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Home My WebLink AboutBuilding Permit #136-2017 - 69 WATER STREET 8/10/2016 NORTH BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION o ' ;M ?o ))-7 Permit No#: Date Received �RA°RATED "I" � _ �I [Q� �SSACHUS�� Date Issued: I ORTANT:Applicant must complete all items on this page e� LOCATION C Prin PROPERTY OWNER Print 100 Year Structureno MAP PARCEL: /� ZONING DISTRICT: HistoriqS7 c District �no Machine Shop Village e " wo- TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New^Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement - ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other--- L-6 ther rte---; - - =�r -� Septics ®Well Floodplain ®Wetlans t �'� ®} 1 /atershed istrict' - � 1+ ®_ Water_%Sewers , - DESCRIPTION�c F WORK TO BE PERFORMED: a t Identific tion- Pleasea or Print learly OWNER: Name: _ Phone: Address: Contractor Name: Cil CG{AC_CvP_hone: Email: Address: Supervisor's Construction License:(�s Date: { Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. C �. Total Project ost: FEE: $ Check No.: Receipt No.: 3b3 NOTE: Persons contra ctin with unre istere contractors do not have acces to t e ua �n and Unregistered g t3'.f � G _ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped !Tans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Swu u'ng Pools ❑ Tanni%g/MassageBody.Art ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank, etc. ❑ Permanent Dumpster on Site ❑ i - THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF m U FORM I PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed ori Si nature COMMENTS Z?ning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes y 6 ' Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: I Located 384 Osgood Street a F DEPA10 NTx Tem� 'Dtampster�o` p n site yes nn Located at 12.,4 Main partme_ aeeet �entsi natu ' :�� `� #'r ! »s S'�`�� 1,• 1 =+��'7�^t'yy�, �'�.�.xi�� '.:s .x °OMMEIVT�S�:� �:s-�=.�_a.�.��..�r� ::>...� . ....`3''�° ,�=1r��,�• 't-�'.w�.�� f`� {a�'4�..�+.:t:F.�A.:,17.:.a: i'ai�Ri°:A.�'. .t � f i 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 DANCER 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 Date Time Contact Name Doc.Building Permit Revised 2014 I Building Department i 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 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 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 Doe:Building Permit Revised 2014 Location [ = - v L4- No. Dated • - TOWN OF NORTH ANDOVER Certificate of Occupancy $�_ Building/Frame Permit Fee $ ' Foundation Permit Fee $ Other Permit Fee TOTAL $ Check# 7 Build ng Inspecto"r fit" NORThr Town o ? _ 6Andover O ` , 0 .yam. No. .T Z h ver, Mass O LAKI coc"Ic"IWICK yq. �d ORBITED PPa,�� S BOARD OF HEALTH Food/Kitchen ERMIT T LD Septic System .. THIS CERTIFIES THAT ....... , BUILDING INSPECTOR ................................................ ... ........................... pi...Q&J(Ck ..%tofte Foundation has permission to erect .......................... buildings on . .............,,........... � Rough to be occupied as .......... !.%'r6!. .....Q.... ....49. iftN�3 ...I!.�............................ 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 MONTHS ELECTRICAL INSPECTOR UNLESS CONST TION T Rough Service . .. ........ ... . . ............ . ........ ........... Final BUILT G 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. � at — V Y m o � N N X L 4 .U1 \ I IIIII uP II = Li V ON IIIII UP � � 0 4' FM m O m z JONATHAN t APATA FIRST FLOOR ENTRY 69 water Street NEW DIVISION WALL North Andover.MA. UNIT#2 UNIT# 1 o_ - Proposed New Wall Section _ 7k4"studs Q ib"O.G.wl sheetrock 518"both side. Double Top Plate Existing Door 36' to Closed a 0 5� D D T- > >03 ry LO �rn 03 Orn � z D Z N The Commonwealth of Massgchusetis zf Department offlndustrialAccidents 1 Congress Street,Suite 100 'F d Boston,MA 02114-2017 www mass.gov/dia �• Workers,Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FMED WITH TEE PERMITTING AUTHORITY. A licant Information Please Print Le ' I NaMo(Business/Organizationfludividual)' /We 15v Address: City/State/Zip: Ln-1 C Phone#: Are you an employer?Checktlie appropriate box: 'Type of project(required)' 1. am a employer with .2 _employees(full and/or part-time).* 7.- F1 New colistraction 2. 1 am a sole proprietor or partnership and have no employees working for mein 8. 1i Remodeling any capacity.[No workers'comp.insurance required.] 9_ ❑Demolition I Q I am a homeowner doing all work myself[No workers'comp..insuraace required.]t 10 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole I LQ Electrical repairs or.additions proprietors withno employees. l2:❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. Roof repairs These sub-contractors have employees and have workers'comp.insurance.T 6.Q We are a corporation and ifs officers have exercised their right of exemption per MGL c. 14.F1 Other 152,§1(4),and we have no,employees.[No workers'comp.insurance required.] *Any applicant that checks box 41 must also fill out the section below showing theirworkers'compensation policy information. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors 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 then workers'comp.policy number. lain an employer t]zat is pi'ovidingworkers'compensation insurance for my employees.'Beloiv is thepolicy acid job site information. Insurance Company Name: Policy#or Self-ins.Lir'.#: �,,,��C_ 3�5= S �7 _ irationDate: � �' Job Site Address: � City/State/Zip: Attach a copy of the workers' compensation poficy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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 'olator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage ver' tion. X do hereb rtifyAundergaEmsand penaltfes ofpeijury that the information provided above is true and correct Si atur . Date: Phone#: Official use only. Do not write in this area to he 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.PIumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for them employees. 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 defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee 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 local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonweaM for any applicant who lias not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill-out-the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary, supply sub'contractor'(s)name(s),address(es)and-phone number(s)along with their certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees'other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of•Industrial Accidents foi-con-H oration 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' compensation policy,please call the Department at the number listed below. Self-insure_d 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 of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as axeference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"rob Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where 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 permit to bum 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 978-685-0310 Silverio Ens. 11:54:11 a.m. 06-16-2016 212 A REY CERTIFICATE 4F LIABILITY INSURANCE DATE` "°°' '"' 06/16/2016 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 NAME_ Johanna Gutierrez Silverio Insurance Agency PHONE . (978)685-0209 Nal: (978)685-0310 10 S.Broadway ADDRESS, info@siherioinsurance.com IN AFFORDING COVERAGE NAIC i Lawrence MA 01843 INS RER A: WESTERN WORLD INSURANCE INSURED INSURERS: LIBERTY MUTUAL FIRE CARLOS CASTANAZA DBA CA Construction INSuRERo: CA CONSTRUCTION INSURER D: 317 So.Broadway-Suite 154 INSURER LAWRENCE MA 01843 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. TYPE OF INSURANCE POLICY NUMBERPOLICY EF POLICY EXP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE s 1,000,000 DAMAGE TO RENTED CLAIMS-MADE 17 OCCUR PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 A NPP8326275 05/18/2016 05/1812017 PERSONAL RADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000.000 X POLICY❑PRO- ❑ JECT LOC PRODUCTS-GOMPIGP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMEIN C SINGLE LIMIT Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY Per accident $ AUTOS AUTOS ( ) NON-OWNED PROPERJY DAMAGE HIRED AUTOS AUTOS Per a ent $ $ UMBRELLA LIAB OCCUR EACH OG URREJCE $ EXCESS UAB CLAIMS MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATIONOTH- AND EMPLOYERS'UABILITY YIN ATUTE ER B OFRCERIMEMEERECCLUDED?ANY PROPRIETORIPARTNERVECUTI� a NIA WC2-31S-365147-036 02/24/2016 02124/2017 E.L.EAC1iACCIDENT $ 100000 (Mandatory In NH) E.L.DISEASE-EA EMPLOY $ 100000' If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks schedule,may be alached K more space Is required) Additional Insured is added automatically as long as there is a written agreement requesting to be added CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of North andover ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood street AUTHORIZED REPNEsENTATIVE North Andover,MA 01845 ®1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Fire Services Office of the State Fire Marshal P.0.Box 1025 State Road,Stow,MA 01775 PERMIT Date: ld_!_G 7,-/el, Z-1 47 00�/fd Permit No (City of Town) (HApplicable) Dig Safe Number In accordance with the provisions of MG.L. Chapter 1 Das provided in section 5 2 7 CMR 34 /, Start Date This Permit is granted to: a / •f�,�Y�f% c/l C/l% 9 Full name of person,Firm or Corporation Permission to locate dumpster for construction/renovation/demolition of structure Comments: dumpster be 25 ' from structure or covered with tarp or plywood Restrictions: at end of workday at 1161��77!'t- (Give location by street and no.,or describe in such manner to pprr�ovied adequate identification of location) Fee Paid S — et'fv' This Permit will expire U/ (Signature of offical granting permit) Offical granting pernut Mae) �� TWIR PERMIT MI LCT FBF ('_`OKI-gPIf_I In91 ICI V Pn1QTi:n I IPn KI TNF PPI=MICl=Q ��