HomeMy WebLinkAboutBuilding Permit #591-2017 - 57 PINE RIDGE ROAD 12/2/2016 NO RTf-/
BUILDING PERMIT
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TOWN OF NORTH ANDOVER o , 00-
APPLICATION FOR PLAN EXAMINATION wo
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Permit No#: ` Date Received A�R�reo�QaygS
SSA CHus��
Date Issued:
ORTANT Applicant must complete all items on this page
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EMAP : ARCEI_ �" �®N11�1G, 1STrR�ECT
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building Y-One family
❑Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
Demolitionthey jj
❑ Demou�--- ,
-_ w ❑ WatersIN!TheEl 119 trio=
Ur 5 tic r� ells ❑ f 7R
SW
F.Ioodplam p0 Wetlands
IilNaterySewer. d <.
a
.. h .M �, �. . .�
DESCRIPTION OF WORK TO BE PERFORMED:
Identification- Please Type or Print Clearly
_
OWNER: Name: IF r-2-CA erg C-IC CJ Phone: (0M _q
Address: 's-) ) Y\.Z'r t do,
•,h, d .-.., . r .ca te+'�,-'`�.. r?+ 3s..-v _ .�y, �- s tr h.._ i
may s ^nC.. i�..•. �y a xk r ....s:;: a, +v f �i� -#.' �T �'x ,r "w
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'F
�� .�°� _ � � Y � � E`x� Date
S. perV�sors Constr et. l �cense �
� .e4..
o e .Im .ro�ernen <License
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COS BASED ON$125.00 PER S.F.
Total Project Cost: $ 3SS •Caw FEE: $
Check No..
:1�9 -7 Receipt No.: '2i21
NOTE: Persons contracting with unregistered contractors do not have access to the uaranty fund
r,nati irP of AnenfCO.vvrier Signature of contractor
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
i
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 Perm it'Application
o 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:Building Permit Revised 2014
Plans Submitted ❑
Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans
p ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑
Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑
Private (septic tank,etc. ❑ Pennanent Dumpster on Site ❑
THE FOLLOWINGI
SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
i
I
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Si nature
I
COMMENTS
I
3
: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 Town Engineer: Signature:
Located 384 Osgood Street
AFIRE DEPARdTMEIVT�Temp,Dumpster on}site
..
;,L tea Ij, 4. Str�� =M
FireDepartments�gnature/date
+,A�x
COMMENTS.f
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 Ch _
Chapter 166 Section 21A F and G min.$100-$1000 fine
NOTES and DATA— (For department use
I
❑ Notified for pickup Call . Email
1 Date Time Contact Name E
Doc.Building Permit Revised 2014
fLocation
qq V
No. Y L� Date t hyo
• TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ '
jFoundation Permit Fee $ r
Other Permit Fee $
TOTAL $ '
Check#
.1 273
n3 �` tuuil✓ding Inspector
own of
�. : : . A
ndover.
mlk;a
Mas"ks
oh ver, , e
cocNicHew�cw �1'
x,95 RATED
U BOARD OF HEALTH
RNIT low-
PE
Food/Kitchen
Septic System
THIS CERTIFIES THAT .... \� .....
BUILDING INSPECTOR
... ..............•.................. ......... .. ...
�. � Foundation
has permission to erect .......................... buildings on .... ... .. . ...��.:;!..... �.... '......
`� Rough
to be occupied as ......... !�04
. . .........1.........
.�!.... ...`...................................................... Chimney
provided that the person accepting this permit shall in every respect conform to 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. PLUMBING INSPECTOR
Rough
VIOLATION of the Zoning or Building Regulations Voids this Permit.
Final '
PERMIT EXPIRES IN 6 ONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCT AR
Rough
Service
............................................
........ .. ....
BUILDING INSPECTOR Final
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.
I I
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
' 600 Washington Street
r' Boston,MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
applicant Information Please Print Legibly
Name($usiness/OrganizatiorYIndividual): Merrimack Valley Insulation Corp.
