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HomeMy WebLinkAboutBuilding Permit #577-15 - 81 WINTERGREEN DRIVE 12/29/2014 NORTfl BUILDING PERMIT 0,,-ED ,� TOWN OF NORTH ANDOVER h ''. �_>• ` APPLICATION FOR PLAN EXAMINATION i yh �04R\y10 Permit No#: ( � Date Received �RtTEO �5 �SSACHUs�t Date Issued: Z �� IMP/OR ANT: Applicant must complete all items on this page /�fQrZr not IP,R®PERN' Ui/NIC P,1 3 -- _i-'.Tor €Pnnt1100 Year Struc u yes mg-t P _z"" � ��OQ ti � x x EMAP° I CEL ZONING�DISTRJCT;7 Fust©ric ®istrict� dyeDs 0 �A •.-� 1..� MachiLne ShopUillage yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ne family ❑Addition [I Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ?Vle-pair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑_Other T DSe tic ®Welly y "� FI o am iWetl n s f� } Wate �"d ®"stric t `� ❑.. I 1 DESCRIPTIO OF WORK TO BE PERFO ED: 14 Identification- Please Type or Print Clearly OWNER: Name: %�J9i�q i�i i� S Phone: Address: tract©rtName - rlu�PyPhone= k7 '' � o * 4 � Con;_��„ �}� 'AddressXn - ti ,'Speniis®r s<Constructi®nlLicense0 cS� Exp f,D tee_==`7� . h� a 611M. _ p ' ornelrn'ro�ement-LicensesExp ®ate4 .�.�®r NO�. - _�.,.& ARCHITECT/ENGINEER Phone: Address: Reg. Na.-- FEE SCHEDULE:BULDING PERMIT;$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COSTf.BASED ON$925.00 PER S.F. Total Project Cost: $ BW FEE: $ Check No.: I ® Receipt No.: 3�� NOTE: Persons contracting with unregistered contractors do not have access°t guaranty fund Signature of°Agent/Owner � j ? ..: :Signature of contractor4 . :. : f . ti}• ;�:.:-, Plans Submitted ❑ Plans Waived 0 Certified Plot Plan ❑ Stamped Plans ❑ FTyp-.F OF SEWERAGE DISPOSAL Public Sewer ❑ Taming/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 Signature_ COMMENTS CONSERVATION Reviewed on _ Signature COMMENTS HEALTH Reviewed on Signature a COMMENTS 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 ,�Locatedat�124�MAainiaSt�eet� � �H. _ Street DFIRE ERARs _ - Fre Depar`tment4s nature%date 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 I DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) I I I i 1 I ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 I 1 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 HJ.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 i Addition Or Decks I ❑ 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 I Doc:Building Permit Revised 2014 Location n No. t! �� Date 2 �� • - TOWN OF NORTH ANDOVER Certificate of Occupancy �$ Building/Frame Permit Fee $ r— �, -,; ] Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# 60 2- 28 3 � 5 2835 -�- Building Inspector � NORT1i Town of : : ., Andover J.- : C% h ver, Mass, 61 t 01 coc«Ic"tw1cr s � BOARD OF HEALTH PER IT T LD Food/Kitchen Septic System THIS CERTIFIES THAT . .. 1W.W miuka.. .......... ..... BUILDING INSPECTOR ........... ......... ....:j .... Foundation has permission to erect .......................... buildings on ........ .....WMA4. • •• 4 Rough T00kall.000fow to be occupied as ....... . ... .......... ................................................ Chimney provided that the person acce2 0111p ing this permit shall in every respect conform to the terms of the application Final on file in 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION R Rough Service ... .... .. ................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing .or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. The Commonwea/th ofMassaehusetts .Department oflndustrial-cc dents Offl"of Investigations 600 Washmgton street Boston,MA 02111 www masr:govlft Workers' Compensation Insurance Affldavit: Bunffders/Contrsctorg/Eleddeitus/pinmOers �.aIDticant Information Please Print Ltbly Name(Business/Organization/lndividual):_&O ew c ` — `o n1 VV 1 der e✓X Address:- 30 �or6s agl, City/State/Zip: Q Kl hone#: Are you an employer?Check the appropriate box: Type of project(required): l J2 i am a employer with '74) 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 sheet. 7. remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' [No workers'comp.insurance comp.insurance.: 9. ❑Building addition required.] 5• ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their ing rept or additions 11.❑Phrnrb' myself.[No workers'comp. right of exemption per MGL 12.0 Roof insurance required]t c. 152,§1(4),and we have no repair; employees,[No workers' 13.