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HomeMy WebLinkAboutBuilding Permit #625-15 - 8 FOUNTAIN DRIVE 1/23/2015BUILDING PERMIT ".. TOWN OF NORTH ANDOVER �_�� APPLICATION FOR PLAN EXAMINATION Permit NO: / Date Received Date Issued: / Z IMPORTANT: Applicant must complete all items on this page LOCATION 71 r n Q �.t Z : A� PROPERTY Ol1�NEf2tl1/i�i 11lAP N d �F?ARCL& `©NINC DST�tI°CTS His#ri D srt`=� r � e.S)1opiVillaaez v �t�'cy 16• .rO\ O � � - >no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition K(Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg '„Others: ❑ Demolition ❑ Other IF"t"i�c- 1rtSU�-�1"tl� D.- Septic . b Well ❑ Flbotl�lairr We�tlaatl ❑ Watershetl Ditnct : EWater/Sewer g u Identification Please Type or Print Clearly) �t OWNER: Name: v12. "l ���� P, one: Address: I ARCHITECT/ENGINEER. Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ 'k((a 1 FEE: $ Check No.: b Receipt No.: NOTE: Persons contrac ing un ister contractors do not have access to t e guaranty fund Signature of Agent/Ow :, S1gnaure.01c r t y .. 4. u Permit No#: Date Issued: BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received M.' 0 IMPORTANT: Applicant must complete all items on this page LOCATION __..- Print Orr D � �_2 r h� �t LE��� 19 k -1 _... PROPERTY OWNER Print 1 oo Year Structure yes no MAP _ PARCEL: __ ZONING DISTRICT: Historic District yes no Machine Shop Village ves no 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 0 Floodplain p Wetlands ❑ Watershed District ❑ Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification - Please Type or Print Clearly OWNER: Name: Phone: At1Hracc- ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 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 Signature of Agent/Owner 4 `y Signature of contractors n --- (),IV Location 6 -t—e)A)�J� Ou, No. � 2:S7 -1 C Datel-I 13 1\0�� , Check # — 26449 TOWN OF NORTH ANDOVER Certificate of Occupancy $ A Building/Frame Permit Fee On Foundation Permit Fee $ 1 Other Permit Fee $— TOTAL $ -- Building Inspector O < Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ -TypF'OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swnruning 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 Signature COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH COMMENTS Reviewed on Signature N,Zoning Board of Appeals: Variance, Petition N Planning Board Decision: Comments Zoning Decision/receipt submitted yes Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Locatea i254 Usgooa Street FIRE DEPARTMENT -Temp Dumpster on site ;yes no--_ Located at 124Main Street Fire Department$ig iaturaldate COMMENT.,,_ Dimension Number of Stories: Total square feet of floor area, based: onExterior 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 Doc.Building Permit Revised 2014 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 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 ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ 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 ❑ 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: Building Permit Revised 2014 Eation LLC Job Location 1=ouwain urine k Mountain Drive North Andover MA Estimate Date Estimate 1 t3;` 191201 d 21 S J Q WCL = O O fA Z Z O ~~ W to Z Z O W CL H Z U 0 V W ? z W W Q 0 0 m !A o LU .0 m C d LLJ J W LL Y \ O LL ?O N U O. y mv -O 7 LL t bf C E U f0 C LL = � OC jp C LL r O a, j N V1 m LL to 0O ` i m O Z N i1 ++ Ln N Y O N O �a : O ,o V G� rL "r CO) 0 z r S •: E : 0 m W COr v or Z 0' S aw. E m _ 0 �a Z F- �N V L O 01 3 �- �� N J E CO 01 • N j, O F. a . >_ c0 w w� AU) o y _�r aZ •= = t s LLI - E -- 0 c CL U) CO y C o G ■ �� i3 w J�0 O S w c o �-- '0 0- Z 0 r 0 0 O .V m d WC v +'��' O OLLJ . C o O W E � -a O O vco Q. o •0 Ea' 0 C J ! F— t 0U. O V O :, v P• -e S.: O '4C40R O®CERTIFICATE OF LIABILITY INSURANCE 1/13%20115 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). PRODUCER TGA Cross Insurance, Inc. 401 Edgewater Place Suite 220 Wakefield MA 01880 CONTACT Jill DeHetre NAME: PHOAIC.NENo, (781) 914-1000 NC No: (781)224-5777 ADDARES :jdehetre@tgacross.com INSURERS AFFORDING COVERAGE NAIC # INSURER AArbella Protection 41360 INSURED Air -Tight Weatherization, LLC 9 Story Ave. Beverly MA 01915 INSURER BArbella Mutual 17000 INSURERC: INSURER D : INSURER E: INSURER F : COVERAGES CERTIFICATE NUMBER:CL14111923181 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. INSR LTR TYPE OF INSURANCE ADDL U R POLICY NUMBER POLICY EFF MMIDD/YYYY POLICY EXP MM/DDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMDAMAGE T RENTED 100,000 PREMISES Ea occurrence $ A CLAIMS -MADE OCCUR 8500046432 /8/2014 /8/2015 MED EXP (Any one person) $ 5,000 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 X PRO LOC $ AUTOMOBILE LIABILITY Ea BINEDISINGLE LIMIT 1,000,000 BODILY INJURY (Per person) $ A ANY AUTO ALL OWNED X SCHEDULED AUTOS AUTOS 1020015286 /8/2014 /8/2015 BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident X HIRED AUTOS X NON -OWNED AUTOS Ph scial Damage Perils $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 AGGREGATE $ $2,000,000 B EXCESS LIAB I CLAIMS -MADE DED I X I RETENTION$ 10,OOC $ 4600052930 /5/2014 /5/2015 WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVEE.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N / A (Mandatory in NH) E.L. DISEASE - EA EMPLOYE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Town of North Andover 1600 Osgood Street Building 20, Suite 2035 North Andover, MA 01845 ACORD 25 (2010105) INS(125l9mnnai m L.AN1,tZLLA 1 IUN 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 s Gregory/JD2 4-6�- ©1988-2010 ACORD CORPORATION. All rights reserved. Tha Arir)pn nnma nnf1 Innn nra ranie4ararl mnrirc of Ar.r)Pn / 16 A� o CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 01/13/2015 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). PRODUCER MassPay Insurance Services, LLC 27 Garden Street, Unit 1 B(AIC,Nc CONTACT Jacqueline Marie Melanson, CLCS PHONE 978 774-4338 x105 FAX (978) 774-1318 Ftl: ( ) A/c No E-MAIL I @p ackie hilrichardinsurance.com ADDRESS: Danvers, MA 01923 INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: AmGUARD Insurance Company 42390 DAMAGE TO RENTED PREMISES Ea occurrence $ INSURED Air -Tight Weatherization, LLC INSURER B: INSURER C : 9 Story Ave GEN'L AGGREGATE LIMIT APPLIES PER: POLICYLIJECT —1 PR LOC$ Beverly, MA 01915 INSURER D: INSURER E : AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIREDAUTOS AUTOS F 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. NOTVVITHSTANDING 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. INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MM/DD/YYYY LIMITS AUTHORIZED REPRESENTATIVE GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS -MADE F—I OCCUR EACH OCCURRENCE $ DAMAGE TO RENTED PREMISES Ea occurrence $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICYLIJECT —1 PR LOC$ PRODUCTS - COMP/OP AGG $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIREDAUTOS AUTOS F COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident $ UMBRELLA LIAB EXCESS LIAB HCLAIMS-MADE OCCUR EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE F OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If es, describe under DESCRIPTION OF OPERATIONS below NIA AIWC576437 07/01/2014 07/01/2015 WCSTATU- OTH- IT E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Proof of Workers Compensation CERTIFICATE HOLDER CANCELLATION ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood St Bldg 30 ACCORDANCE WITH THE POLICY PROVISIONS. Suite 2035 North Andover, MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD To Whom It May Concern, 1, James Fortin, do authorize William M. Crowley to act as my agent in the process of applying for building permits and other necessary documentation pursuant to the conduct of my business by Air -Tight Weatherizaiton LLC. ignature State of Massachusetts County On this day of 2014, before me personally appeared to me known to the person (or persons) described in and who executed the foregoing instrument, and acknowledgement that he/she/they executed the same as his/her/their free act and deed. Z/ kOBERT A. MONAHAN Notary PublicNotary Public COMMONWEALTH OF MASSACHUSETTS My Commission Expires Print Name: UI) September 17, 2021 My commission expires: ('01j11jj1(W10,('W111� `4 Off ice of ConSLImer Affairs and Business RegUlatioll 10 Park Plaza - Suite 5 170 Boston, Massachusetts 02 116 Hone Improvement Contractor Registration Reqistration: 165640 Type: LI -C Expiration: 3/15/2016 AIR - TIGHT LLC. WEATHERAZATION JAMES FORTIN 10 PINE KNOLL DR. BEVERLY, MA 01915 ZL ZI Offitcc Of Consu oler Affairs & 11 ts shiess llcgii 1:1 t ioll I�;'NOME IMPROVEMENT CONTRACTOR Registration: 165640 Type: v xpiration: 3/15/2016 LLC AIR - TIGHT LLC. WEATHERAZATION JAMES FORTIN 10 PINE KNOLL DR, BEVE PLY, MA 01915 Undersecrctar% Tr# 248557 Update Address and return card. INIark reason ft". C11,111(re. Address j Renewal E'mployment Lost Card I.Accose or registration valid for individut, rase only before the expiration (late. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, MA 02116 Not vat id 1vitlsout signature CS -052576 .1AAIES 1:' FORTIN 13everh NIA 0191'51 10/ 03/2015 The Commonwealth of Massachusetts --; Department of Industrial Accidents Office of Investigations 1 I Congress Street, Suite 100 t Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: � �` w City/State/Zip:_ t � , 's{ , V Are you an employer? Check ttte appropriate box: I. I am a employer with ft employees (full and/ or part-time).* 2. ❑ I am a soft proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised their right of'cxcmption per c. 152, § 1(4), and we have no employees. [No workers' comp, insurance required]** 4. ❑ We are a non-profit organization, stafTed by volunteers, with no employees. [No workers' comp. insurance req.] Phone #:` �,._-�"t t--t�� �f Business Type (required): 5. 0 Retail 6. ❑ Rcstaurari1/f3ar/I_*ating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) ti. Q Non-profit 9. ❑ Entertainment 10.n.Manufacturing I I.❑ I-Ical th Care 12. ❑ Other T_ — nny apptrcant mat checks Box it r must also fill our the section below showing their workers' coin pcttsation policy information. "If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #1. I am an employer that is providing workers' corn:ptssatiots itisurance for nay employees. Below is the polier information. m Insurance Company Nae:__ ___ _----_(, --A t ;(` — C" L c, It. Insurer's Acldress:_; ._ •� a `�_� l t- _ r City/State/Zip: Policy # or Self iris. Lic. t{ ��. ( �� % �_{-�� E.xpiration Date: ] i 1 C� C, 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 MGI_ c. 152 can lead to the imposition of criminal penalties of a fine up to 51,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORi)lR 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, under the pains andpetnalties ofperjury that the information provided above is true and correct. Phone fl: l C—�'cl Li Ce Official use only. Do not write its this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3, City/Town Clerk 4. Licensing Board S. Selectmen's Office 6. Other Contact Person: www.mass.govrota Phone M