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HomeMy WebLinkAboutBuilding Permit #774-2017 - 60 WILLOW STREET 2/15/2017L.- TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: --mg— o l Date Received nate Issued: A Al LVIPORTANT: Applicant must complete all items on this page L4 C'6Lj G✓''I�O ul P int PR:QPERTYOWNER _ �a � G_G�-�1✓� poi � - { Paint 100 Year,OldStructure yesrno,MAI? NO , PARCEL:,_ __ ._ ZONING�DISTRICT Historic�Distr%ct yesy TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family f6 Industrial Iteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: -947emolition ❑ Other I] Septic D W611 .(flFloodplain - 11Wetl5nds -[D Watershed District----- M Water/Sewer OWNER: Name: DESCRIPTION OF WORK TO %-)i or wt W/ n L4 e 'o,6 r I► H p �- , PERFORMED: Please Type or Print Clearly) Phone: / h 4/ -It CPd FR�R Name-✓. , / t- o�./rL-- - Phone:,. 60-3 ' 7/6_- G31 3Q Address: r7►K4%� %������ • - �. Ex Date: Supervisor's Constructiori License ._5_ Y�'�°�_ E p Horne Improvement License m.. Exp Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE., BULD/NG PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $aly0'�� FEE: $ �Z� Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature ofi Agent/Owner .:. Signa Plans Submitted ❑ Plans Waived Certified Plot Plan 0 to ed Plans ❑ 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS r t Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Y .. Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW To -vv Engineer: Signature: Located 384 Osgood Street FIRE DEPA.RTMENT - Temp Dumpster on site yes no Located at'124 Mair,' Street Fire Departmerit $ignaturelclate 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 chop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A -F and G min.$10041000 fine NOTES and DATA = (vor c;iepartment use El Notified for pickup - Date Doc.Building Permit Revised 2010 Building Department Tine fol?owing 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 (COTE: 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 ❑ Fioor/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 40TE: 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 I0TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all ce scs if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appaal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must boF- subrn:tied with the building application Doc: Doc.Building Peanut Revised 2012 Location , z ' ' C{,", — No. -114-261-7 Date TOWN OF NORTH ANDOVER d Certificate of Occupancy $ Building/Frame Permit Fee $ O Foundation Permit Fee $ Other Permit Fee $ TOTAL $ r� Check #��' •"� Building Inspector 9 H J W LL CO = U Y LL Eco n LO Q 0 a Z Z O J O O y N O LL O LL' T 41 U LL W G. Z Z ca G J L O _ LL 0 0. Ln Z V u W LU tv : N r:Cry LL a: O a 4A Q �Y LL' _ LL z W 2 F - Q W W SC LL v m Z (% N p N YOO N I 0 Q CD o w� 2. cn y,. O = • Mi c a VOW) z 13 O O t.1 i w � c R N J i a' z 44. -0 2 m a :42 H > C � Cl) O (D to O W O� O ) O 0 0 > CL w Z tmM.2 o N3c W c� 0 CL Aw m m 0 o c Q o 0 H O Q'2 � w = - o o Li •2 rn c O �s o H vs d' LU O v � 0 m •� 0 H U m o m N sZ O > w J •O o 0 F 4- a. o U > z v U) ujJ 5"--, 14) N W 0 Q� L Z 0 00-0 L ••• 0 �+ 0 0 ca c CL a CL �CL04) �z V N CL ccs � New England Fire & Sprinkler Protection, Inc. 80 Brick Kiln Road Chelmsford, MA 01824 (978) 452-2895 • (978) 453-5475 - Fax February 9, 2017 North Andover Fire Prevention 795 Chickering Rd. North Andover, MA 01845 978-688-9590 RE: Dow Chemical. 60 Willow St. North Andover, MA Title: Acoustical ceiling tile removal Scope of work will consist of the following: A) Removal of pendant type sprinklers to accommodate A.C.T. Demo and removal 13) Raise branch lines into bar joist where applicable C) Provide upright sprinkler coverage in areas lacking upright protection D) A1.1 work to conform with NFPA 13 codes and standards Sincerely, Ted Flanders New England Fire & Sprinkler Protection De commonwealth of Massachusetts -DepaFtrnent of I-ndustrialAccidents 1 congress Street, S4 to 100 - d Boston, lVlA 02114-2017 wrvw mass govldld Wa kexs' Compensationbsuxaned A£fcdavzt: Bzriidexs/CO tra ctorsIfflAec�ciax�s/�'Xr�abexs. TO SE�'ILID�STHEP��� �io�aA2�rint 1 Name (Business/Ozgaaiizatiovllndividual�: Address: fi G Phone 4: City/State/Zip:_Al Che -1- #1 OLY ......: _ ,., eck. ro riatebox: Type ofproject(maired) Are you an employer. CJi tiieapp p em loyees full andlor pact time). 