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HomeMy WebLinkAboutBuilding Permit #1330-2016 - 58 PETERS STREET 6/22/2016 f BUILDING PERMIT o`"°or"�+ a o ��� TOWN OF NORTH ANDOVER o APPLICATION FOR PLAN EXAMINATION Date Received Permit No#: / 74p�RA ED I•pp'.�y �SSHCHU`��� Date Issued: �&41V(ORTANT: Applicant must complete all items on this page LOCATION 4er��uAr,' Pr nt PROPERTY OWNER cl 4o' o Print 100 Year Struct re yes MAP _PARCEL ZONING;DISTRICT: Historic Districtyes- n . Machine Shop Village yes; 4 TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One.family ❑ Addition ❑Two or more family ❑ Industrial 9?'Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic Wel1, ❑Floodplain [�+Wetlands ❑ UVateshed^Ristnct `Water/Sewer - =- -- -/ DESC . IPTI N OF WORK TO BE PERFO M : Identification- Please Type or,Pri}t Clearly. OWNER: Name: 01014f I�7�c•l� �o r7 Phone: 6/7 51f �00 Address: 2J570 lNcs4io /UZI .A„'. c7—) . IA 02,V , Contractor N : ._ _ .. - -- ame: ��r+ g'qPhone: 67 ` o Email: h p C,os n e4 c)o ` Address: &4k4i SLI, ire 0 01777 Supervisor's;Construction License:Cb5-0533�,3 Exp. Date: j2-..3Q,/7 Home,improvement Licenser Exp. Date: - =t � ARCHITECT/ENGINEER G( e v>h ll l e- Phone: S10—Rve Address:_ ko KJ "f 1 AL)-� 14A pad d Reg. No. �S3(-) FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COSTBASEDON$125.00 PER S.F. ltiC1 Total Project Cost: $ �•� � ��� FEE: $ Check No.: ` u Recei t NOT : ns contracting with unregistered ntractor d n e access to the guaranty fund Y Plans,SubmitteA Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanuing/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF e U FORM 117) PLANNING VELOPMENT Reviewed On Signature_ 1'„ Wk��_ COMMS S CONSERVA N Reviewed on Signature COM ENTS HEALTH Reviewed on �' Si nature COMMENTS IUU (d,.�5 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: FIRE DEPAc 84 Located Osgood S 3 d ree t t RTMEIVT Temp bumpster on site dyes' "} " no k Located at 1 Main Street . ; '~ �;., E n Fire De artme - " e/datet ,�} o p nt signatur . § �«•.:, � �i P, tp l�. R ray'." x ,��s..i s'""T€�A�` �, ,. ti <+i•:, { }:w �a dr. sT '4.9�d'f 4}R.. d Y i COMMENTS . ,,a° � _ E - _.y � g. k Aja e5A�.v _ n.�c - i i Dimension Number of Stories: /' Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: 41,.5-30 5i�-- Tce��� �. ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No I DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA- (For department use) I I i i i i I U Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 i 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 _ I 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 OTE: 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 OTE: 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 2012 IECC Energy code Engineering Affidavits for Engineered products IN OTE: 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 LocationF'�'.f c v No. DateV�f,cU. f . • - TOWN OF NORTH ANDOVER , Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee_ $ Other Permit Fee $_='� TOTAL r rr oZ.e_ Check# ( 7 30543 /` Building Inspector-_/' Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 72,862.00 m $ - $ 874.34 Plumbing Fee $ 109.29 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 109.29 Total fees collected $ 1,192.93 58 Peters Street 1330-2016 on 6/22/2016 Panera Remodel NORTH Amp-%_ '' ®ver Town of to No. j", h ver, Mass, e� O� LANE COC NIC NE wI[N �,1' S U - BOARD OF HEALTH Food/Kitchen rER I Septic System ��h �� � � �. P �� BUILDING INSPECTOR THISCERTIFIES THAT .............................. .... ............ ................. ..................... . ........... . ....... Phas permission to erect ............... buildings on ... Foundation p Rough to be occupied asN. ... .. ....��.!!1 .. ' .®.... ..... � .................. chimney ....... . . ................... . ............... . .. provided that the person accepting this permit shall in every respect conform to the term of t e 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. Yft ��-a*AS_ . PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONST TIO Rough Service Final BUILD INSP00: TOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final NYtl No Lathing or Dry all To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. CORNER ONE DESIGN/BUILD SERVICES, INC. 6/7/16 Town of North Andover 1600 O good Street Building 20,suite 2035 North Andover, MA 01845 RE: Parra Bread 58 Peters Street North Andover, MA LETTER OF INTENT E Please be advised that the intent of the construction services shall be to complete a minor non-structural alterations to the beverage counter,POS counter,and associated finishes with a proposed budget of: $72,862.00;as follows: :Building $ 47,677 Electrical i 8,960 E Plumbing $ filN ! 4 Mechanical -0= Fre Protection -0- ' Fre Detection _^0- The terms of this agreement will be submitted in the form of an AIA Contract between the parties prior to the start of E construcdon, Respectfully, Ac I}Y: �•Pres. Robert E.Sanford Jr. Li President gnstruction&Facilities Director I Cornerstone Design/Build Services,Inc. Parra Bread/PR Restaurants E 163 Grand Army Highway—Swansea,MA 02777 508.679.2900 Phone 508.679.2600 Fax E E t mom The Commonwealth of Massachusetts Department of Industrial Accidents lb Office of Investigations 600 Washington Street Boston,MA 02111 www.massgovldia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leitibly Name(Business/Organization/Individual):Cornerstone Design/Build Services,Inc. Address:163 Grand Army Highway City/State/Zip:Swansea, MA 02777 Phone#:508-679-2500 Are you an employer?Check the appropriate box: Type of project(required): 1.❑✓ I am a employer with 22 4. I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. F-1 New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 21 Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9. E] 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.[]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 13.❑Other employees.[No workers' comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t 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:St.Paul/Travelers Policy#or Self-ins. Lic.#:DTAUB978K751-8-1 5 Expiration Date:7/19/2014 Job Site Address:Panera Bread -58 Peters Street City/State/Zip:N-Andover, MA 01845 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 certifyun pa' s an allies of perjury that the information provided above Is true and correct. Signature: Date: 6/7/16 Phone#:508-679-2500 Official use only. Do not write in this area,to be completed by city or town ofliciaL 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#: F /IMPORTANT: CO® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) �...� 6/7/2016 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), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. 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 NAME: T Ann Rymszewicz Newport Insurance AgencyFAX (401)619-1660 Ext: (401)619-1660 A1C No: (401)619-2689 460 East Main Road E-MAIL zewicz e ortinsurancea enc com ADDRESS:ar YMs n @ wP g y INSURER(S)AFFORDING COVERAGE NAIC# Middletown RI 02842 INSURERA:St. Paul/Travelers Ins. Co. TPCO01 INSURED INSURER B Cornerstone Design Build INSURER C: 163 GAR Hwy INSURER D: INSURER E: Swansea MA 02777 INSURER F: COVERAGES CERTIFICATE NUMBERMASTER 2015-2016 REVISION NUMBER: THIS IS TOCERTIFY 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. INSR TYPE OF INSURANCE DDL SUBR POLICY EFF POLICY EXP LIMBS LTR POLICY NUMBER MM/DD/YY MMID X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 300,000 AFP CLAIMS-MADE X OCCUR PREMISES Ea occurrence $ DT—CO-97887518—COF-15 7/19/2015 7/19/2016 MED EXP(Any one person) $ 10,000 i PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 POLICY❑jE a LOC PRODUCTS-COMP/OP AGG $ 3,000,000 OTHER: Employee Benefits $ 1,000,000 MBINEAUTOMOBILE LIABILITY Ea..derOriSINGLE LIMIT $ 1,000,000 A X ANY AUTO BODILY INJURY(Per person) $ ALL OSCHEDULED AUUTOSS AUTOS BA-97887518-15 1/19/2015 7/19/2016 BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident Underinsured motorist $ 1,000,000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED FX I RETENTION$ 10,000 DTSM—CUP-4217L829—TIL-15 7/19/2015 7/19/2016 $ WORKERS COMPENSATION X PE 27, AND EMPLOYERS'LIABILITY Y/N STATUTE EH ANY PROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? N/A DTAOB978R751-8-15 7/19/2015 7/19/2016 A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE1$ 1,000,000 It yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) I 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 1600 OSGOOD ST ACCORDANCE WITH THE POLICY PROVISIONS. BUILDING 20, SUITE 2035 NORTH ANDOVER, MA 01845 AUTHORIZED REPRESENTATIVE Ann Rymszewicz/NEWAR1 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(zotaot) Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-053393 ConstructionSupervisor ROBERT E SANFORD, JR 100 SAWYER AVENUE SWANSEA MA 02777 Expiration : Commissioner 12/30/2017 i 1 Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Department Building 20, Suite 2035 1600 Osgood Street North Andover, MA 01845 RE: Insured: Gerald Brecher& Louise Borke Property Address: 488 Pleasant Street Company: Merrimack Mutual Fire Insurance Company Policy/Claim Number: HP2524607, HP2524607 Date/Cause of Loss: 6/20/2016, Water/Rain Seepage Our File Number: 33437-RP Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Rob Parilla, Ext. 119 On this date, I caused copies of this Notice to be sent to the persons named above at the addresses indicated above by First Class Mail. Signature and Date ANDERSON ADJUSTMENT CO., INC. 50 Nashua Road, Suite 303 PO Box 1098 Londonderry, NH 03053 Cc: North Andover Health Department North Andover Fire Department Building 20, Suite 2035 795 Chickering Road 1600 Osgood Street North Andover, MA 01845 North Andover, MA 01845 i