❑Other comp:insurance required.] •any applicant that checks box#1 must also fill out die section below showing thea workers compensation policy;information. t Homeowners who submit affidavit indicating they are.doing all work and then hue outside contractors must sanform new affidav$indigting such =Contractors that check this box mast attached an additional sheet Showing the name ofthe sub-contractors and state whedux or not those edea have employees. If the Sub-contractors have employees;they mast provide their..woiiceas'comp;policy number. . I am an employer that n providing workers'compensation insurance for my edrPl oYte� pelota Ls the ,btformatlon. P6&7 Mdfob site Insurance Company Name: l LIL- ve\ a Policy#or Self-ins.Lic.#: fildon Dom: . Job Site Address:P_ ld/ � �/� 1. 1�K4 Attach a copy of the workers'compensation policy declaration page(showing the policy number end 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 fotm of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do herebyc u a the pains and penaUles of perjury that the information provldrd obove is lure and correct S' attire: Dom. Phone O)ieial use only. Do not write in this area,to be completed by city'or town offidl City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6:Other . Contact Person: Phone#• ANDECOR-01 YADAVYO CERTIFICATE OF LIABILITY INSURANCE �1011no�"r°101112014 MID THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT. U the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT CRrRiCaS�WllI1S.COm Willis of Minnesota,Inc (7I do 26 Ce Blvd :($T!)945-7378 1 I(F (8N)467-2378 P.O.Box 305191 E-NAIL Nashville,TN 3723M191 ADDRESS:- rNS1RHt1S1 ARG COVERAGE NATC# INSLIRMA.01d Republic Imurance Company 124147 INSURED INSURER B Renewal by Andersen Corporation INSURERC: 30 Forbes Road INSURER o Noftborough,MA 01532 INSURER E. 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_ 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. INSRLTR TYPEOFUISURANCE 'p wL POLICYNUMBBR SUBIR PDLICY MMIDDTYYY P°UD)YyYCY LIMITS A X 00) QAL GEiERAL LBABfLIrY T ACH OCCURRENCE $ 1,0D0,00 qAIA°E X1, OCCUR MWZV302M 10/01/2014 10109Y1015 °A � g gyp, I MED EXP IAny cne pewnD $ 10,00 PERSGNAL&AOVINJURY $ 1,000,00 GENLAGGREGATE LIMIT APPLIES PER" GENHRALAGGREGATE $ 4,000,00 X POVC ;�LOC PRODUCTS-COMPJOP AGG $ 4,000,00 OTTER: i I AUTOMOBILELJAMLITY � COMBINED SINGLE LIMIT $ 51000,011 A X ANY AUTO j �MWTB302575 1010112014' 10/01/2015 BODILY INJURY wPetsmnD I $ L �°OS AS�U�LED � � BODILY INJURY(Per��W�'I $ HIREDAUTOS A1�O.S� R PROPE_TY DAMAGE $ UMBRELLA IIAB f 1 j 'OCCUR i I, EACH OCCURRENCE 1� $ EXCESSUAB =1MS4AA°E AGGREGATE � $ DED RETENTION$ $ WORKERS COMPENSATION XATTtiE O T S'LI AND EMPLOYERS' YIN A ANY PROP RIET ORMARTNERIEXECUTtvl MWC30r91.W0 10101120141 10/01/2015 E.L.EACH ACotDENT $ 1,0DD,0D 1 OFFICER MEMBER EX11'X ODH� ®.NIA. LrWardatorya�NHt E_LDISEASE-EAEMPLOYEE$ 1,000,00 j If yes,des[rbe ander DESCRIPTION OF OPERATIONS bekm EL DISEASE-POLICY LIMIT I $ 1,000,00 � I I I i I OESCRIPTIONOFOPERATIONSILOCATIONSIVEMCI (ACORDIM,AdffwnaORemad6Sdveih uMbealladmddmorespaceisrequrtem CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED FOIICOES BE CANCELLED BEFORE THE E)wm-TtON DATE THEREOF, NOTICE WILL. BE DELIVERED M ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORRED REPRESENTATIVE vidence of Insurance ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD t Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction super�isor License: CS-M125 , r JADH L MORIN t. i . 86 GARDINER ST t- LYNN MA 01%15' `' t Expiration Commissioner 10/06/2016 Vfie�ay�n2yn�lect�o�'C�/�aaauc�uaeC�t Mee of Consumer Affairs&Business Regulation OME IMPROVEMENT-CONTRACTOR Registration: 4?081.0 Type:;! Expirdtiotl: '12!2312015 Supplement s RENEWAL BY ANDERSON'CORPORATION aF JAIME MORIN 104 OTIS STREET NORTHBOROUGH,MA 01532 -- 4 Undersecretary 1 > 6 • xJ- Y i" f- T T 4 `ePi. YJ'1�1�u1F-0)��'t. �1:.lfil witJ ���p ��"y�i���� yTq� t'��"��.�1"yS�i�C��������1_ ".�kn•. ly�+.,I��B,�i� l�$s�E����" t � LY � r Z ^9 * ••a43'i...R" -'p �.���k�i� x�t`!' IrL 1�� � C ISS a• -aTvi+e�,c. .Itr,;wrx S:M.s'7�sr� y� _.A�-�i�a" w"�"�c�`�`� . -• .� s;� `��191 zau�v lbs`+a ai p paa� ny7t � Apr ' �*' few �► .. a a;���dd�Y���a�➢j�,`-.�o�������tl ��< ��; �' ¢ .c. i �. ? 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