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Home My WebLink AboutBuilding Permit #Exception - 70 ELM STREET 5/1/2018 • Of 00RT/1 q BUILDING PERMIT �� y 'tD 6.6�°� TOWN OF NORTH ANDOVER ° p APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received 4 4 Date Issued: S l/ 9SS�CHU IMPORTANT:Applicant must complete all items on this page LOCATION _70 i,�1M 5�. Print PROPERTY OWNERS;n t xr',an a cc as} C kum Print MAP NO: PARCEL:_ZONING DISTRICT: V41 Historic District yes no Machine Shop Village a no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ Ne uilding ❑ One family ddition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg thers: ❑ Demolition ❑Other ;reltss a(AMUf"M�" S Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District D Water/Sewer Mei �LS DESCRIPTION OF WORK TO BE PREFORMED: ,.el r tnr'4 5 6e IO')v4i5 anJ 6�VS e9u,nmen � rWW� under s�(-c',rs Identification Please Type or Print Clearly) OWNER: Name; ' Ah (uaft%�:fjml awr(,h �M� ��L S� Phone: 5°7 '0? ' 71:711/0 Address: t ,(4 d, C)P 4 sf ay dra CONTRALTO k.( S Phone: ?7o - F-3(o— 70s3 Address: 3 'Ne, 1 t 019-3 Supervisor's onstruction Li ns 0 S'U P. Date: 3--30 —a?O!( Home Improvement License: Exp. Date: ARCHITECT/ENGINEER HU0&n ks'` rcXi Phone: `i 'SS`7 SSSS Address: ( A 0IM— Reg. No. O 7 090 FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ SS, UCS u FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with un egistered contractors do not have access to the guaranty fund Signature of Agent/Owne (,F✓(/%Signature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/BodyArt ❑ Swimming Pods ❑ Wel I ❑ Tobacco Sales ❑ Food Pgckagi ng/Sal es ❑ 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 DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS 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 signature/date 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 NOTES and DATA — For department use ❑ Notified for pickup - Date Doc.Building Permit Revised 2007 The Commonwealth of illassachusetts Deparhnent of Industrial Accidents Office of Invesiigafions 600 Washington i.5treet .Boston, QUA 02111 rvi~vtr.rnass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aimlicant Information Please Print LeZibly Name (Bitsiuess/Organtzattoi11rndividtill): Timberline Const action. Corp Address: 300 Pine Street City/StatelZip: Cwton, MA02021 Phone 339-502-5000 Are you an employer? Check the appropriate box: Type of project(required): I.❑I am a employer with_60_ 4. [1 I alit a general contractor and I 6. E] New constnictlon employees(frill and/or part-there).* have lured the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. } 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp. insurance. 9. ❑Building addition [No workers' coinp..insurance . ❑ We are a corporation and its required.] officers have exercised their 10 0 Electrical repairs or additions .❑ I am a holtteoxsmer doing all work right of exemption her MGL 11.[:]Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4), and we.have no 12.0 Roof repairs insurance required.] = eiYtployees. [No workers' comp. insurance required.] 13.� !tjii y applicant that checks box 91 must also fill out the section below showing their workers,compensation policy information. T Homeowners who submit this affidavit indicating they Are doing all Nvork and thee//lire outside contractors must submit A new affidavit indicating such. Tcontractors that check this box inuft attached an additional sheet shoiyin¢the name of the sup?-contractors and their workers*torula.]policy infomiation. Four an employer that is providing workers'compensation insurance-for my einplgees. Below is the pollry andjob site information. Insurance Company Name: +Cornmerce&Industry Policy#or Self-ins.Lic.i#:_5315049 Expiration Date: 3/12/10 :fab;Site Address:!713 7'/?P(�f City/State/Zile: 4(1 e/, b2g Attach a copy of the workers'compensation policy declaration page(shouring the policy"number and expiration date). Failure to secure coverage as required tattler Section 25.E of MGL c. 152 cart lend to the imposition of criminal penalties of a fine up to$1.500.00 and/or one-year imprisolunent..