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Home My WebLink AboutBuilding Permit #684-2017 - 6 ALLEN STREET 1/3/201701 NORTy q �4W BUILDING PERMIT TOWN OF NORTH ANDOVER �I�PPLICATION FOR PLAN EXAMIN10 ; ,b Permit NO: Date Received� t5 s o A . ;tea• ,. TANT: Applicant must complete all items on this LOCATION U A11 -Z -a7 �— Pnnt PROPERTY OWNER Print MAP NO; PARCEL:I+E "ZONING DISTRICT: Historic District yes no j Machine Shop Village yes no/ TYPE OF IMPROVEMENT 121; PROPOSED USE Res'dential Non- Residential ❑ New Building One family 0AAddition ❑ Two or more family ❑ Industrial lteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: 0 Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain 0 Wetlands ❑ Watershed District ❑ Water/Sewer I"/\ -i-- h I , v r v -�. w.cc 1 t 4_,fq&0�_ OWNER: Name: Address: Identification Please Type or Print Clearly) r,I,n 049w) -r_ Phone: et07-4v9- 11-.10.2 CONTRACTOR Name: Phone: Address: AD 6051 ren A1, _ A r\2a� c � L ✓►�- c� i 3�� -' Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date:: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BOLDING PERMIT: MOO PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ P11 %,Pd FEE: $ Q� Check No.: i 3 O Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Location 6 Iq L L C No. U11 - 4 017 Check # /3077 r 1 't 397 ST Date 3 0 ( 7 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $1 90''� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ �,/ Building Inspector Plans Submitted ❑ Plans Waived El Certified Plot Plan ❑ Stamped Plans ❑ T F -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 PLANNING & DEVELOPMENT Reviewed On COMMENTS Signature CONSERVATION Reviewed on Signature COMMENTS HEALTH COMMENTS Reviewed on Siqnature 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 FIRE DEPARTMENT'- Temp Dumpster on site yes no Located at 124 Main Street Fire Department signatureldate COMMENTS a 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 o 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 NQ TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit I all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Nppeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof recording must be submitted with the building application Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 1imension 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.$100-$I000 fine Doc.Building Pen -nit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. r Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract o 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 o Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit o 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 VOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) o Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses o 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 o Engineering Affidavits for Engineered products DOTE: 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 j Doc: Building Permit Revised 2014 permit No#: [)ate Issued: BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION' Date Received TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Building [I One family 11 Addition 0 Two or more family [I Industrial 0 Alteration No. of units: [I Commercial 0 Repair, replacement El Assessory Bldg 0 Others: 0 Demolition [I Other ❑Septic Well I Floodplain oc), 2n- 171' A'plain-- I Wetl' 8 91 VYV6t&s!-iOd Unstriat,: DESCRIPTION OF VVUKK I L) tit FtK1-Ur,1VJr-LJ; Identification - Please Type or Print Clearly OWNER: Name: A -1 -1 Pho 6- Cdnff5b-td Name:— Phone; A4- License'L, --19ate� up VISGK§;�C --str(iqf t -L bMb, Im-, pr H- ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDINGPERIKIT.- $12-00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. i. ,'---,notal Project Cost: $ FEE: $ ;- Check No.: Receipt No,: NOTE: Persons contracting with unregistered contractors do not have- access to the guaranty fund Aci A r C1 ��W�f n7n-f h� Si nature Of con �i Z C Cft T .a� Z T A co 3 rm T ,v 0 m;u n 3 7 fD ; 0 S Err 3 cn ic T a n n ' ao v O x m D r 0M z Z m cn �z G) 0 O v " Ow = 0 < C N O c CDCC`n D (m) -4 .-� CL n m ov+�(D -n 0 o rt Q rn W F;- CD cn y p c = CD C - CD 2 O'�% O 'r V rt N rt = _• O G1 , rt n � O CD -0 0 O C (CEMMA oo�a DCD 7� C 0 �, CO 0 CLW SCD �"i rN D) 'O ID vii C) Q 3 (D � r Z c Cft T .a� z cn n O a T A co 3 r m y r LA m n 0 T ,v 0 T ° n 3 7 fD ; 0 S Err 3 C n 0 N n 3 T a n n ' ao v O x m D r 3 (D � r Z c m m T O S z cn n O a T rD 0 3 r m y r LA m n 0 T A o°o S M C z vzi n 0 T ° n 3 7 fD ; 0 S T c O. w C n 0 N n 3 T a n n ' ao v O x m D r l` Board of Buflding 9egyatkmaand Swfl.d /-i } g� CS-1WIM ) aRMKB= ) 68aUMLLSTRMƒ f - \ �e QW29MV : -HJT!