Address: 23 A Sullivan Rd.
City/State/Zip: Billerica MA 01862 Phone#: 978-888-3495
Are you an employer?Check the appropriate box: Type of project(required):
1 1.FX_1 I am a employer with 18 4. ❑ I am a general contractor and I
employees (full and/or part-time).
have hired the sub-contractors 6. New construction
listed on the attached sheet. 7. ❑ Remodeling
2.❑ I am a sole proprietor or partner-
ship and have no employees These sub-contractors have g. ❑Demolition
working for me in any capacity. employees and have workers'
9. [] Building addition
[No workers' comp.insurance comp.insurance.*
required.] 5. We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.E] Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs
insurance required.) t c. 152, §1(4),and we have no
employees. [No workers' 13.0 Other Insulation
comp. insurance required.)
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
('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 state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: 5Star V3 AAIC American Alternative Insurance
Policy#or Self-ins.Lie.#: V9WC749118 Expiration Date: 6/18/2017
Job Site Address:-,--)-I P 1 rn f. R\dq e Rd.- City/State/Zip:N AnCl()y f. . M A 01�S4S
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL 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.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Si attire: Date:
Phone#: 4-8&'8-349\d
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 5.Plumbing Inspector
6.Other
Contact Person: Phone#•
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DATE(M MfDD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE 11/07/2016
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), AUTHORED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(iss)must have ADDITIONAL INSURED provisions or be endorsed.
9 SUBROGATION IS WANED,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 N TACT CarolAME, yn A Coughlin
Charles J Coughlin Insurance PHONE (978)g57-3588 FAX Nor.
14 Dinley Street aC No Ext:
P.O.Box 10 EE�: carolyn@coughlinins.com
Dracut,MA 01826 INSURERS AFFORDING COVERAGE NAIL#
INSURER A: Northland Insurance Company 24015
INSURED Merrimack Valley Insulation Corporation Joseph A.Ryan,Jr. INSURER B: Safety Standard 39454
23A Sullivan RoadTorus Specialty Insurance Company INSURER C: p ty I� Y A0159
N. Billerica,MA 01862
INSURERD:
INSURER E:
INSURER F:
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 CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ILTRR TYPE OF INSURANCE IVSD WVO POLICY NUMBER MMIDDPOLICYEFF P�pYD(P UMIfTS
A COMMERCIAL GENERAL LIABILITY WS274182 01/21/2016 1/21/2017 EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE [—\AOCCUR DAMAGE RENTED 100,000
PREMISES Ea occurrence $
MED EXP(Any one person) $ 5,000
PERSONAL&ADV INJl1RY $ 1,000,000
GEHL AGGREGATE LIMITAPPLIES PER GENERAL AGGREGATE $ 2,000,000
J POLICY F-1JEECCT [::]LOC PRODUCTS-COMP/OP AGG $ 2,000,000
OTHER $
B AUTOMOBILE LIABILITY 6205006 11/25/2015 11/25/2016 COMBEa acINED SINGLE LIMIT
cident $ 1,000,000
ANY AUS BODILY INJURY(Per person) $
OWNED SCHEDULED
AUTOS ONLY V AUTOS BODILY INJURY(Per accident) $
/ HIRED / NON-OWNED PROPERTY DAMAGE $
V AUTOS ONLY �/ AUTOS ONLY Per accident
$
C V UMBRELLALIAB OCCUR 87593L161AU 01/21/2016 01/21/2017 EACH OCCURRENCE $ 1,000,000
EXCESS LIAR HCLAIMS-MADE AGGREGATE $ 1,000,000
DED I I RETENTION $0 $
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LVABILITY YIN STATUTE1 ER
ANY PROPRIETOR/PARTNERIEXECUTiVE E.L.EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? NIA
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
Insulation Installation
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE VALL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Town of North Andover,Massachusetts
120 Main Street
AUTHORED REPRESENTATIVENorth Andover,MA 01845
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD