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HomeMy WebLinkAboutBuilding Permit #1028-2016 - 598 SALEM STREET 3/30/2016 l TO�r BUILDING PERMIT 6 NORT06 H Y' TOWN OF NORTH ANDOVER 32 h 4.46 APPLICATION FOR PLAN EXAMINATION Permit No#: ` Date Received SsgcUs���y Date Issued: 6 1 I PORTANT:Applicant,mmust complete all items on this page \�iNn LOCATION S� -f s 1 Print PROPERTY OWNER lA ct-'' ,.,e,, I'� �� Pi (� l nt 100 Year Structure yes no MAP 6-M PARCEL-.66'11ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building KOne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic 61V`6 lll ®❑iFloodp alai in ®We atl nds k ❑` INatershedi�®rstrict` I LI - I DESCRIPTION OF WORK TO BE PERFORMED: Identific ti - Please Type or Print Clearly OWNER: Name: V�Q',v, �� , >� Phone: ��7 �-{-�17L Address: II Contractor Name: ,Iw Phone: p. 7L — Em1�-n A jZ3.n a !Cin 16.!!J _ Address: I Supervisor's Construction License: Exp.Exp. Date: q/,2 4/16, I _ Home Improvement License: ��. �' Exp. Date: A , ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ �� k _ �(� FEE: $ II Check No.: 12-Z Receipt No.: �1 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 4r _ _ �__ - 6b,-, . .. 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 4� Building Permit Application 4. Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses 4, Copy of Contract 4. Floor Plan Or Proposed Interior Work 4. Engineering Affidavits for Engineered products ®TE: 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) 4� 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 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 J Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped flans ❑ TYPE OF SEWERAGE DISPOSAL i Public Sewer ❑ Tanning/Massage/SodyArt ElSwimming Pools El 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 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 conservation Decision: Comments Water& Sewer Connection/Signature ®ate Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPAR EiV�7 ;,� � ,-= r 1% . Temp Dumpk .ste zgmsitehz;ayes , , s ono �' " Lo� at 124 Main Street ? � r,�a - .Fire ®epdrtnl�ntsig +� t . a nature/datex'� �� � 3 � r3't `',yy,, rt,ft w'z`it4x,�]r l�y�g9.� .. 3 + `' ,y{r� b. �- t 1 ��� F'.-*�'t";'Ft'7"tr �,A F C=�� � 'r� ,'�;r' NvtlE-At♦ aA t s ' tia.YTfia } ��a♦� .1 r u.•;. y l 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) i ® Notified for pickup Call Email I Date Time Contact Name 3 Doc.Building Permit Revised 2014 Location Q� l - -�&-' No. � 2.ol Dated s e • TOWN OF NORTH ANDOVER � Certificate of Occupancy $ Building/Frame Permit Fee $��—'`"", Foundation Permit Fee $ Other Permit Fee $ .. TOTAL $ Check# V-'</ f 3U1 36 Building Inspector f Town of ndover : �10RTIy � 0 : - z o K§ h ver, Mass Olt 2A �,9CoCNICMIWICK s RATEo ►P�,��(5 U BOARD OF HEALTH Food/Kitchen PERMIT 6 L D Septic System THIS CERTIFIES THAT .......... .. ��. . ...... ...................... BUILDING INSPECTOR ........ ........... .. .... . .... ... ...... .......... Foundation has permission to erect....... .................. buildings on .. .. .. ... .. ............. • � Rough to be occupied as . .- .. �..... caz ................................................................... 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONT S ELECTRICAL INSPECTOR UNLESS CONSTRUCTION S S Rough / Service ................... ...... . . ....r/..�. ..... .. ............... 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. s READY TSCHEDULE Al gist:F.,,�t,t4�ctt$ fln RISEal\ixlr.47lerhes t.tGwr++� e�f w�+ w CONTRACT ' I ltlli"'n1-S•na 6;aX iaOtl9UJtio PABX I PROMAM ..KneacreL.+t*renroLeremrae C\7A-ql.T r�mr«nramwa I Lmtom w ne wn .naresw t(fim iia.anti i97$).a44-9744 pl'?8''_1}16 L'841. 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The Commonwealth of Massachusetts Print Form Department of Industrial Accidents Office oflnvestigations { ' = _7' I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Builders Services Group d/b/a Quality Insulation Address: 110 Perimeter Rd City/State/Zip: Nashua NH 03063 Phone #:603-324-1974 Are you an employer? Check the appropriate box: Type of project(required): 1.❑✓ I am a employer with 100 4. ❑ I am a general contractor and I employees (full and/or part-time). * have hired the sub-contractors 6� ❑ New construction 2.El am a sole proprietor or partner- listed on the attached sheet. 7. E] Remodeling ship and have no employees These sub-contractors have 8. ❑,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.❑ 1 am a homeowner doing all work officers have exercised their 1 1.❑ Plumbing repairs or additions right of exemption per MGL myself. [No workers' comp. right Roof repairs insurance required.] c. 152, §1(4), and we have no 13.❑ Other Weatherization employees. [No workers' comp. insurance required.] "Any applicant that checks box#1 must also fill out the section below showing their workers-compensation policy infimnation. 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 emplQver that is providing workers'compensation insurance./or mV employees. Below is the policy and,job site information. Insurance Company Name: ACE American Insurance Company Policy #or Self-ins. Lic. #:WLRC 48151553 Expiration Date:6/30/2016 / Job Site Address: 5 � _0A-\ S City/State/Zip: 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 thepains and penalti c of erjuty that the information provided above is true and correct. Si nature: Date:l Phone#:603-324-1974 Oficial use only Do not write in this area, to be completed bV citV 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#: DATE(MM/DDrYYYY) CERTIFICATE OF LIABILITY INSURANCE I 06/28/2075 THIS CERTIFICATE 15 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 INSURERS), 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 P certificate holder in lieu of such endorsement(s). 1PRO DUCER CONTACT AOn Risk services CentralNAME: , Inc. PHONE (8663 153-71?? FAX (800) 363-0108 m Southfield MI Office (A/C.No.Ex:): (A/C.No.). 3000 Town Center E-MAILO Suite 3000 ADDRESS: _ Southfield MI 48075 USA INSURERS)AFFORDING COVERAGE NAIC INSURED INSURER Old Republic Insurance Company 24147 Topzild Corp. INSURER B. ACE American Insurance Company 22667 ?60 Jimmy Ann Drive Da y"LOna Seach FL 32114 USA INSURER ACE Fire Underwriters Insurance Co. 2070? INSURER D: INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: 570058348882 REVISION NUMBER: THiS I INDS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD ICATED. 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. Limits shown are as requested INSPI TYPE OF INSURANCE OL CY t O C tY, UM(75 LTR INSD V VD POLICY NUMBER MMJDD/YYYY I/rtgM/DDIYflYI A X I COMMERCIAL GENERAL LIABILITY mhzY304834 00/1, 120151061'-30120161EACH OCCURRENCE S2,000,0001 CLAIMS-MADE X❑OCCUR. DAMAG O RENTED 12,000,000 PREMISES Ea o¢unencel MED EXP(Any one person) 125,0D0 PERSONAL S ADV INJURY 12,000,000 p GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE 14,000,000 m X PRO- POLICY ' �JECT ❑LOC PRODUCTS-COMP/OP AGG S4,000,000 m OTHER.: o A AUTOMOBILE LIABILITY MhR-B 304835 06/30/2015106/30/20261 COMBINED SINGLE LIMIT Ea acudenl 55,000,000 I ANY AUTO BODILY INJURY(Per person) Z AU ALLTOS AUTOS OWNEDD SCHEDULED BODILYINJURY(Per a cadem) N X HIRED AUT OS X NON-OWNEDPP.OPE PTY DAMAGE AUTOS Per acodenl — - O U1F-HRELLA LIAR OCCUR, EACH OCCURRENCE U ESCE55 LIAR ri CLAIMS-MADE JAGGREGATE DED P.E TENTION B WORKERS COMPENSATION AND wLRC48151553 06/30/2015 06/30/2016 PER OTH- EMPLoI'ERS-UABILITY YIN qll Other SLateS X SiPTUTE ER C ANY PP.OPF--Ic TOR/PARTNER/EXE EXECUTIVE N E L EACH ACCIDE N7 S1,000,000 DFPICEP'RIc BcR EXCLUDED' ❑ N/A SCFC4815190 06/30/2'015 06/30/12015 "'es(Naric—crib. in NHI wI Only E 1.DISEASE-EA EMPLOYEE S1,000,000 If ycs,dcscnbe under - DESCRIPTION OF OPERA71ONS below E L.DISEASE-POLICY LIMIT 11,000,000— E SCRIP710N OF OPERATIONS/LOCATIONS/VEHICLES(AC ORD 107,Additional P,emarks Schedule,may be attached i1 more space is re Ouire d) vidence of Coverage A>t .�J -J RTIFICATE HOLDER CANCELLATION �C SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE `�P EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Builder Servi C"5 Group, Inc. AUTHORIZED REPRESENTATIVE o— A TopBuild Company .r 260 Jimmy Ann Drive r- Daytona Beach EL 312114 USA ©1988-2014 ACORD CORPORATION.All rights reserved. %CORD 25(2014/01) The ACORD name and logo are registered marks of ACORD `q Off ce of Con4zume, 5 �1 � ��s l ��s Reti ion =_ - = i �- 3' az - Sui >170 Bostoi3- TAass-achusetts (32)116 Hon,,e Improvement Contractor Registratioll Repisiration: 179141 Type: Supplement Card Expiration: 6/2512016 BUILDER SERVICES GROUP, INC. RICHARD SCHV./ARTZ 116 PERIMETER RD NASHUA, NH 03663 1;1x1ate Address anti return card.'Stark reason fo> change. Address Rene�%,il F_mipk;�ment Lust( and f)1'iice of Corsuner Affairs c� Businrss Rt,-�ulation t.icrnse or re<gistratian valid For individul use at:t .'. OM!E IMPROVEMENT CONTRACTOR bc`ft re the pin titen chit•. If found retarn to: Office fjl,onsumer Affairs ant] Business Rt-gulation 'Registration: 179141 Type: 10 P�irk Plaza i:e Sl 70 Expiration: 6P55I2016 Supplement .'-and Poston. NIA 02 116 UILDER S_RVtCES GROUP, INC. IC`A,RD SCt':`PJARTZ AYTONTA BEACH, FL�21 1, €'ndrrsctre;ar� fiat v:::tid._nithout sigristure ft,;c�l,�rttr rertvtfntrrr �k�`�..'��'�' ft•'fruacftcstcr Nil (131W osrzE��zcr.tfl �cstrit,Ft:ct T o. C:Sst:IC tftsul ftian Cafttraranf HMPM possess a ea aum Win 0 the h9amchuse m ace Buitdma Code is CAUSe for myoc.atinn of tMs ...................