HomeMy WebLinkAboutBuilding Permit #692-2017 - 57 CANDLESTICK ROAD 1/4/2017Vtion q�d<�k I�
BUILDING PERMIT V/
TOWN OF NORTH ANDOVER
APPLICATION FORPLAN EXAMINATION` -
Date Received
TYPE OF IMPROVEMENT
PROPOSED USE
Residential.
Non- Residential
0 New Building
W One family
0 Addition
0 Two or more family
0 Industrial
KAlteration
No. of units:
0 Commercial
$Repair, replacement
0 Assessory Bldg
0 Others:
0 Demolition
0 Other
eptle
0- Mob- t�pj in
a er8 M District
O Wa
i i N ur vvumt\ i U bt FtKt-UKMED:
Identification - Please Type or Print Clearly'
OWNER: Name-.' Phone: 6t' — 51711 1 — 65_5-c',
Address: f -/
Contractor N
m
Ad'dfb88. 30—FOR73
I M,
w -C ),qAmmd,R-hone:...
ARCHITECT/ENGINEER A.)/4
Juew rw
Phone:
Address: Reg. No.
FEE SCHEDULE-- L3ULDING PERMIT' $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ c;?&, e 6
FEE: $
Check No.: -7
Receipt No-, 3 iLf 64
NOTE: Persons contracting w1th unFegistered contFactors.-de--n-al"
L �__ i'�� '� ve.-access to the guarantyfund
�Tg7at'Lw of
f co' fr�5btor`;
.. .... .....
Plans Submitted ❑ Plans Waived 0 Certified Plot Plan ❑ Stamped Plans ❑
•TypF'l7F SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/Massage/Body Art ❑ Swing Pools ❑
Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑
Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFPICE USE ONLY
INTERDEPARTMENTAL SIGN OFF U FORM
PLANNING & DEVELOPMENT Reviewed On Signature
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
u Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Sign.atare:
Located 384 Osgood Street
FIRE DEPARTMENT- _ Temp Dumpster on site yes no
Located at 124. Main Street
Fire Department signatureldate
COMMENTS
-imension
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 .droprequires approval of
Electrical Inspector Yes No
DANCER ZONE LITERATURE: Yes
MGL Chapter 166 Section 21A—F and G min.$10041000 fine
No
Doc.Building Permit Revised 2014
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy o CContr act -
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
40TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doe: Building Permit Revised 2014
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Porkers' A"otlopenm ion tmurance Affidavit: l$utdexWContmetorsrRAecW.th, &an
Name RENEWAL BY ANDERSEN
Aad: 30 FORBES ROAD
NORTHBORO. MA 01532 ?hmr 508-351-2214
Are yeea on emp%W. Cbwk tiro ap'proprbtte boat
1. Q I am a employer with 30 4. ❑ I am a gmad contraetor and I
emnkmeas (fall imWor mar6ftnal.s have hired to
2.0 lama sole proridw or po hat -
ship and have no employees
working for me in ww capacity.
[No wodoms' gyp. hammoo
roquireQ
3. ❑ I am a homeowner dung all work
myself: [No workers' vamp.
insamnee required.] t
Hdod on the attwhod sheet.
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employem and irava worker'
Gk►• bsufa=t
S. ❑ We are a ompmudon and its
offices have aaarmu d their
right of awroptionporMOL
a 152,11(4), and we have no
cmployaea. We worker'
soap. hwm=ce M nked.l
Ty re ails (reqwlx�:
6. ❑ Naw oonsimctiast
7. Rmnodelatg
9. ❑ Demolition
9. ❑ Building addifion
10.❑ Placii ed repahs or W&tinr
11.❑ Phuubing repairs or addidoia
12.E Roof:apain
13.❑ Odwr I
,.i
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rentasSayan►t iQr+ot�.afAcg>aarkws' lrr a fora ► Ojs s. aebwb djepaft fatjaesir
Inanwoo Company Nam: OLD REPUBLIC INSURANCE COMPANY
Policy # or Sed inch Lic. MWC30823100B10/01/2017
rpiYs�aat i�te:
Job Sibs Addroas: 57 Candlestick Road CjtV18bjarzj=North Andover, MA 01845
Art wA a eopy of the worker' mar polEe9 deda WV (darrbig to p dL-y number end eW_ mum date).
