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HomeMy WebLinkAboutBuilding Permit #846-13 - 855 GREAT POND ROAD 6/5/2013Permit N TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received Date Issued: 14 11 -3 IMPORTANT: Applicant must complete all items on this page._,______ N ell )0E T j'YV 0-,W' A SQ kN - &A, R -0 R Pring1 A 000" e m@ OR -ON INQ -lSTR yes j no ,MA -A lan -0-'. 2- Machirie pUill, p yes nog 1 TYPE OF IMPROVEMENT PROPOSED USE N Residential Non- Residential [I New Building 11 One family D Addition 11 Two or more family 11 Industrial D Alteration No. of units: El Commercial El Repair, replacement El Assessory Bldg 11 Others: El Demolition kbther 7e/n Pre n W r ed DESCRIPTIUN L)I- VVL)KM I u mr- rcmrumivir-u- PemQVPel Identification Please Type or Print Clearly) Phone: F -SF- SX- 9 G-� V OWNER: Name: 0& -0 , - hp S24 ;1 742 /K Address: Aec4- P01d PC( A -Z M A714vevc /W I 0NTPAC Ne a$'q F-7- .7, Address JV p r License.: e,vi��,q bnitide b(oo-a 3 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.: -(fl NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 9. Plans Submitted ❑ Plans Waived El Certified Plot Plan D Stamped Plans ❑ 0 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL �r 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 ❑ 1-1 COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS Reviewed on Signature Reviewed on Signature 4 �r Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Com Conservation Decision: Comments "Water & Sewer Connection/Signature & Date Driveway Permit IDPW Tow ]Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at'124 Mair Street Fire Departinerltsignatia"re/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 ZOITE 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 2010 Building Department The foliowing 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 ❑ 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 Li Building Permit Application ❑ Certified Surveyed Plot Plan o 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) 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) o Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract o Mass check Energy Compliance Report o 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 appx al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm;4ted with the building application Doc: Doc.Buil ling Permit Revised 2012 -66 Q�-m- 0",Y) Location No.—VI, --I Date LA'3 TOWN OF NORTH ANDOVER T, Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL Check 4��3 26486 Building Inspector • 0 rA W O ti- W LLZ O O m C N u Y \ O 0 E In U O.. a)LL In 0 0 W d Z mJ C O a 7 LL L = C E U LL p G LLJ (A Z J d L LL O G CL N Z a U U W W , L � U Ln LL c U Wa Z to L � 0: LL Q W 2 Q W C ui 5 LL y m O Z v N N 41 O In O U W Z CD Z s J m CO Z N a Z Ln N W ti 0 c x Z U3 O a cn. W c W J a Z `o rn _ N d t O Z � O O N 5 5 5 mill 4 OPO pr ISO L c ca ca L CJ E r 0 A 'O _O m CL v 4) c U z W i Co CO E W E U s = ~Cf) C.O a -O ---z ++ O ZZ ?1 E i U O W co (D r O c N CD L 7cso='cSqts O =_- o U L N ooi - r4 N Vi C o� CD 0 ISO L c ca ca L CJ E r 0 A 'O _O m CL v 4) c U z W i Co CO E W E U s = ~Cf) C.O a -O ---z ++ O ZZ ?1 E i U O W co (D r O c N CD L U cn to 0 Z O V z Q RA L Li O cu 4 :a U cc o a) a E m c U - u z c' CO c a o Q Z o E cu z 'S t6 ' G.1 C O 00 L s CL L � Cts O a) = C r Cc 0 CD c � A LL. c � t0 CU c CL c M > 'A m V Q �+ Co � O � M L) , o O V U co e-� � Q E A .� • 9� 'C3 O U .A. o cAa ,E cz ' L) F- v LL. U cn to 0 Z O V z Q RA L Li O cu 4 :a U cc o a) a E m c U - u z c' CO c a o Q Z o E cu z `./ CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 10/19/2012 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 Bonacorso Insurance Agency, Inc. 83 Cambridge Street P.O. BOX 1502 Burlington MA 01803 CONTACT Michael Bonacorso NAME: PHONE (781)273-3200 FAX (781)273-0600 Ext,AICA/C N.I: ADDRIE :mike@bonacorsoins.com INSURERS AFFORDING COVERAGE NAIC # INSURERA:Acadla Insurance Company INSURED Peterson Party Center, Inc. 36 Cabot Road - ---- -- - Woburn MA 01801 INSURER B :C N A Insurance Co. INSURERC:AIM Mutual Insurance Co. INSURER D: - ---- — ---------- -i- — -- — INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:2012 Master 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. NSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS GENERALLIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 100,000 PREMISES Ea occurrence $ X COMMERCIAL GENERAL LIABILITY MED EXP (Any one person) $ 10,000 A CLAIMS -MADE ❑X OCCUR X X CPA 5061026 10 10/9/2012 10/9/2013 PERSONAL 8 ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 $ POLICYX PRO LOC AUTOMOBILE LIABILITY - COMBINED SINGLE LIMIT Ea accident $ 1000 000 BODILY INJURY (Per person) $ A ANY AUTO ALL OWNED X SCHEDULED AUTOS AUTOS NON-OV11ED X HIRED AUTOS X AUTOS X X 5063173 10 10/9/2012 10/9/2013 BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident Uninsured motorist BI split limit $ X UMBRELLA LIAB X OCCUR X EACH OCCURRENCE $ 10, 000, 000 AGGREGATE $ 10,000,000 B EXCESS LIAB CLAIMS -MADE 5085496458 10/9/2012 10/9/2013 DED X RETENTION$ 10,000 $ C WORKERS COMPENSATION ' WC STATU- OTH- AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVEY / N OFFICER/MEMBER EXCLUDED? (Mandatory in NH) NIA 28006586 10/9/2012 10/9/2013 E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYE $ 1,000,000 E.L. DISEASE - POLICY LIMIT 1 $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) CERTIFICATE HOLDER CANCELLATION ACORD 25 (2010/05) INS025 (201005).Ot 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 ael J. Bonacorso © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD The Conirnonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, AIA 02111 www. inass.gov1dia mpensation Insurance AffidaNdt: Build ers/ContractorsTlectricians/Plumbers licant Information Name (Business/Orcanization'Individual): ase Print J Address: City/State/Zip:/ (u�yr2✓� _��---Cr1-��i -_-_Phone:-��"�--%Z�<--=�C3-moo --_- ------ ----- Are you an employer? Check the appropriate box: L © I am a employer with _-,� c)C3 4• ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t These sub -contractors have employees and have workers' comp. insurance.1 5. ❑ We are 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 required.] Type of project (required): 6. ❑ New construction 7. Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.[Z Other Vin. * ^.ny applicant that checks box rl must also fill out the section below showing their workers' compensation policy information. 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 -contactors and state whether or not those entities have .`%p� =s Tf tie cu'^-CCr,taC*O', ha v P-..�t,V _ .t_ ;A= i --- -`-'•Y=- - - — -- •, iii: yc ustpr„.. ditii 'dvorkt.o Cvmp. pviiCy uiiiuGcr. I anz an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: / / f rc / - �6 S LC Policy T or Self -ins. Lic. : 6,L).M- Expiration Date: —/ --c A /3 Job Site Address: �S� ���P �� City/State/Zip: p: &.14V611n 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 ao-ainst the violator. Be advised that a copy of this statement maybe forwarded to the Office of InvestiLyations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct. Phone r: 1 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 #: ift Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Super%i-sor License: CS -06,0,.219 MARK TRAINA 33 HANFORD RIS� Stoneham MA 02180 Expiration Commissioner 04127/2015 & HOME IMPROVEMENT CONTRACTOR Registration: 1699122 Type: q Expiration: tion: 0/1 0'20 ual Ci P T 1 A MARK, ORD RD. 021,q -O clal" 1ACIISU nr I Cist I;Iti.)Il N;Ih11 Iur indiN itjlji osc old, hef'ol C the (ion elate. I V FULI M.1 I CLUI-II to: Office of C I.) risilitier A f'kiii-s :I it (I 1',tisi I I ess I I I; It i,, If) P:1 I -k 1)1;lz;l - tiuitc 5 1 �O Bu.stoil, iNIA 02116 No( N ;I I id %N i t h oil t signature