HomeMy WebLinkAboutBuilding Permit #504-2017 - 740 SALEM STREET 11/14/2016At
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
0 Two or more family
❑ Industrial
Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
0 Assessory Bldg
❑ Others:
❑ Demolition
0 Other
❑ Septic 0 Well
❑ Floodplain 0 Wetlands
❑Watershed District
❑ Water/Sewer
REPLACEMENT OF 2 DOORS - NO STRUCTURAL WORK TO BE PERFORMED
Identification Please Type or Print Clearly)
OWNER: Name: WAYNE CHANG Phone: 617-967-6619
Q
caress: 44 KAKA UKIVt NUK 1 H ANUUVtK, MA U1b45
CONTRACTOR Name: JAMIE MORIN Phone
Address:
30 FORBES ROAD. NORTHBOROUGH MA 01532
Supervisor's Construction License: Exp. Date:
090125
Home Improvement License: Exp. Date:
170810
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
508-351-2082
10/06/2018
FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ 2654.00 FEE: $
Check No.:. Receipt Receipt No.: f173
NOTE: Person; bontracting with unregistered contractors do not have access to the guaranty fund
Ueq- a9r%,e
nature
I
to
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FORPLAN EXAMINATION'.
Permit No#: Date Received
nate ipfi-
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
0 New Building
[I One family
0 Addition
El Two or more family
0 Industrial
El Alteration
No. of units:
0 Commercial
[I Repair, replacement
0 Assessory Bldg
0 Others:
0 Demolition
El Other
F� ------ S,
El Septic - El e
El Flood El Wetlands
a ers -e,, District
V f f
OWa *45"o
DESCRIPTION OF WORK TO BE PERFORMED:
Identification - Please Type or Print Clearly
OWNER: Name: Phone:
Arfrirp-q-q
Contractor' Name Piton
Address:
§upbr s q-- Jl;c
M86r2§,Cbn U�- i h -ireh 6 ,., Dafe
Home jMp'I-c- ioe'hse;- Exp - Date "
ARCH ITECTIENGIN EER
Address:
Phone:
Zeg. No.
FEE SCHEDULE. BULDING PERMIT.• $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
-
_,notal Projert Cost: $
FEE: $
Check No.: Receipt No, -
NOTE: Persons contracting with unregistered contractors do not have.. access to the guaranty fund
0fe_6f--A t/bw7ner Signature 6f contractor
-
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
❑ 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
o Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ 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)
❑ 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)
❑ 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
o Engineering Affidavits for Engineered products
40TE: 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: Building Permit Revised 2014
It Plans Submitted ❑
Plans Waived El Certified Plot Plan ❑ Stamped Plans ❑
'TSEWERAGE DISPOSAL
7P
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
COMMENTS
Signature.
CONSERVATION Reviewed on Siqnature
COMMENTS
i
HEALTH Reviewed on Siqnature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comments
Conservation Decision: Comments
Water & Sewer Connection/Siqnature & Date Driveway Permit
DPW Town Engineer: Signature:
_ Located M4 Usgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
1—dBated at 124. Main Street
Fire Department signature/date
COMMENTS ?
limension
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 lies No
®ANGER ZONE LITERATURE: Yes
MGL Chapter 166 Section 21A—F and G min.$10041000 fine
No
Doc.Building Permit Revised 2014
Location
No. 1l3�" 101 Date i) i
i t /
Check # # it
31173
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $3b
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
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ReineWal Agreement Document and Payment Terms
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The Commonweafth of Massaehttst o
Department ofInduMAd Accidents
Offlee of'IRvesdoa&ns
600 Washington Sired
Boston, MA 02111
www mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Apalieant Information Please Print LemMy
NameMusinesetorgaoizadonlhxiividual): RENEWAL BY ANDERSEN
Addreas: 30 FORBES ROAD
NORTHBORO, MA 01532 Phone M 508-351-2214
Are you an employer? Check the appropriate boa:
1. R] I am a employer with 30 4. ❑ I am a general contractor and I
employees (fall and/or part-time).* have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. fiwilzanee
required.]
3. ❑ I am a homeowner doing all work
myself [No workers' comp.
insurance ] t
listed on the attached sheet.
These sub -contractors have
employees and have workers'
comp. insurance;
5. ❑ We aro a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance r eauired.l
Type o(project; (required):
6. ❑ New cona*uction
7. FL] Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.[] Plumbing mpaus or additions
12.❑ Roof repairs
13.❑ Other
'Any epplEcsnttbat checks bac MI must also fill out the section below showing their worlxrs' oomPoasetion PolirY infDangtioa.
t eownas who submit this affistavit indicating they are doing all work and thea hue outside conbactors mcat subunit a am affidavit mdicatnig such.
:Con4ac6crs that check this box must atfachad an additional sbeet ahowmg the mime of the sahcoa� and state whafbar or not dare notifies have
employees. If the sub-coneoactata have empl%—. that must provide their work ess' camp, policy number.
Iain tae employer that is provlddtg workers' compmffa don tnrwaacejor my ettlployem Below Is the
worm"1on. per}' mtdjob alts
Insurance Company Name: OLD REPUBLIC INSURANCE COMPANY
Policy # or Self -ins. tic. M MWC30823100 10/01/2017
FJcpiration hate:
Job Site Address: 740 SALEM STREET City/StatclZip: NORTH ANDOVER, MA 01845
Attach a copy of the workers' compensation policy declaration page (*owhlg the policy number, and eViratiem date).
Failure to secure coverage as required under Section 25A of MGL e. 152 can lead to tate imposition of criminal penalties of a
fine up to $1.500.00 and/or ogle -year iroprisonm=14 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 OEifoe of
1nvc9figetioSAfAvQDIA for insurance coverage vmification
I do h96by eM&
ttie pains atrdpenalaPea olpetjruY tthaa tklee o fi►r on, ed abow is true and aoar+ect
14
O ictal use onbr. Do not write In obis a►e% to be completed by city or town oj)iciaL
City or Town:
Issuing Authority (chvie one):
Permit(License #
10/28/16
1. Board of Health 2. Building Department 3. CRY/rown Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
Contact Person: Phone P
ANDECOR-01 SALWAN.iV
`4 C>M�' CERTIFICATE OF LIABILITY INSURANCE
DATE(MMIDDJYYYY)
9/30/2016
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(ios) 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
Blvdinnesota, Inc.
Willis of Century
do 26 Cerrtury Blvd
P.O. Box 305191
Nashville. TN 37230-5191
CONTACT Willis Towers Watson Certificate Center
NtE (8� 545-7378 F No : 888 457-2378
ADDRESS; certiflcatesQwllils.com
INSURER(S) AFFORDING COVERAGE NAIL S
INSURER A:Old Republic Insurance Company 24147
INSURED
INSURERS:
INSURER C :
Renewal by Andersen
INSURER D :
30 Forbes Road
Northborough, MA 01532
INSURER E:
ENSURER F.'
GUvr-KAUr-5 CER firIGA i E mumminw- Mckfiernu aruun�s.
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.
LTR
TYPE OF INSURANCE
POLICY NUMBER
EPP
PMIDDIYYYY
MOM
LIMBS
AX
COMMERCIAL GENERAL LIABILITY
CLAIMS4IADE 0 OCCUR
MWZY 308234
10101/2016
10/01/2017
EACH OCCURRENCE $ 1,000,000
DAMAGE M ERENTEre— $ 500,00
MED EXP (Any one person) $ 10,000
PERSONAL& ADV INJURY $ 1,000,000
GEN'LAGGREGATE LIMIT APPLIES PER:
X POLICY ❑ LOC
GENERAL AGGREGATE $ 4,000,00
I
PRODUCTS-COMPioPAGG $ 000,000
$
OTHER:
A%�
AUTOMOBILE
LIABILITYBIN
ANYAUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
HIRED AUTOS DOS WNED
I
MWTB 308232
I
1010112016
10/0112017
CEOMdED• SINGLE ULQT $
5,000,000
BODILY INIURY (Per pereon) $
BODILY IMURY (Per accident) $
Para 1 DAM $
UMBRELLA LIAR
EXCE55LWB
OCCUR
CLAIMSMADE
{
l
I
EACH OCCURRENCE $
AGGREGATE $
DED RETENTION $
WORKERS COMPENSATION
AND EMPLOYERS' LIASUN
ANY PRoPRIEToRIPARTNERIEXEcuTrvE YIN
OFFICERIMEMBEREXCLUDED? -I
(Mandatory in NH)
M yes, dasarlbe under
DESCRIPTION OF OPEIZ4TIONS below
A
N/A
I
i
MWC30823100
10/0112016 110/0112017
I
$
PER OTH
ST TOTE I ER
E.LEACHACCIDENT $ 1,000,000
EL. DISEASE - EA EMPLOYEE $ 1,000,000
E.L. DISEASE - POLICY LIMIT $ 1,000,00
DESCRIPTION OF OPERATIONS /LOCATIONS 1 VEHICLES (ACORD 101, Addtdonal Remarks Schedule, may be atfschad If more space is required)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
®1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
r
s
Massachusetts Department of Public Safety
Board of Building Regulations a_nd Standards
License: CS -0g0125
Construction Supervisor
JAIME L MORINa,
86GAROW, R ST 3 �
LYNN MA 01805i�
Expiration:
Commissioner 4070612018
t
Construction Supervisor
Restricted to:
Unrestricted - Buildings of any use group which contain
less than 35,000 cubic feet (691 cubic meters) of
enclosed space.
s
Failure ba possess a eunent edition of the Maasaehasdta
State Stdlding Cede Is cause for revowttlen Willits license.
OPS Licensing infonnafbon vish: WWIN.MASS.GOV/DPS
C- ��ae �ammao�zu�ea� o��aacYic��
ice of Consumer Affairs & Business Regulation
ME IMPROVE,.MENT CONTRACTOR
Regi TO
SPI Supplement Card
RENEWAL BY AND,;
JAIME MORIN ;> '
30 FORBES RD•—
NORTHBOROUGH, MA 01532 Underseeretxry
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 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
PLANNING & DEVELOPMENT ❑
COMENTS
CONSERVATION ■ ■
COMMENTS
HEALTH
COMMENTS
DATE APPROVED
El
DATE REJECTED DATE APPROVED
❑ ❑
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decisi
Comments
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/date
i
COMMENTS