Failwo to m=e coverage as reqused under Soctum 25A of MUL c. 152 can lead to &a impodfio n ofadmicalpenalties of a
Etas up to $1,500.00 and/or one -you impHisonment, as weU w civil ponatti= in *a foam of a SMp WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a cagy of this statm=t may be f mwarded to the Ofiiaa of
lnvmtlgodoog.af tnPiA fbr tammace ooverage va 0mmom
Ido r, p ofparj9reryBirt b +dm►pr+at�ie:r(erbnva o7raea+edoorre
12/09/16
-2214
QAMW ow on&. Do not wdo in dab areff, 9 be compk*d by ety or mom goje&L
City or'rown: Fermib�f loe�oaes! !E
Laaaog A dhewfty (ChwIc one):
L Board edBem L BmBdbtg skparfineat 3. City/Tam C)wk 4. Fhwb*a: iusper w 5.Mumbtg bspedw
6. Cher
£ewtact Person' Phtme M.
---owses"Ill ANDECOR-01 DUBEAA
'4� R� CERTIFICATE OF LIABILITY INSURANCE °A'
THIS CERTIFICATE M 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 cerdflcab holder is an ADDITIONAL INSURED, the pollcy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to
the ten. and conditions of the policy, certain policies may require an endorsement. A statoment on this card icate does not corder rights to the
cardHcata holder In lieu of such endonsement(s).
PRODUCER
Willis of Minnesota Inc.
Flo 26 Century BWJ
P.O. Bo: 305191
Nashville, TN 37230. 5191
INSURED
Renewal by Anderson LLC
104 Otis Street
Northboro"h, MA 01532
F:
Old
Towers Watson Cardfleate Center
FAX
► 945-7378 /ALO. Rel, (888) 467-2378
COVERAGES CERTIFICATE NUMBER: 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 COMMONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TM
LTR
TYPE or INSIIRAIICE
ADOL
SUM
POLICY NUMBER
POLICY
sxD EFF
Urns
A
X COMME3tm4LeENERALuAsLrry
CLAIMS -MADE ❑X OAR
MWZY 308284
10/01/2016
10/01/2017
EACHOCCURREMCE f 1,000,00
f 500,00
MED EXP (Any ons person) $ 10A
PERSONALAADVNJURV f 1,000,000
GEMLAGGREGATE UNIT APPLIES PER:
X I'OUCY ❑ J� ❑ LOC
OTHER
GENERAL AGGREGATE f 4,000,00
PRODUCM-COMP/OPAGG s 4,000,00
A
AUTOMOBILE LIABILITY
X ANYAUTo
ALL OWNED AUTOS SCHEDULED
HIRED AUTOS A
MWTB 308232
10/0112016
1010112017
COMBINED SINGLE LIMIT(Es accidend S 5,000,0
BODLYINJURY(Perperson) s
BODILY INJURY (Per accident) f
per f
s
UM IUUA LIASHGLAINISQADE
ID Ess UAB
OCCI R
EACH OCCURRENCE S
AGGREGATE f
DED I I RETENTIONS
f
A
wOMUM COWMSATM
AND EMPLOYEW LIABILITY
ANY PROPRIETORrPARTNERIExECUI1VE YIN
O EnN EXCLUDED? ®
N yyaese,, describe under
DESCRIPTION OPERATIONS below
NIA
WC30823100
10/01/2016
10101/2017
X PER
EL E, ACCO f 1,000,0
E.L. DISEASE- EA EMPLOYEEf 1,000,00
EL DISEASE - POLICY UMR f 1,000,00
DESCRIPTION OF OPERATIONS! LOCATIONS f VEHICLES (ACORD 101. Additional Rensi Schad" may be attealred If more Mm b requhsd)
Evidence of Insurance.
SHOULD ANY OF THE MOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED M
ACCORDANCE WITH THE POLICY PROVISIONS,
Town of North Andover
120 Main Street AUTHORIgD REPRESENTATIVE
North Andover, MA 01845 _ IA
® Traa-LU74 ALrUKi7 UUKrUKAIJUN. All nigra reserved.
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
Se- CS -090125
JAIME L MORIN
88 GARRDINER ST
LYNN MA 01905
7
bd
10062018
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1�Oflire of, C'011S itileI• Affairs & Itu; i�r��ss lac ►�iN
CAME IMPROVEMENT CONTRACTOR
I", Registration: 170810
�..�• Expiration 12/23/2017 Supplement Card
RENEWAL BY ANDERSON LLC.
JAIME MORIN
30 FORBES RD
NORTHBOROUGH, MA 01532
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