@ iSf'Lt�tIQJIBI�!/1�1t O�(�?-$�flgflcliKi�a��i A(ME MPROVEMENTCONTRACTdR 1 X81826 Type. uP,raanre_=ar�r11)a7 DBA CBA WOODS _- The Commonwealth of Massachusetts Department of Industrial Accidents Off"ree of Investigations ' d l Congress Street, Suite 100 Boston, MA 02114-2017 N s www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):_(,3 nx +ars 3z k6 Address: b1D P>y� iyn S�• City/State/Zip: A/orMArrx�„/Vb,�1�U5 Phone #: W��--30y —'ate LI Are you an employer? Check the appropriate box: Type of project (required): 1. ® I am a employer with 4. C1 I am a general contractor and I 6. New construction ruployees (full and/or part-time).* 2. I am a sole proprietor or partner- ' have hired the sub -contractors listed on the attached sheet 7. C) Remodeling ship and have no employees These sub -contractors have g, CJ Demolition workingfor me in an capacity. y p �'• employees and have workers' 9. C1 Building addition [No workers' comp. insurance required.] comp. insurance.$ 5. CJ We are a corporation and its 10.CJ Electrical repairs or additions 3 -a I am a homeowner doing all work officers have exercised their I LC1 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.C] Roof repairs insurance required.] t c. 152, §1(4), and we have no 13.Cl Other employees. [No workers' comp. insurance required.] *Any applicant that checks box fit 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. $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 thepolley and job site information. Insurance Company Name: Policy # or Self -ins. Lie. #: Expiration Date: Job Site 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 the pains and penalties of perjury that the information provided above is true and correct. Phone #: A 7` 7-3 V 1 — A 1 LI? 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 S. Plumbing Inspector 6. Other Contact Person: Phone #: 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 PLANNING & DEVELOPMENT ❑ COM ENTS CONSERVATION COMMENTS HEALTH COMMENTS 7 DATE REJECTED DATE APPROVED 0 DATE REJECTED DATE APPROVED 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 Located at 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes, no Located at 124 Main Street �/ Fire Department signaturefdate COMMENTS 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 IVU 1 t, ana UA 1 A - p -or aepartment use Doc.Building Pennit Revised 2012 ACRD® CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 12/30/2016 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. 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 certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Victoria Lowes, CISR NAME: PHONE.Ext): (978) 681-5700 FAAC No: (978)681-5777 MTM Insurance Associates 1320 Osgood Street AADDRESS,vickiel@mtminsure.com INSURERS AFFORDING COVERAGE NAIC 4 INSURERA:Preferred Mutual Ins Co 15024 North Andover MA 01845 INSURED INSURERS: INSURER C : Brian Beasley dba CBA Woodworks INSURER D : 90 BOSTON ST INSURER E : INSURER F; North Andover MA 01845 COVERAGES CERTIFICATE NUMBER:16-17 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. INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MMI DIYYYY1 POLICY EXP fMM1DDIYYYY)LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 500,000 A CLAIMS -MADE F—xl OCCUR DAMAGE TO RENTED 50,000 PREMISES Ea occurrence $ MED EXP (Any one person) $ 10,000 BOP0100715042 11/1/2016 11/1/2017 PERSONAL &ADV INJURY $ 500,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 1,000,000 PRO- X POLICY ❑ JECT LOC PRODUCTS - COMP/OPAGG $ 1,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE $ Per accident $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR CLAIMS -MADE DED F1 RETENTION $ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N / A E.L. DISEASE - EA EMPLOYE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below - E.L. DISEASE - POLICY LIMIT 1 $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) This certificate of insurance represents coverage currently in effect and may or may not be in compliance with any written contract. CERTIFICATE HOLDER CANCELLATION Town of North Andover Building Dept Paul Hutchins 120 Main St. N Andover, MA 01845 ACORD 25 (2014/01) INS025191)14n11 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE P MacDonald CPCU, CIC l/KW4,__ ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD