The URL can be used to link to this page

Home My WebLink AboutBuilding Permit #373-2017 - 815 CHESTNUT STREET 10/7/2016 Not Scp,uweD BUILDING PERMIT c TOWN OF NORTH ANDOVER ,o PPLICATION FOR PLAN EXAMINATION w Permit NO: Date Received ATI 1, Date Issued: f0 'e-Ol'�/ ��SSneNus t� IMPORTANT:Applicant must complete all items on this page OCATPnnt PAOPE lstoricpl�#r%cE Sho age �� TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial Alteration No. of units: XC-ornmercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition XOther Floodplain �:,Wetlands ❑ Waters eO District Mitt�x � a zcw VM +vim y'b8111'�d(+'Over m� '�c�+f�inu / films Identification Please Type or Print Clearly) OWNER: Name: 0IS Phone: b5) 'lcQl1 Address: \aSt11(J+ S+ -VON L Phone:TO All ,fid ,, se: S G I t Z Exp. bate: Exp. Date. ARCHITECT/ENGINEER F-be- Knott -ClAi`µarwi AAAPhone: ( 3q,q Address: aS Nr(*, 54 Reg. No. 3QuSc� FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ k30, 93co- W, FEE: $ .3•z- Check No.: Receipt No.: 3 i 40,x_ NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund i nature of contractor BUILDING PERMIT ' • of 0 TNOK TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION `' ~ Permit No#: Date Received �s9 ❑R�ren�eR` SSACHus�� Date Issued: - IlVIPORTAIVT:Applicant must complete all items on this page -------------- G'-AgTION q o _� v N ❑ u e� + Pnnt 1DOYrStruct�ur�e h }yews ��o F, � aRGEL , _ ___ aZ®NING ®15TR1CT Historic ',. s ;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 ❑ Se tic ❑Well ❑ Flood Iain ❑Wetlands ❑ Watershed E,is D V1la_te_r/Se_w_e_ r:.. �,�.�»��. :,� :�.`.a._�.nr.�. _�:.,»...,e.._s:��. � �,:.�� •� DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: -ContfaCtOC Name. Lit�fF!'6"d'Y ..`^* aiCSti g ,.r��s '4; .i �• .. '-- '�+!.W MMf';'�}4.ra��.�.� e.}�rr w � Address i_} � "r V 'ii � ., S'l_ :w?` -�.1`i',Y:... _4-41; 1"4 �� L� Supervisorg�Construction �cense � IExp� Date 1" s{':K^ "e��w' s'k" } y ""?•i� r ,r•• -F_ t Luc-) MORTrne�Irnprover��ent�Lieense ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.,BULDING PERM/T:$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,; DOTE: Persons contracting witli unregistered contractors do not have access to the guaranty fund Signatu�e_of_Age"rif/Owner Signature of contractor? Location OK r Y- No. 3�3l Date /O a6 Z9/�j • TOWN OF NORTH ANDOVER , a Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# J`� 0 0 8 ,� Building Inspector 1 z Plans Submitted ❑ Plans Waived Certified Plot Plan ❑ Stamped Plans ❑ TYPE bF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swirnining 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 i f HEALTH Reviewed on Signature w COMMENTS i I Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments I 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 signatureldate Z COMMENTS ' 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 DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMENTS CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer ConnectioniSignature& Date Driveway Permit Located at 384 Osgood Street RE. rte[hum sten©n slte x p yes no 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 Yes No DANCER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$loon fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email ate Time Contact Name Doc.Building Permit Revised 2014 li r 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 i 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 o 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 o Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract u Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (if Applicable) o Mass check Energy Compliance Report (if Applicable) o 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 o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o 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 DOTE: 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 t` Doc:Building Permit Revised 2014 r , V 40RT#i - ve" - No. 3 . 1 +� � 1 i b �A COCH 0141 Wh ver, Mass, ICK`y1' U BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT BUILDING INSPECTOR ..... .*. .. S............. ..... .......... .......................... ........... . .. . . .. . ...... .... . .... . Foundation has permission to erect .. . buildings on �l,�......G . . .^/..� ..... ................ .... ........ . . 5 Rough to be occupied as _44 ... .. ... .......... Chimney provided that the person accepting this permit shall in every respect o form 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 CONST 10 Rough Service .. Final BUILDING INSP TOR 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 Commonwealth of Massachusetts = Department oflndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Aunlicant Information Please Print Leeibly Name (Business/Organization/Individual):A&E Fire Protection Inc. Address:25 North Street City/State/Zip:Canton, MA 02021 Phone#:781-329-9799 Are you an employer?Check the appropriate box: Type of project(required): I.Q I am a employer with 70 employees(full and/or part-time).* 7. ❑New construction 2.M I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 4.F]I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will ]0❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.�Roof repairs These sub-contractors have employees and have workers'comp.insurance. 6.❑We are a corporation and its officers have exercised their right of exemption per MGL C. 14.[DOther Fire Sprinkler Install 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:ABC MASS WORKERS COMP. SELF-INSURANCE Policy#or Self-ins.Lic.#:ABCMA15000715 Expiration Date:01/01/2017 Job Site Address:815 Chestnut Street City/State/Zip:N.Andover, MA Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify der the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: U Phone#:781-329-9799 Official use only. Do not write in 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.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Client#:1261909 AEFIR ACORD,. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 10/0412016 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 CONTACT Kathy Wagner USI Insurance Solutions,LLC AICNNo Ext:855 874-0123 FAX 610 537-9481 (AIC No 123 Interstate Drive EMAIL Kath Wa usi.biz West Springfield,MA 01089-3600 ADDRESS: y• g ner -- 855 874-0123 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:ABC Mass Workers Comp Self-Insu ;9999_9_ INSURED INSURER B A 8r E Fire Protection Inc. INSURER C: 25 North Street Canton,MA 02021 INSURER D: - 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 CONTRACTOR 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 TYPE OF INSURANCE ADDL SUB POLICY EFF POLICY EXP LTR INSR WVD POLICY NUMBER MMIDDIYYYY MMIDDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE F_OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ _ MED EXP(Anyone person) $ PERSONAL&ADV INJURY $ GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO- POLICY JECT LOC PRODUCTS-COMP/OPAGG $ OTHER: $ AUTOMOBILE LIABILITY EOMaBIINdEeD SINGLE LIMIT$ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED ( ) AUTOS AUTOS accident) BODILY INJURY i$ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ __ $ A WORCOMPENSATION PER 0TH AND EMPLOYERS'LIABILITY ABCMA15000716 0110112016 01/0112017 YIN 11 SSATSIE ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICERIMEMBER EXCLUDED? a N/A ---- (Mandatory in NH) E.L.DISEASE-EA EMPLOYEEI$1,000,000 If yes,describe under ------ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT_;$1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Proof of Massachusetts Worker's Compensation Coverage CERTIFICTE-IfOtDE CANCELLATION Evidence of Insurance SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE HE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN HE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) 1 of 1 The ACORD name and logo are registered marks of ACORD #S19052281/M168132310 KXWCD