7. ❑ Nci-'d6nSf'x&UoR 1. I am a employer with P . I am a sole proprietor or parfnersbip andhave no employees vrorking forme m 8. Remo deluig any capacty jNoworkers' comp. insurance required] 9. ❑ Demolition e oworlcers' comp. in=.neerequired] r 10 ❑ Building addition 3.❑ I am a homeowner doing all workmys lf- [N 4.❑ I am ahomeowner aadwM be hiring coniractorsto conduct all work Onmy property -'will 11 ❑ Electrical rppa= or additions eitherkavo workers' compensation instance ar are sole ensure r%at all confra„'dors 12. UP17imbing repairs or additions proprietors ViffiL no employees. 5_❑ I am a general coacipr and Ihave htredthe sub -contractors listed onthe attached sheet 13•.r]Roofreliairs These sub-contractorshave employees andhaveWorkers' comp. insurance.? 14ther 6.❑We are a corporatiov. and its. of iDdrs have exercisedthcir rigbt of'exemptiou per MGL o. 152, §1(4), andvrehavzno employees_ [Noworkers' comp. insurance required] Pens'9 on policy informatio= Any appltcam that checks box#1 g Fhmey are doinglali work andihen bile outside emontwtors must submit new affidavit such i Homeowners wha submii•tbig afft• - _ �Coniraciorstbatcheckthis�otx�r�� �Pj y� ��o�tpTO�dethes workerse comp_policynraabera�statewhetherornotthose.e�ilies ave - emplcyecs. Ifthe sub -cot .. . X wn arz errzploye.� tliai isproviding-rvorker�s' cornperzsation irzsurancefor° my errnloyees .8elaw is t/iepolacy arzdjo� site infor'Plat dOn. Insurance CompauyName- ExpirationDate' Policy # or Self -ins. Lic. #: . tAll A02 f City/State/Zip: Tob Site Address:— showhig the policy number and expiration date)' Attach a copy of the fvoxkexs' compensationpolicy declaraitonpage to $1,500-00 Failure to secure coverage as required under M n� 152, s , §he f is aofrSTOP WORK ORDER and a fine oationpuuishable, by a Bib fup to $250.00 a and/or one-year' iznprlsonmen� as well as cavil p be forwarded to the O day against the violator. A copy of this statement may Office, of investigations of the DIA. for insurance coverage verification. r do 7iereby certify �� /` Ep�� �ee�calties ofperjury Haat file infar7nvtionprovided above isstxue/cu�?d corJrecir r�fP• — /� ,�f Q l/ '7, Do xzot write in this area, to be completed by city ox to-Wn of officiaz use 01z 1Y. • PeranzilLicense # City or Town' .8srring-A.uthority (circle one): eetor �. Plumbing inspector 1. Board offfealth 2- )3nldingDepartznent 3. C%iy/ToQva Clexk id. Electxicalinsp 6. Other Phone Contact Person: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their empldy�es. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is d'efiued as "an individual; Partnership, asso dation, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enferprhe, and including the legal representatives of a deceased employer, or the receivi,for trusted of an individual, partnership, association or other legal entity, employing employees:.However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or to cal licensing agency shall withhold the issuance or renewal of a license or permit to opdrate a business or to constant buildings in the commonwealth for any applicafntwho has not produced -acceptable evidence of compliance with the insurance coverage xequiired." Additionally, MGL chapter 152, §25C(�) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fll out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply mb=contractor(s)name(s), addresses) andphonenumber(s) alongwiththeir cerdflcate(s) of insurance. LimitedLiabiiity Companies (LLC) orLimitedLiabiliiyPartnerships (LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If a u L LC or LLP does have employees, a policy is required. B e advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial -Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compematioitpolicy, please callthtDepaziment atthenumberlistedbelow. Self-insured companies should enter their self insurance license number on the appropriate line. City or Town. Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom ofthe affidavit for you to fill out in the event the Office oflnvestigations has to contact you regarding the applicant. Please be. sure to 01 in the p ermit/license number which will be used as a reference number. In addition, an applicant thai must submit multiple permit/license, applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "lob Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamp ed or marked by the city or towm may be provided to the applicant as proof that a valid aff7davit is on file for fature permits or licenses. Anew affidavit must be filed out each year. More a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or p ermit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA.02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877 MASSAFE Fax ## 617-•727-•7749 Revised 02-23-15 wwwmass.gov/dia A� b® CERTIFICATE OF LIABILITY INSURANCE F-9/2016MIDDIYYYY) 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. 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 Elaine Dozois, AAI NAME: Fred C. Church, Inc. PHONE 978 3227243 FAX (978) 454-1865 /C No xt • AIC No 41 Wellman Street Lowell 01851 E-MAIL edozois fredcchurch.com ADDRESS: 5. (800) 225.1865 INSURERS AFFORDING COVERAGE NAIC N • INSURER A: Commerce Insurance Company 34754 INSURED INSURER a National Union Fire Insurance Company of Pittsburgh, PA 19445 New England Fire & Sprinkler Protection, Inc. INSURER C: Associated Industries Insurance Company Inc 25372 80 Brick Kiln Rd C Chelmsford, MA D1824 INSURER D : %Nar� al Liability & Fire Insurance Company 20052 INSURER E: CLAIMS -MADE —J OCCUR INSURER F: ( COVERAGES CERTIFICATE NUMBER: 51456 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 SUER POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MMIDD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1.000,000 % COMMERCIAL GENERAL LIABILITY _ DA AGE TO RENTED 50,000 rr PREMISES Ea occuence $ MED EXP (Any oneperson) s excluded CLAIMS -MADE —J OCCUR ( PERSONAL&ADV INJURY $ 1'000,000 C i AES7034276 - 3/26/2016 3/2612017 GENERAL AGGREGATE S 2.000.000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S 2.000.000 _ POLICYr% PRO- LOC I S AUTOMOBILE LIABILITYj BIKED SINGLE LIMIT 1.000,000 Ewa cci am $ BODILY INJURY (Per person) $ ANY AUTO j I I A ALL OWNED X j SCHEDULED AUTOS AUTOS Ii BBNT95 3123/2016 3/23/2017 BODILY INJURY Per accident $ ( ) % HIREDAUTOS NON•OWNEO AUTOS I PROPERTY DAMAGE $ Pereccitlanl $ I I II % UMBRELLA LIAR X OCCUR, EACH OCCURRENCE s 1.000,000 B EXCESS LIAB CLAIMS•MADE SE0624569U 4/612016 3/26/2017 AGGREGATE $ 1.000.000 ED % RETENTION S None DE.] $ I WORKERS COMPENSATION X I WC STATU- I IOTH-- AND EMPLOYERS' LIABILITY E.L. EACH ACCIDENT s ` 000 D (ANY-PROPRIETOR/PARTNER/EXECUTIVE —y OFFICERIMEMBER EXCLUDED? NIA V9WC704214 3/2312016 3/2372017 E.L. DISEASE - EA EMPLOYEEI $ 0,000 (Mandatoryin NH) If es, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT S 500.000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is requlred) p Brian Flanders+ Kathy Flanders - see BEF CERTIFICATE HOLDER CANCELLATION Town of North Andover Nor Main St Nora North Andover. MA 01845 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 /1 Client a """ MstIf 01400 CertHolder # 70luu ©'1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD � Commonwrealth of Massachusetts. Department of Public Safety License: SJ -149959 Sprinkler Journeyman JEFFREY J BELIVEAU 57 PINGREE HILL RD �� AUBURN NH 03032 Commissioner. Expiration: I 07/10/2018 I