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HomeMy WebLinkAboutBuilding Permit #463-15 - 70 ELM STREET 11/12/2014a BUILDING PERMIT TOWN OF NORTH ANDOVER r APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: TANT: ADDlicant must complete all items on this LOCATION—7 D ELY -Y) Print PROPERTY OWNERTrL, w ,z '4 ►J : a A� Print MAP NO: PARCEOML ZONING DISTRICT: HistoricetrAcAr' no Machine Shop Village <;;*SK no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial Iteration No. of units: ommercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: .demolition [I Other I ] Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District [-] Water/Sewer OWNER: Name n Jdress: Identification Please Type or Print Clearly) 13; 11 ps 6-lC3 C-6 Phone:9 —2 fir— b�3%19v2S �� CONTRACTOR Name: irSS 367 Ss�' hone: Address: c l0 1L.E 0113enAl�� t�C�-1 UCS 1...A14E_y1JJ IE Y7l4q 0Q> - Supervisor's Construction License: Exp. Date: CS )off 6 q b 3 Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COS=BASED ON $125.00 PER S.F. Total Projectost: $ 'cnr7 FEE: $ 6 t Check No.: 11 5 Receipt No.: Cal NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor Permit No#: Date Issued: LOCATION BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received IMPORTANT: Applicant must complete all items on this page I Print PROPERTY OWNER Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no 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 ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification - Please Type or Print Clearly OWNER: Name: Phone: AddrP-q-,- Contractor Name: Phone: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: ARCHITECT/ENGINEER . Date: 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. Total Project Cost: $ FEE: $ Check No.: Receipt No.: NOTE:. 4Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor I Plans Submitted ❑ Plans Waived 0. Certified Plot Plan ❑ Stamped Plans ❑ TYPE'OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody 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 �� Signature_ COMMENTS I l0 i CONSERVATION COMMENTS HEALTH COMMENTS Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes L Planning Board Decision: Conservation Decision: Comments Comme Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: FIRE DEPARTMENT - Temp Dumpster on site yes Located at 124 Main Street Fire Department signature/date COMMENTS t_ocatea M4 Usgooa Street no A Location / %S F/M., S No. Date Check # S, 6 3 . ♦ A TOWN OF NORTH ANDOVER i Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ � l � Building Inspector l Z wo O N � c ,C C ayi � a y Q �mm LOd :E Z >s U R C .a a �a th O rte•.C til M to fl O d � ? 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O O O m -0 O O LL E v N O. d U) p U N Z z m C 7 O LL bDU 0 O K cu t U @ O LL O LU H Z Z m J d Op O d' O LL O W LO) Z u u J w 510 O d' N N C LL U LU Z N i p tr 76 C LL W cC w o o"'c LL j m O z a+ N UJ 0 N Y O {n o O F— � o U p W a cQc Z E o s o r E Q, L N <v W 0 0 Z F- L CO N G GtL,i U) J L CO a a Z F- _ m = LV O W �. hoc = O v/ Cl) a,'> o c W J c ca O "a p E Q L Lcu: O = m Q dj = N W = -0O O —® LL N LUC v1 G O LU -E V __ " O • _ L O O �' 0-0 p �4L=Q F-1 N > �- rn .p p O I=- t � QoU > w I.: i m m The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 " " y www. mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organizationdndividual): Top Tier Site Development Corp. Address: 210 Kenneth Welch Dr LaKevwe, nmH uzs4r Phone #: 855-367-8873 Are you an employer? Check the appropriate box: 1. I am a employer with 52 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees ' These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.t required.] 5. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.❑N other wireless communication *Any applicant that checks box #11 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 thepolicy and job site information. Insurance Company Policy # or Self -ins. Lic. Liberty Mutual WCS-31 S-382146-014 Expiration Date: 9/3/15 Job Site Address:`7t- (_Y-,� 1 y pJ jz�: t\ 1111-4 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. Ido hereby certify un a ins and penaltiesl ofprjury that the information provided above is true and correct \ 10/28/2014 8553678873 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 5. Plumbing Inspector 6. Other Contact Person: Phone 2-- CERWICATE OF LIABILITY INSURANCE TMS CERTIFICATE IS ISSUED ASA MATTED OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THISl CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED 13Y THE POLICIES BELOW: TI -95 CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AtffHORIZED REPREsENTAmVE OR PRODUCER, AND THE CERnFICATE HOLDER. . IMPORTANT: if the certifica#e holder iS ars; ADD17lONA1. INSUREm D, the policy(les) ust be endomed. if SUBROGATION IS WAIVED, sulgect to the terms and conditions of the policy, certain policies may require an endorsement. A Stat' Dment on this certificate does not confer rights to the certificate holder in lieu of such endorsmeni s). PRoovcER NAME: Maria F Almeida Legacy insurance Agency Croup, PHONE 213 Main Street: .(508) 295-1315 Ira N.Y.- {5081 295-6730 Wareham, MA 02571 AoIAR16s: maria. almeida@legacyinsuranaecgroup. com, INSURED Tap Tier Site Development Corp 210 Kenneth Welch Dr Lakeville, MA 02347 4UVbKAGE3 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 POLIGY PERIOD INDICATFJ,. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFJCA7E MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUS)ONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INS R ADD SUBR PppUCY EF POLICY EXP LTR TYPEOFINSURANCE ---PO NUMBER MM/DD/Y MM1DfyyYYY LIMITS ,A GENERAL LIABILITY Y 2CT5222 9/6/14 9/6/15$ 1' 000 000 EACH OCCURRENCE X COW ERCIALGENE PAL LIABILITY DANIA GE TO RENTED REMI E Ea o $ 50 000 CLAIMS MADE OCCUR MED EXP (Arryone pa=) s 5 000 PERSOML&ADV INJURY $ 1 000 000 GENERAL AGGREGATE $ 2 000 000 P OLICYECT GEN'icy. GATELIMITAPPLIESP PRODUCrS-COMPIOPAGG S 2 000 000 PX PRD LOCG $ 13 AUTOMOBILELL%MLITY BG7RNP 9/2/14 9/2/15 COMBINED MBIEssedEDd M $ 1 000 000 ANYAUTO BODILY INJURY(Perpelson) $ ALLOWNEAUTOSD X SAUTOSCHEDULED BODILY INJURY (Per amidenl) $ X HIREDAUTOS X NON -OWNED PRDPERRryryDMMGE AUTOS PereccI ent $ Is UMBRELLA LM X OCCUR 7008EI31ALI 9/23/14 9/6/15 EgC'I OCCURRENCE s 5 000 , 000 X EXCESS UAB CLAIMS MADE AGGREGATE s 5, 000 , 000 DED X RETENTION 0 DN ANDEMPLOYER'LIABI IT yITC2-31S_382146-014 9/3/14 9/3/15 wcSTATU- DTH- $ AND EMPLOYERS'LIABILITY ARTNMEXECUTAIE Y 1 N X • OFFICERIMEMEBERPEXCLLDEOV NIA EL.EACHACCIDENr 1,000,000 (MYaensdabryin NH) E.L. DISEASE -EA EMPLOYEE $ 1,000,000 OESCRIt'P- Obi OF OPERATIONS bebw E.L. DISEASE-POUCYLNACr S 1,OQ0 OOO DESCRIPTION OFOPERA77ONS / LOCATIONS /VEHICLES (Anach ACORD 701, Addldonal Remarks Schedale, If more space Is requred) CERTIFICATE HOLDER CANCELLATION ! SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BECANCELLEDBF FORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AU RIZED REPRESENTATIVE © 7488.2090 ACO CORPORATION. All rights reserved. ACORD 25 (2010/05) The AC ORD name and logo are registered marks of ACORD Phone: Fax; E -Mail: