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HomeMy WebLinkAboutBuilding Permit #39-12 - 733 TURNPIKE STREET 7/15/2011 RECEIVED TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION ��'� -7 10�� _ I TOWN OF NORTH ANDOVER Permit NO: Date Received L HEALTH DEPARTMENT Date Issued: IMPORTANT:Lkpplicant must com Tete all items Vinis)_eag LOCATION , , I�� ` it.e 1 ,/'�t PDAIL PROPERTY OWNER /C Unit# Print MAP NO: _PARCEL: ZONING DISTRICT: Historic Districtye no Machine Shop Village y no 100 year-old structure ye no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building �Qev�.6��' ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg 69Others: ❑ Demolition ❑ Other u ❑ Septic ❑ Well ❑Floodplain ❑ Wetlands ❑ Watershed District 0 Water/Sewer DESCRIPTION OF WORK TO BERPERFO ED: -rrl �r , d� � e Px a�� W, o l rt U., � r e.w cGL�c -� „ (Aide jfi do lease Type or r' t C arly) �} —7 OWNER: Name: /Vl l Jo nt%(-S Phone: 1� �I 1 Address: I ooc;) n 54000 0GN r1 © C> CONTRACTOR Name: T, W �LJ '-t-Phone: 1 '7 1Z C) ! `� G Address: S Supervisor's Construction License: j Exp. Date: I d 20 11 Home Improvement License: N Exp. Date: ARCHITECT/ENGINEER -�.Tc m e D- S v4 tI1 Phone: 50a 2 �7 g _D�,_) Address:_ 5 T4 rop L 1,4 Is 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: $ j �,C�OCD . FEE: $ Check No.: l,TS g „ Receipt No.:c;� 7 ,3 NOTE: Persons contracting with unregistered contractors do not have access to the gua fund ignature of Agent/Owner Signature of contractor y 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 ❑ V THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS I CONSERVATION Reviewed on Signature nature g COMMENTS HEALTH Reviewed on Si nature COMMENTS YG C f ci 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 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 j NOTES and DATA— For department use ❑ Notified for pickup - Date Doc:.Building Permit Revised 2011 June/mi i i Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. r 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 Permit 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) j ❑ 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) ❑ 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 Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ 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 Doc: Doc.Building Permit Revised 2008mi Location ��, agA f No. Date �oR,N TOWN OF NORTH ANDOVER row Y ' Certificate of Occupancy $ Building/Frame Permit Fee $ .� s�cnus Foundation Permit Fee $ Other Permit Fee $ ( TOTAL $ Check # 2 46 r J Building Inspector VkORTfq Town of Andover. , SOLAKE O dover, Mass. • COCMICME W ICK ��t• 0RATED A �S BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT........... h..�j�/!!!. .. .. R........................................................................... Foundation buildin son ............ ... ,l !J... ... .. •. Rough has permission to erect............................� 7....� • g to be occupied as.......... h.... .... .�.�.1 !....... ... O.�/..A." /!ISS.............................. ...... Chimney Ch' e provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN THS ELECTRICAL INSPECTOR UNLESS CONSTR TIO S TS Rough mom ............. ................................................................................. Service BUILDING INSPECTO Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIREE_DEPARTMENz: Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. ;Massachusetts- Department of Public Safety Board of Building Revelations and Standards Construction Supervisor License License: CS 81897 Restricted to: 00 GREGORIj J ,NOLAN 13 WOOD'" ND AVE KINGSTON, MA qp,364 Expiration 10!2312011 Tr 8798 r0 97td"i2lL+ p'�[U'SJSIlCYttl ._� HoaW g1wilding Regula so d Standards jCFAt1*jgOVE ENT TRACTOR ,L. a a O ' !2 -twtMn: 1 7 R ? Ad= 3/15/ o Tr# 282647 L _ 03 0 w o ;Arfpe: individu ! GREGORY J'5 AtV q GREGbRY-NblAX O M j 13.W ODLAND AVE. KING tON,MA 02364 Administrator w y 0 ai m o 'g ;;tgeV = e w t 4 G7 w o c w 3i ~ 3 � w ° � 42 D � L 1 I J � ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MMI l:Zt IO U1/Z4/'LUI l 11:'L'/ PRODUCER (800)225-1865 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Fred C.Church,Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 41 Wellman Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Lowell,MA 01851 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. (800)225-1865 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA: Charter Oak Fire Ins.CO. igjoC�fn,LLC INSURER B: National Union Fire Insurance Company of Pittsburgh North Andover,MA 01845 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. INSRADWL POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS TYPE OF INSURANCEGENERAL LIABILITY EACH OCCURRENCE $1,000.000 X COMMERCIAL GENERAL LIABILITY DAMA E TO RENTED PREMISES Ea oocurence $300,000 CLAIMS MADE a OCCUR MED EXP(Any one person) $Excluded A 680192M8710 10/5/2010 10/5/2011 PERSONAL 6 ADV INJURY $1,000.000 GENERAL AGGREGATE $ 2,000.000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG $ 2'000,000 POLICY PRO- 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 aocident) $ PROPERTYDAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO EA ACC $ OTHER THAN AUTO ONLY: AGG $ EXCESSIUMBRELLALIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WC STATU OTHER - EMPLOYERS'LIABILITY 1,000,000 B ANY PROPRIETOR/PARTNER/EXECUnVE WC3250371 7/21/2010 7/21/2011 E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? E.L.DISEASE-EA EMPLOYEEI$ 1,000,000 If yes,describe under 1,000,000 SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER R OkeStAdCiMA CWSKNSADDEDBYENDORSEMENT1SPECIALPROVISIONS !3T ,NoOV Operations Usual to Carpentry and Construction CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Town of North Andover DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN 120 Main Street 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 North Andover, MA 01845 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE P ACORD 25(2001108) Client# '4411 Mst# 10-11 GL+WC Cert# 0 ACORD CORPORATION 1988 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25(2001108) 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 number(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 carry 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 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. Citytior Town Officials 1 J 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 permit/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 permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit 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 C0111intonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax# 617-727-7749 www.mass.gov/dia The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant-Information Please Print Legibly Name (Business/Organization/Individual): t Pi t/1 I AUG i Q1�� 11 Address: City/State/Zip: v1 JOye'-A d t g y 5"Phone #: 6 8 1 Z Are you an employer?Check the appropriate box: Type of project(required): 1.4ffNL am a employer with 6) 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sh%et. # 7• gRemodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g, ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.EJ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 13.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f 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 y Name:Company , `° P 6 n V-A ° Or Policy#or Self-ins.Liic.#: Vy G 3 25 0 Expiration Date: -7 /2 j Job Site Address: 'Vr-r%` P 11i v e Is1T City/State/Zip: h,,A.16VQ-r ,MQ) L�S� 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. I do hereby certify un the 'ns nd penalties of perjury that the information provided above is true ind correct. Signature Date: �1 Phone#: FnD only. Do not write in this area,to be completed by city or town official. n: Permit/License# hority(circle one):Health 2.Building Department 3.City/I'own Clerk 4.Electrical Inspector 5.Plumbing Inspector son: Phone#: