Loading...
HomeMy WebLinkAboutBuilding Permit #471-10 - 701 SALEM STREET 12/8/2010Permit NO; Date Issued: TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION kn d IMPORTANT: -KTRT? must Print rL 6t-'l'z Date Received all items on this Print MAP NO:'S PARCEL: Ob ZONING DISTRICT: �'3 Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT ❑ New Building ❑ Addition ❑ Alteration *Repair, replacement ❑ Demolition- OWNER: emolition__ OWNER: N PROPOSED USE Residential Non- Residential ❑ One family ❑ Two or more family ❑ Industrial No. of units: J3 Commercial ❑ Assessory Bldg ❑ Others: ❑ Other DESCRIPTION OF WORK TO BE PERFORMED: t N0 (2-0 Lentification Please ,*— M r - e or Print CIearly) T?'z-vS T- of t cuxAvcsz 13o SOS' Address: �J CONTRACTOR Nance: �C/ /,vL.A'fi c� �,¢.�.D /3yr t o C lt-f Phone:7�y_4'V -0 SZ S Address: ��irvr T y �-% /� �,✓D O vl' � /l/�d� - Supervisor's Construction License: �2 Exp. Date: Home Improvement License: / fl U I I Exp. Date: Z� ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT: $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cost: $ � ;�FEE: $ Check No.:Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 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 ❑ 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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permh 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/Crossection/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 !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 ❑ 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 Pian And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products J®TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit li i all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals is t the appeal period is over. the applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording it st be submitted with the building application Doe: Doc -Building permit Revised 2008mi Plans Submitted ❑ Plans Waived ❑ 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 Durupster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF --U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMME CONSERVATION COMMENTS HEALTH POMMENTS Reviewed on Sinature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments !later & Sewer Connection/signature & Date Driveway Permit DPW Town Engineer: Signature: Located 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 2008 Location No. - Date �c NORTH TOWN OF NORTH ANDOVER o� 0 w 9 � Certificate of Occupancy $ s�CNus `�' Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 23770 ` Building Inspector �s � k�q �E ■ - 2 E. 4 . 2 03 . / z . g 00 o f:F . Ul ƒ»% § a M. \ 0 n § � § ƒ e .£ N H m m M m CO) m y F) m . v y C � G � d CO2 Cl) 'v Cl CDn CCZ y D O 'v CL 1= CO) n CO O o v CD a O 0-0Q d CD CD 0 CD C CD N! CD CLO CO) O CO CD S- CO) O CD 'o Z a O CD O CCD w", C_ O O O CD 0 0 tC O W CD co a C Co 0 N C 0 s: to H m CO) cr EL :9.m h CA CD CL CD Cae- o m v, mr. C-) �. = w H '1 m H T � CL CL. 0 m =r m : m x -0 o .�mo. o� I o 0 O N� C2: O m : H a m m y ;. ■� m O1 =r: C Dt ym C _ M CD �CIS co a N,..� . � O om: Wim: a� y CD CD n -+ CD CD m Co n "o ncc C.: � co cn Cl) m �o o o rL ( C/) oo x CD o� GOD y b 7d "ti � M . • z H 0 O C m m m m x m v m z r cn n O cn �1 z C O O O CD O _ _ to O W n m 0 H C 0 CL N N d y CCD"cl H y CC a ® C7 m C7 H •m d C M. ff's N �1 ...r m H T �a••a m ..4 O ® H O ml O O m: m a C.00.r �{ O Z�•82 . O y m �O =rH 7 a =' CDCD H �• nCDCos: m O H d p=j Q W — CID fl. CDH CD CD C.S: CD aW H Wim: ?m ..�F H O �Wso: _ C n c _CD w w P W y C � cn O CDn Z t� 'C CS D O n CL m � c CL o CA d O o CD v CDcr O CD CDC CD C CD C CA CD CA O O I CQ CD CA v O 'oCD Z o CD 0 CD z r cn n O cn �1 z C O O O CD O _ _ to O W n m 0 H C 0 CL N N d y CCD"cl H y CC a ® C7 m C7 H •m d C M. ff's N �1 ...r m H T �a••a m ..4 O ® H O ml O O m: m a C.00.r �{ O Z�•82 . O y m �O =rH 7 a =' CDCD H �• nCDCos: m O H d p=j Q W — CID fl. CDH CD CD C.S: CD aW H Wim: ?m ..�F H O �Wso: _ C n c _CD w w P W �v cn � ;z t I 'n n ro z d • duo z O H 0 9 O C CD ACORD CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DD/YYYY) 11/30/2010 PRODUCER 978.374.6352 FAX 978. 521. 5127 COSTELLO INSURANCE AGENCY 2 South Kimball St. PO Box 5248 Bradford, MA 01835 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED Quinlan & Rand Contractors 34 Trinity Court No Andover, MA 01945 INSURER A: National Grange Mutual Ins. Co 14788 INSURER B: INSURER C: INSURER D: INSURER E: COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR DD' NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MM/DD/YYYY POLICY EXPIRATION DATE (MM/DDIYYYYL LIMITS AUTHORIZED REPRESENTATIVE Ne buryport, MA 01950 GENERAL LIABILITY MPS73609 03/12/2010 03/12/2011 EACHOCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DA PREMISES Ea occurrence) $ 500,000 CLAIMS MADE FXI OCCUR MED EXP (Any one person) $ 10,000 A PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG $ 2,000,000 POLICY PROJECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS / UMBRELLA LIABILITY EACH OCCURRENCE $ AGGREGATE $ OCCUR F_] CLAIMS MADE DEDUCTIBLE RETENTION $ $ WORKERS COMPENSATION W STATUOT - AND EMPLOYERS' LIABILITY Y / N TORY LIMITS ER E.L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? � E.L. DISEASE - EA EMPLOYEE $ (Mandatory in NH) If yes, describe under E.L. DISEASE - POLICY LIMIT $ SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS GtK I iFiCA I E HOLDER CANCFLLATInN ACORD 25 (2009/01) ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR Newburyport Medical Center, LLC REPRESENTATIVES. Attn: Matt AUTHORIZED REPRESENTATIVE Ne buryport, MA 01950 Ben Costello ACORD 25 (2009/01) ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD A \ The Commonwealth of Massachusetts c Department of Industrial Accidents Office of Investigations 600 Washington Street j Boston, MA 02111 j� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Qi/1NLA-1-( q-- gAyp 1uIL0rz(2-5 Address: -,:? q I—(Z- I N l r Y L� City/State/Zip: MA pIV.)KS Phone #: �770 ,t-1 C? -US" z o Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I atn a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. 1 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. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. t 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 their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under tfiepy7ins,_4jtd pe9a1ties ofpeijury that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # /v 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 #: 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 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 commonwealth for any applicant who has 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 nurnber(s) along with their certificate(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 cant' 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 for confinnation 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 pen -nit 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 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 pen-nit/license number which will be used as a reference 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 "Job 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 pen -nits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or pen -nit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person 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 not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents: Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFB Fax # 617-727.7749 Revised 5-26-05 www.mass.gov/dia