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HomeMy WebLinkAboutBuilding Permit #634-15 - 70 OGUNQUIT ROAD 2/3/2015BUILDING PERMIT opt Leo b;�tio TOWN OF NORTH ANDOVER 0�2h;y- o? APPLICATION FOR PLAN EXAMINATION Permit No#: Date ReceivedArao 0,V Date Issued: I IMPORTANT: Applicant must complete all items on this page LOCATION r7f) PROPERTY OWNER'- �"i� Print 100 Year Structure yesCno MAP PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes 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: Arlrirace- one: ARCHITECT/ENGINEER Address: Phone: Reg. No. .. FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ �/�� FEE: $ Zd (� Check No.: RIO I q Receipt No.: NOTE: Persons contracting 6ith unregistered contractors do not have a cess to the guara d Signature of Agent/Owner Signature of contracto. Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPF' ' F 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 PLANNING & DEVELOPMENT Reviewed On COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS Signature_ Reviewed on Signature Reviewed o Sianature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Com Conservation Decision: Comments .y Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signa>pre: FIRE DEPARTMENT - Temp Dumpster on site yes Located at 124 Main Street Fire Department signature/date COMMENTS uocatea 364 Usgood Street no 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) t:: ❑ Notified for pickup Call Email i Date Time Contact Name Doc.Building Pen -nit Revised 2014 3 Building Department 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 o Building Permit Application o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract o Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract ❑ Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) o 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 o Engineering Affidavits for Engineered products NOTE: 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 No. Date ' Check # 2 6 4 - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permitfee $ Other Permit $ TOTAL to -A $- Building Inspector 4 �£ © . 0 . - . e � $ $ g ' 9 k� � -�• or « `• \* © ` % E 3 � / \ �� � • . . 3. 0 \\f% k©k� \ � 0 x J Q 2 LL O Q m s Y \U O LL E °; > V) fl_ In O tan Z z O m c O ++ "t3 7 LL i � �' ? C E U ra LL W tai Z zu m a L 7 :3 �.' O ro LL tail Z J �pC; W lL _C > d' N > to — LL Q w N Z N h0 00 d' co LL W ~ Q w LU L O m p z N v In a N 'x O 0 n o ca w �O I�1 Q , cca .c o r S N v E n := c O �. <v W • V j y_ c �� \ • °cc • Q tNG �Q; Aw. N Z** Q 3 d R N J i L m ILN : r—S _ y. =QOO >N o = ; OP ID: OUJA '4� oQ CERTIFICATE OF LIABILITY INSURANCE 1 DATE01/2 D/YYYY) 01 /29/15 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). Phone: 978-688-6921 Macdonald & Pangione Insurance P.O. Box 428 Fax: 978-688-5350 104 Main Street North Andover, MA 01845 Michael Pan Ione g CONTAPRODUCER NAME: Jane Ouellette A/C NNo Ext : 978-688-6921 a c No): 978-688-5350 EMAIL M Ins.net ADDRESS: Jane p PRODUCER DASFI-1 CUSTOMER ID #: INSURER(S) AFFORDING COVERAGE NAIC # INSURED DAG Fire Protection Inc N ewburyport, MAA 01950 Graf Unit INSURER A:Starr Surplus Lines Ins Comp INSURER B: Underwriters At Lloyds 15792 INSURER C., INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION til WIRED. 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 LNSR DD B POLICY NUMBER POLICY EFF MM DD/YYYY MM/ DY/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY SLPGGL02675 07/08/14 07/08/15 PREMISES Ea occurrence) $ 100,00 CLAIMS -MADE I OCCUR 5100 MED EXP (Any one person) $ PERSONAL & ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 17 POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS$ (Per accident) NON -OWNED AUTOS $ $ UMBRELLA LIAB HCLAIMS-MADE OCCUR EACH OCCURRENCE $ EXCESS LIAB AGGREGATE $ DEDUCTIBLE $ $ RETENTION $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY Y / N T MIT E E.L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ N / A E.L. DISEASE - EA EMPLOYEE $ (Mandatory in NH) If yes, describe under E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS below B Professional Liabi PGIARK03933-00 07/08/14 07/08/15 1,000,00 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) Sprinkler installation CERTIFICATE HOLDER CANCELLATION U 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover 120 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE U 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD The Commonwealth of.Massachusetts Department of ludustrigl Accidents Office of Investigations 6#0Washington. ,Sheet .Boston, .MA 02111 -www.mass.gov/dia Workers, Compensation insurance Affidavit: Builders/Contrac Name .Address: Phone #: .AVIu an employer? Check appropriate box: 4• ❑ I am a contractor and 1 Type of project (required): 1, am. a employer wiih general 6. ❑ New c0siritciion employees(fall and/or part-time)* have hire dthe sab-contractors listed on the attached sheet. `/• ❑Remodeling 2. ElamI aa sole proprietor or partner ship and'have no employees These sub -contractors have S. ]] Demolition working forme in any capacity. workers' comp. insurance, 5. ❑ We are a corporation and its g, ❑ Building addition [No workers' comp. insurance officers have exercised.theix 10 1] Electrical repairs or additions required.] 3. ❑ 1 am a homeowner doing all work right of exemption per MGL 11.E] Plumbingrepairs or additions myself. [ZV'oworkers' comp. c. 152, §1(4), and wehave no 12,[] Roofrepairs insuran,cerequired.] t employees. [No workers' 13.❑ other comm insurance required.] NAny applicautthat checks box#1 must also fi11 outthe section below showingtheir workers' compensation policy information. i Homeowners who sobmitthis affidavit indicating they kdoing ail wont and then hire outside contractors must submit anew affidavit indicating such. k-ontractors that cheekthis box must attached as gdditional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees Below is t``he policy and job site infoximation. —n A n n] � � A ] � � � ; .. � A A a 1r\ C\ - insurance CompmyN Policy # or Self ins. Bic. Job Site Address: j l ) Attach a copy of the workers' ,4r Date: policy declaration page (showing the policy number and expiration date). -.—Failure-to secure -coverage as regoedunder Section 25A ofMGL o.152 can lead to the imposition of criminal penalties of a flue up to $1;500:00 and/ox oils=year iiuprisonniexit; as wellas szvQpp realties in-ihe form o_f a STOP WORK ORDER an a fns -_ of -up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the _GM66 -6f- Investigations fInvestigations of the DIA for insurance coverage verification. AT do Hereby certiry under tliepa wattles ofperjury thattli ire• fo at'7+1-- rovided alloy is true an correct. - � h ,) '� , �1. �� � .-� /1S official use only, .Do not write in this area, to be completed by city or town official. City or Town: PermitfLicense # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - rnntaetPprsnn: Phone #; Information and Instructio'- Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuaxif to this statute, an employee is defined as ,,...every person tri the service of another under any contract dhire,- express orimplied, oral or written." An employer is defined as "an individual, partnership, association, corporation ox 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 ox trustee of as individual, partnership, association or other legal entity, employing employees. ISpowever the owner of a dwelling house having notmore than three apartments and who resides therein,, or the occupant ofthe 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 loeal 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 applicant who has not produced -acceptable evidence of compliance with the insurance coverage required." Additionally, MGI, chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpubHo work untilacceptable evidence of compliance with the insurance requirements of this chapter have b eon 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-contxacfor(s) name(s), address(es) andphone number(s) along with their certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees oilier than the members or partners, are notrequired to carry workers' compensation. insurance. IfanLLC or LLP does have employees, a policy is required. Be 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' compensation policy, please call the Department at the number listed below. 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 andprinted legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of hwestigations has to contact you regarding the applicant•. Please be -sure to fdl in the permit/license number which will be used as a reference number. In addition, an applicant thatmust submitmuliiple permitliicense applications in, any given year, need only submit one affidavit indicating current Policy iuformation (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or towu): ' A copy of the affidavit that has been officially stamped or marked by fihe city or town may be provided to the applicant as proof that a valid a davitis on file for £uiure permits or li licenses. now affidavit must be filled out each _ year. 'Where homeowner or citizen is obtainin a ME;— W- ergot not related to any bus .n ess ax comm ercial eniuxe _ YY - (i,e. a dog license orpermit to buizi leaves eta.) saidperson. is NOT required to complete this affidavit, The Office Of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do nothesitde to give us a call. The Department's address, telephone and fax number: Tho CQmmojiwcaltIxofMassachvsetf - Depa eut of fndmWal ,Accidents Office of rwestigation3 6QG WaM gtm Stmt BWon, MA 02111 TQJ. # OM21.7 4900 at 406 or. x- 877-MAs Revised 5-26-05 Fax# 617-727-7749 WWW-Ma.ag4V1CHa