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 thata, copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. do lierebl"rertif1,under the porins and penalties of perjuwl that the inforntaiiorl pror irlpd above is.true and correct. 2) q Siaitature: Contract Manager Date: 511,6 -1) Phone tt': 339-503-5000 0jr1cial use only. Do not ivrite in this area,to be completed by rin,or to►vn of,0cial Cite or Town: Permit/License# Issuing Authority(circle one): t.Board of Health 2.Building Department 3.Citi/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone 9: r Client/#:23415 TIMCO1 1123 ACORDIM CERTIFICATE CSF LIABILITY INSURANCE MtDD.fYYYYI 5/1232oas PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Sullivan Insurance Group,Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE One Chestnut Place HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 10 Chestnut Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Worcester,MA 01608-2804 INSURERS AFFORDING COVERAGE MAIC# INSURED IISISURERA: First Specialty Insurance Cor otatio Timberline Construction Corporation INSURER B: North River Insurance Company 300 Pine Street INSURER C-. Commerce&IndustryCanton,MA 02x21 INSURER D: Travelers INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOYl HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERN4 OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE I.AY 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,AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Lilt SR TYPE OF INSURANCE !POLICY NUMBER PO G E E P LI(.Y iRATI LIMITS A GENERAL LIABILITY IRG996112 06/20108 06120/09 EACH OCCURRENCE S11000,000 X CO tVI RCIAL GENERAL LIABILITY DAMAGE�C RENTED I S5O O0O CLAITAS MADE ®0=11OHIED EXP(Any one iwrson) S X $10,000 Per Claim PERSONAL&ADV INJURY 51.000.000 Products Ded. GENERAL AOGR=GATE $2.000.000 GEN`LAGGREGATELIMIT APPLIESPER: PRODLICTS_CQtWOPAGO 52.000,000 POLICYPRO- LOC D .AUTOMOBILE LIABILITY 810977KS104 08/23108 08/23109 COMBINED SINGLE LIMIT X ANY AUTO (EaaccidsrkI 51:000,000 ALL U NED AUTOS BODILY INJURY S SCHEDULED AUTOS ,Per Gerson) .X HIREDAUTOS BODILY INJURY S X NON-WMEO AUTOS r'Pereccidwn PROPERTY DAMAGE S (P�r acciden't) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S ANY AUTO OTHER THAN E4 P.CG S AUTO ONLY. AGO S B EXCESS?UMBRELLA LIABILITY 553x913145 06120108 06120/09 EACH OCCURRENCE S10,000,000 7X OCCUR MCLAIM,MADE AGGREGATE 526 x00.000 S DEDUCTIBLE S RETENTION S S C WORKERS COMPENSATION AND WC5315049 03/12/09 03112110 X I We STATuT OTH- EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXECUTILE E.L.EACH ACCIDENT $1,000,000 OFFICERAAEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE s1,000,000 I'M f yes,desahe under SP ECIALPRaOSIONSba m E.L.DISEASE-POLICY LIMIT $1000000 OTHER DESCRIPTION OF OPERATIONS t LOCATIONS f VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS RE:Job#093686 MetroPCS BOS0380C Trinitarian Congregational Church 20 Elm Street,North Andover,MA 0184*.is included as Additional insured as required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION MetroPCS DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL _(ice DAYS WRITTEN 285 Billerica Road,3rd Floor NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FMLURE TO DO SO SHALL Chelmsford,MA 01824 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2001/08)1 of 2 #S101448/M95915 KJA o ACORD CORPORATION 1988 i 9 1 � 9 Mme owtOcate holder is an ADDITIONAL INSURED,the pollcy(les)must be endorsed. A statement C.!I `ii f!4 t,-ido%di& dins- h0i conte l fohis io 1114 Ceriffirbie holder in ileu of such endorsemenils', ! I r m If SUBROGATION IS VVIAV ED. subject to time terms and conditions of the policy, certain policies may rojuire an arddorsernent. A statement On this cerM tcate boas not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing Insurer(a), authorized representative or producer.,and the certificate holder, nor sloes It affirmatively or negatively amend, extend or alter time coverage afforded by the policies listed thereon. ACORO 25-S(2001 tog) 2 of 2 #SI0144SIM95915