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HomeMy WebLinkAboutBuilding Permit #Exception - 70 MAY STREET 1/31/2017 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page - Print, PROPER TW®1NNER; Print _ 100yYear101dlStructures yes, n_or MAP NO ____ __ FAEtCEL:'. ZQNING3DISTRI,CT __._ Hy,Ess rio: MachineaSfi_o Villa e, - ' n TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential [mew Building "ne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: Demolition ❑ Other ;Septic sVllell ' ❑�Floodplain� :Wetlands " D: Wl itershetl,Dist'R DESCRIPTION OF WORK TO BE PERFORMED: �n eNauF ex �s4 i v p iP -r-uvntiy H'-YvnQ u %- d L'4 do( f1e <-v s f I),91 rti 11 Identification Please Type or Print Clearly) OWNER: Name: i�eu Q- Ross qa vC( vt jj� AG Phone: cl 1W -&oGJ:f 1 Z 3 Address: S4 U V) La Si r op w r-e 0 0'00, AM .Phone, � -79 (k- �..`kk . : E P 3 Address: ._hie u Sc .. __ .-S � • V?-d, V e r .1 . Su ervis0s.Const'-uction•License- .s -k 6 L o, y tSExp, «Date ._ _ Hbrn' Improvement.License,- �e Cr L e._��5: �1 U.377 p �N _ 2__Ex Date: CI.: _. ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ �.��,, C� 0 a FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund g Signature,.of.confiracto Signature:of A +ent/.Owner . :: Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped 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 ❑ ❑ i COMMENTS CONSERVATION Reviewed on Signature COMMENTS I HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes_.. Planning Board Decision: Comments Conservation Decision: Comments I Water & Sewer Connection/Signature& Date Driveway Permit ]DPW Tow -, Engineer: Signature: Located 384 Osgood Street FIRE DEPARTRENT - Temp Dumpster on site yes no Located at 124 Mair:Street Fire Departmerit 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 B Notified foricku Date p p - at z Doe.Building Permit Revised 2010 Building Department The folowing is a list of the required forms to be filled out for the appropriate permit to be obtained. FRoofing, Siding, Interior Rehabilitation Permits o Building Permit Application o 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 o Engineering Affidavits for Engineered products (VOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o 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) ❑ Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o Mass check Energy Compliance Report L3 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 apn,al period is over. The applicant must then et this recorded at the Registry of Deeds. One co and roof of recording g g Y PY P g must be- subwted with the building application Doc: Doc.Buhding permit Revised 2012 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 ❑ ❑ COMENTS 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/dateit /,1 COMMENTS LEVIS-1 OP ID: KM ACORO' D / Y) 0113CERTIFICATE OF LIABILITY INSURANCE . 1/2017 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(les) 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 Michaud,Rowe And Ruscak Ins. NAME: Lawrence R.Michaud,CIC P.O.Box 188 AIC NN Ext:978 688 8829 C No): 978 557 2130 North Andover,MA 01845 E-MAIL Lawrence R.Michaud,CIC ss:lmichaud@mrrinsurance.com INSURER(S)AFFORDING COVERAGE NAIC k INSURER A:NorGuard INSURED Levis Companies Inc. INSURER B:Preferred Mutual Insurance Co. 15024 Joseph Levis INSURER c:Harleysville Insurance Company 26182 154 Pleasant Street North Andover,MA 01845 INSURER D: INSURER E: 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. ILTR TYPE OF INSURANCE INS ADDL UB POLICY NUMBER MMIDDPOLICYEFF/YYYY MM DDYEXP LIMITS B X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 CLAIMS-MADE OCCUR CPP0100589059 10/26/2016 10/26/2017 PREMISES Ea occurrence $ 100,00 MED EXP(Any one person) $ Exclude PERSONAL&ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00 POLICY PRO- JECT F_� LOC PRODUCTS-COM P/OPAGG $ 1,000,00 OTHER: $ AUTOMOBILE LIABILITYO aBINEDtSINGLE LIMIT $ 1,000,00 LE. ciden) C ANY AUTO BA150132 01/01/2017 01/01/2018 BODILY INJURY(Per person) $ ALLOWNED X SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOSPer accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER A ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N LEWC869538 02/27/2017 02/27/2018 E.L.EACH ACCIDENT $ 100,00 OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,00 If es,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 500,00 T - DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION NORTH13 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL SE DELIVERED IN 384 Osgood Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD �I IIS 'le Commonwedth of lflassachuses . Department of -ftdUS&jaj.Acc!deWS r X Congress Street,,5 IM 100 Boston,MA 821.74-2417 www mass go-vldia ectricians/ lzmobexs. ' Vpn�:kexs' Comp e TO BEBulld Affidavit FII.ID bsur=cWTTH'�FERN a :1a`IG AUTH07CtTJC'i'. inease kAnt L l A •'Iicant 7xxfbrmation anizaiion/l'ndividual): e S a P Name(BusinesslOrg • Address: (� rjj Phone#: `7c� (p g ��� 3 Y CitylState/Zip:� �v IN � � �( .. . _.s . eclr,tTie a ro riatebox: Type of project(requires); Are yon an emploper.Ch Pp P 1, m a employer with —=Ploy,-Is(fan(fan and/or part 7 ew constxvction andhavenoemployeesWOT' ng formein 8. IZemodelirig 2.E1 I am a sole proprietor or partnership e required] 9. F!Demolition any rapacity.[Noworkers'comp.insuranc 3.E]I an ahomeowner doing all workmyselt[Noworkers'comp.insurancerequired.]' JOE]Building additifln. ¢-❑ Jam a homeowner and will.be hiring contractors to condnet all work onmy property- 1wiI1 11.❑Electrical repairs or additions ensure that all contractors either gave workers'compensation insurance or are sole 12 K(Plmnbing repairs or additions proprietors with no'n396yaes. 5.Q 1 am a general contractor and I] ye hiod the snb-confrartozs listed ontbe attached sheet 110 Ro6f repairs Thesesub-contractors have employees andhay.worker?camp.insurance. 14.p Other 6.El- e axe a corporation and its o±Fodz wl exercisedtheir right of'exempdon per MGL e. 152,§1(¢),and vre have no empldydes_[No workers'comp.insurance required] Anyapplicautthatcheck�bbx#lmvstalsofdontt3�esectioubelovrshowingtheirworkers'compensationpolicyid0matiom•affidavit i Homeowners who submit this affidavit indicating they are doing all VDIk an name irthe soboutsia contracto rand state whetbs must ssbmit aeIleor nottElose e tie �sncb �Cordractorsthatcheckthisboxmustatiwhedanadditio sshr dewtheirworkers'comp.policymm�ber. employees. If the sub-contractois have employees,they P • tli at is rovidingworkers'correpmsation MSMMance far My employees Belo7ta is t�iepolicy rand job site em to er -p lam an p .Y information. Insurance CompanyName:. Cit v i 0 ExpirationDOG' 7 2 I Policy#or Self-im. date Lic.# Job Site Address: -7y M a�1 V`p Q 1 Crty/stffte/Zip: _o UQ,r _g--Mach a copy oftb.e-�oxkexs' comp— npotxcy declaraiaonpage(sT:to�gthe policynumbex and e�uatzon . G. 52 25A is a criminal violation punishable,by a fine up to$x.,500.00 e•MGL �§ Failure to seGM0 coverage as requrced and x and/or one-year impxisonmen�as-well as civil p enalties in the form of a STOP W ORK ORDER and a fine of up to $250.0 0 a day against the violator.A copy of this statement may be forwarded to the Offtce of Investigations of the DIA for insurance coverage verification. X do Iiereliy certify rider tliepains and en es ofperjury that tTie infoYrnation p�ovided move is rue and correct Si atgre: Phone#: Official us_only. Do not7vrite in this area,to be corr�pleted by city or town official City or Town' PermitlEicense# fss•jugAuthoxity(circle one): p g ectox .)Board axd of Ifealth 2.73nfldiug Department 3.CitylTovn Clerk d•.Electrical l eetox �.Plumbing Xnsp 6.other Phone#: Contact Person Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or'wHtten." An eMployer is defined as"an individual;patnexship,association,corporation or other Iegal entity,or any two or more of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the receivbf or trastde 6f an individual,partnership,association or other legal entity,employing employees.,However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwellrrig house or on the grounds or building appurtenant thereto shalt not because of such employment b6 deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicantw$d has not produced acceptable evidence of compliance with the mmtrance coverage xeq�&ed." Additionally,MGL chapter 152,§25C(�)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 Pleasa fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub=contractors)name(s),address(es)and phone number(s)along with their cerHcate(s)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 dogs have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confnim.ation 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' compensatioi't policy,please call the Department at the number listed below. Self-insured companies shoWd enter their self fi suxabce 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 foxou to fill out in the event y v nt the Office of Investigations has to contact you regarding theapplicant. g g a pp ant. Please be sure to fill in the permit/license number which will be used as a reference number. h addition,au applicant that must submit multiple pennit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town):'A copy of the affidavit that has b een officially stamp ed or marked by the city or town may b e provided to the applicant as proof that a valid affidavit is on file for future permits of licenses. Anew affidavit must be filed out each Year-Where a home owner or citizen is obtavaing a license or permit not related to any business or commercial venture (i.e.a dog license or permit to butm 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.02114-20 17 Tel.#617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-2315 www.mass.gov/dia r"//e` rnuirrr�ruiea//�o`G/�rr;tar/rise/%; Office of Consumer Affairs&Business Regulation ig F HOME IMPROVEMENT CONTRACTOR Registration:, 103772 Type: Expiration: '7/912018 Individual JOSEPH G.LEVIS JOSEPH LEVIS 154 PLEASANT STREET NORTH ANDOVER,MA 01845 Undersecretary i i Massachusetts Department of Pubiic Safety Board of Building Regulations and Standards License: CS-030651 Construction Supervisor JOSEPH G LEVIS " 154 PLEASANT ST. r ' NORTH ANDOVER MA 01846 III � Expiration: Commissioner 01/07/2018 --I............" \\�'�,"P � t�c°+S- f�"P' yr r to $\\ \ 1 \ Alp q Awl, JW t f d t \ 3. rri, 'fix. �\�. 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