices or uivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
fel ecommumcationsWiring:
No. of Devices or Equivalent
OTHER:
I�
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: y[p(Z (When required by municipal policy.)
Work to Start: 5'Inspections to be requested in accordance with NEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such cove a is in force, and has exhibited proof of same o the 7:;
y f�gO ffic�J
CHECK ONE: INSURANCE OND ❑ OTHER ❑ (Specify:) e c?r
I certify, under the pains and enaldes of perjury, that the informal on this application is true and complete.
FIRM NAME: .y �l C LIC. NO.: 9
Licensee: C Sis4ature LIC. NO.: 1F ? r,2C J
(If applicable, enter "exempt" in the licensc numbe 17ius. Tel. No.:
Address: ; Alt. Tel. No.:
*Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE: S
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OFFICE OF BUILDING INSPECTOR
TOWN OF NORTH ANDOVER
CONSTRUCTION CONTROL
PROJECT NUMBER: 2�$4
PROJECTTITLE: DI%M(51NCZ WAL- 5EPAAATI00 jrJTo 2 uN1T$
PROJECT LOCATION: 5(o s 1 U" PI K E-: 5-C-
NAME OF BUILDING: CNE5'Cn1 C� REt�.9 0uI L.Dwc,
NATURE OF PROJECT:
5vt-Ce.5 6-3)
yej��eArtttj4.->-xt5-11 N
4 Go 3 F-7 AN;D OcCu ,
SU tTe-- 403 wTv 2
IN"q 5W►iE 63
IN ACCORDANCE WITH ARTICLE 116 OF THE MASSACHUSETTS STATE BUILDING CODE,
I, JPWH V, LA CZP.A.95r,- REGISTRATION NO. +'15 -3
BEING A REGISTERED PROFESSIONAL ENGINEEWARCHITECH HEREBY CERTIFY THAT I
HAVE PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS;
COMPUTATIONS AND SPECIFICATIONS CONCERNING:
ENTIRE PROJECT ARCHITECTURAL 0 STRUCTURAL 0 MECHANICAL 0
FIRE PROTECTION 0 ELECTRICAL -0 OTHER (SPECIFY)
FOR. THE ABOVE NAMED PROJECT AND THAT, TO THE BEST OF MY KNOWLEGE, SUCH PLANS,
COMPUTATIONS AND SPECIFICATIONS MEET THE APPLICABLE PROVISION OF THE MASSACHUSETTS
STATE BUILDING CODE, ALL ACCEPTABLE ENGINEERING PRATICES.
AND APPLICABLE LAWS AND ORDINANCES FOR THE. PROPOSED USE AND OCCUPANCY.
1 FURTHER CERTIFY THAT I SHALL PERFORM THE NECESSARY PROFESSIONAL SERVICES AND B
EPRESENT ON THE CONSTRUCTION SITE ON A REGULAR AND'PERIODIC BASIS TO DETERMINE THAT
THE WORK IS PROCEEEDING IN ACCORDANCE WITH THE DOCUMENTS APPROVED FOR THE BUILDING
PERMIT AND SHALL BE RESPONSIBLE FOR THE FOLLOWING AS SPECIFIED IN SECTION 116.0
1. Review, for conformance to the design concept, shop drawings, samples and other submittals
which are submitted by the contractor in accordance with the requirements of the construction
documents.
2. Review and approval of the quality control procedures for all code -required controlled nlafArlaj:
3. Be present at intervals appropriate to the stage of construction to become, gene O
with6the progress and quality of the work and to determine, in general, if the g
performed in a manner consistent with the construction documents. No.415�
ANDOVER
PURSUANT TO SECTION 116.2 .2 1 SHALL SUBMIT WEEKLY, A PROGRESS RTMA
TOGETHER WITH PERTINENT COMMENTS TO .THE NORTH ANDOVER BUILDI
UPON COMPLETION OF THE WORK, I SHALL SUBMIT A FINAL REPORT AS TO THE
SATISFACTORY COMPLETION AND READINESS OF THE PROJECT FOR OCCUPANCY.
• - �oSa.�(,t� LQ�se ��
SIGNATURE
SUBSCRIBED AND SWORN TO BEFORE ME THIS--LL—DAY OF
NOTARY PUBLIC MY COMMISSION EXPIRES .5 ' '07 0 /
The Commonwealth ofMassachusetts , -
Department oflndustrialAccidents
Office 0 nvestigations
600 Washington Street
.Easton, MA 02111
IN www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors)ElectriciansfPlumbers
ApOicant Information Please Print Legibly
Name (Business/Organizationlindividual): `Bfj q4 (.i\ List -2 19 �'�E C--�C, ►J`S/C �
Address: (oC iA//L.0VVh aQ
City/-State/Zip:_ Afj IN Q E-A—/'W, 0/ & I 0 Phone #: 97 - 470 - / ?8, 3
Are you an employer? Check the appropriate box:
Type of project (required):
1. VI am a employer with Z•
4. ❑ I am a general contractor and 1
6. ❑ New construction
employees (full and/orpart-time) *
2. ❑ I am a sole proprietor or partner-
have lured the sub -contractors
listed on the attached sheet. x
7. VRemodeling
ship andno employees
These sub -contractors have
8. Demolition
El
working forme in any capacity.
workers' comp. insurance.
g, ❑ Building addition
[No workers' comp. insurance
5. ❑ We are a corporation and its
10.[] Electrical repairs or additions
required.]
3. ❑ I am a homeowner doing all work
officers have exercised their
right of exemption per MGL
11.❑ Plumbingrepairs or additions
myself. [No workers' comp.
c. 152, §1(4), and we have no
12.❑Roofrepairs
insurance required.] i
employees. [No workers'
13.❑Ocher
comp. insurance required.]
'Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information.
I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors 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 is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:. ^ jlya-a.�-7-W_ Ci±6 e1-M7L= JA/5 , C, (4 .
Policy # or 8 elf -ins. Lic. #: NC v6 tp39 l®l Expiration Date: '710 hG t 2
Job Site Address,5T95 •T -44i 0)i se5 ur-trr 631' City/State/Zip: 14, A1V00VEA- LM,4 01,4j,
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as requiredunder Section 25A ofMGL 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.
.1 do 71ereby certify un der the pains and penalties ofperjury that the information provided above is true anti correct
Sianature: ZD/e_
Phone #: 711 1470 — L9 5
Official use only. Do not write in this area, to he 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. EIectrical Inspector 5. Plumbing Inspector
6. Other - - -
Contact Person: Phone #:
Information and Instructs® '
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 person in the service of another under any contract ofhire,-
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 thq 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 not because of such employment be deemed to be an employee'."
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 compliance with the insurance coverage required"
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any ofits political subdivisions shall
enter into any contract for the performance ofpublic work until acceptable evidence 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), address(es) and phone number(s) along with their certificate(s) 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 maybe 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 application for the permit or license is being requested, 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 per number Which will be used as a reference number. In addition, an applicant
that must submit multiple permithicense 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 maybe provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. Anew 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 burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation, and shquld you have any questions,
please do not hesitate to give us a call,
The Department's address, telephone anal fax number:
Tho Gon oar oalth o Tassa.,chv.:sPt€s -
Dapartment of Industdal ,A.ccxdeats
Office ofInVestigailo.w
600 Washill&,a Street
Boston, MA. 021.1.1
TO, # 61.7-727,4900 ort 406 or 1.-877 MA.SS.Ak`B
Revised 5-26-05 Fax # 617"727'774.9
WWW- tass,gov cHa.
Vetalls
Licensee Details
Page I of I
License Address Information
Address:
66 WILDWOOD RD
Address 2:
Profession:
CRY:
ANDOVER
State:
MA
Zipcode:
101810
lCountry:
-- United States
License Information
License No:
CS -000261
License Type:
Construction Supervisor
Profession:
Building Licenses
Date of Last Renewal:
4/10/2012
Issue Date:
3/23/2010
Expiration Date:
3/23/2014
License Status:
Active -
Today's Date:
5/10/2012
Secondary License:
Doing Business As:
IStatds Change:
18
Prerequisite Information
No Prerequisite Information
Discipline
No Discipline Information
Documentum
Fj
I
Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor License
License: CS 261
Restricted to: 00
BRIAN A LAWLER
4�
66 WILDWOOD RD
ANDOVER, :MA.018110
Expiration: 3/23/2012
Commissioner Tr#: 22966
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WORKERS' COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
Information Page. WC 00 00 01
NCCI Co. No.: 29211
1. INSURED:
Brian A. Lawler
66 Wildwood Road
Andover, MA 01810
Atlantic Charter Insurance Company VDAC
Policy Number. WCV00898101
Prior Policy Number: WCV00898100
Federal ID Number:042960346
Risk ID Number:
Producer.
Phil Richard & Associates
Insurance, Inc.
27 Garden Street Unit 1-B
Danvers, MA 01923
Business Type: Individual SIC:9999 NONCLASSIFIABLE ESTABLISHMENTS
Other Named Insured: Other Work Places:
2. POLICY PERIOD: The Policy Period Is From: 7/1/2011 To 7/1/2012 12:01 A.M. Standard Time
at The Insured Mailinq Address
3. COVERAGES:
A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states lister
here: MA
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3A. The limits of our
liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident
Bodily Injury by Disease $ 500,000 policy limit
Bodily Injury by Disease $ 100,000 each employee
C. Other States Insured: Part Three of the policy applies to the states, if any, listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A
D. This policy includes these endorsements and schedules:
See WCE105
4. COVERAGES: The Premium for this policy will be determined by our Manual of Rules, Classifications, Rates &
Rating Plans. All information required below is subject to verification and change by audit.
Code Premium Basis Total Rate Per Estimated
Classifications No. Estimated Annual $100 of Annual
Remuneration Remuneration Premium
See WC 00 00 01
Minimum Premium: Deposit Premium:
$500 $4,250
Interim Adjustment: Annually
Servicin Office: Total Estimated Premium $4,002
25 New Chandon Street Surcharge(s) 248 I
Boston, MA 02114-4721 Total Premium an rcharge(s) $4,250
JUL 0 5 2111
Issue Date 07/05/2011 Countersigned By:1`1rU1ate ;