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HomeMy WebLinkAboutBuilding Permit #415 - 94 MILLPOND 1/9/2009 RT NOh F eo A BUILDING PERMIT o tt, ti ? $t, =eoo TOWN OF NORTH ANDOVER ►°-3 i - ::.� , A APPLICATION FOR PLAN EXAMINATION * ,� n e Permit NO: 1 Date Received 4,* p,���e I <t SSACHUSE Date Issued: IMPORTANT: Applicant must complete all items on this page 4 LOCATION , l Print ff. PROPERTY OWNERS l 4 Print MAP NO: PARCEL ZONING,DISTRICT: HistoricDistnct yes no , Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial ation No. of units: Commercial eplacement Assessory Bldg Others: Denolition Other Septic Well Floodplain Wetlands Watershed District Water/Seaver D JCRIPTION OF RK TO BE PREF RMED: I z - clec , �- Id ntific on ease T or Print Clearly) OWNER: Name: �'�� + � Phone: C�-16--C(60c) . Address: G I � �� 1 Zi- A 611 0os CONTRACTOR Name: t "t - :Phone. . Address: e -may Construction License: -� ( Ex a l' Supervisor's a: - p. Date: 1 t Home improvement Licenser f Exp. Date: f 5 ( 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: $ ® ( no C) FEE: $ /rQ 0 �r Check No.: 7 J� Receipt No.: p ( F NOTE: Persons contractingwith unregistered contractors do not have access uara g g h'f ignature of Agent/Owner w _ Signature of contract,_ r 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 ❑ 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 ❑ 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/Crossection/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 i 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 Application ^ Revised 2.2008 �\ r 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 COMMENTS i CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature 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 Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/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 ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) -1-4 t""4 7- U, d �n ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 Location ` U No. Date M0*T" - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ r TOTAL $ -M77 Check # i 2 1 7 8 5 -----`` Building Inspector Jan 07 2009 10: 17PM HP LASERJET FAX 9794656607 P. 1 oi9D'g �#J1 0lOZ/9wrl :ualeiidzg e'yui unan�� 00000 HVIH ®t :fwlplin��+se� i P. ?SPS Orly d to tuawtJeda 8 jo P.lxog A ACORv CERTIFICATE OF LIABILITY INSURANCE OP ID DW °A�1"""NDD"mn GREAT-9 01/07/09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Chase 6 Lunt LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P O Box 590 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 47 State Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Newburyport MA 01950 Phone:978-462-4434 Fax:978-465-6204 INSURERS AFFORDING COVERAGE NAIC III U+sU� Great North Property Managemen INSURER A: The Travelers 39357 Management JGCA Holding Corp. INSURER B: National onion FireIne. Co. JGCA Inc. JGCA Holding Corp, JGCA Inc INSURER C: Federal Insurance Company 95 Brewerryy Lane INSURER D PortsmoutFi NH INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. - LTR INSR1 TYPE OF INSURANCE POLICY NUMBER DATE MM/DD/YY DATE LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY PREMISES(Ea occvrence) $ X CLAIMS MADE OCCUR MED EXP(Any one person) $ C X Errors & Omission EBU3900861 02/16/08 06/01/09 PERSONAL&ADV INJURV $ GENERAL AGGREGATE $1000000 GEML AGGREGATE LIMIT APPLIES PER: PRODUCTS-OOMP/OP AGG $ POLICY JELOC Ea Claim 1000000 AUTOMOBILE LABILITY COMBINED SINGLE LIMIT $1000000 A ANYAUTO BA-0822M284-08-SEL 06/01/08 06/01/09 (Eaaccide" ALL OWNED AUTOS BA-1245M498-08-SEL 06/01/08 06/01/09 BODILY INJURY SCHEDULED AUTOS (Per person) $ X HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (PeraccideM) GARAGE LIABIL17Y AUTO ONLY-EA ACCIDENT $ ANY AUTO EA-ACC $ OTHER THAN - R AUTO ONLY: _ AGG $ EXCESSIUMBRELLALIABILITY EACH OCCURRENCE $3000000 B X OCCUR FI CLAIMSMADE 82097170 02/19/08 02/19/09 AGGREGATE $3000000 E DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND TORY LIMITS ER EMPLOYERS'LABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ff yesdescribe under E.L.DISEASE-EA EMPLOYEE $ SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ - OTHER C Fiduciary 82097516 02/16/08 06/01/09 combined 1,000,000 Liabilitymaximum DESCRIPTION OF OPERATIONS 1 LOCATKINS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Evidence of coverage CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUBIG INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO So SHALL To Whome it may concern IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. [=7�7VE- ACORD 25(2001108) V 0 ACORD CORPORATION 1988 Client#:65859 JGCAINC ACORD- CERTIFICATE OF LIABILITY INSURANCE o7io9v107109D/YYYY) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION HUB International New England ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 299 Ballardvale St HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Wilmington,MA 01887 978 6575100 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Travelers Indemnity JGCA,Inc INSURER 8: c/o Great North Prop Mgmt INSURER C: P O Box 1480 INSURER D: Newburyport,MA 01950 INSURER I? COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR AWL LTR TYPE OF INSURANCE POLICY NUMBER DATE(UM/DnfM POLICY EFFE POLICY EXPIRATION LIMITS GENERAL LIABIL 17Y EACH OCCURRENCE $ COMMERCIAL.GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS MADE F-1 OCCUR MED EXP (Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GENS_AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY JE�CT F1 LOC AUTOMOBILE LIABILITY COLIED SINGLE LIMIT $ ANY AUTO (Ee ALL OWNED AUTOS BODILY INJURY $ - SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Peraccident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO EA ACC $ R- OTHER THAN AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR E1CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE RETENTION $ $ A WORICERS COMPENSATION AND 6KUB0354860409 01/01/09 01/01/10 X I WCSTIA orH EMPLOYERS•LIABILITY ANY PROPRIETOR/PARTNER/EXECUTVE E.L.EACH ACCIDENT $500,000 OFFICERAAbe and EXCLUDED? E.L DISEASE-EA EMPLOYEE $500,000 ff PRO under E.L.DISEASE-POLICY LIMIT $5OO OOO SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS No.of Days;10 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Millpond Homeowners Assoc. DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL _i0_ DAYS WRITTEN 123 Millpond NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO So SHALL North Andover,MA 01845 IMPOSE NO OSUGATION OR LIABILITY OF ANY IUND UPON THE INSURER,rrS AGENTS OR REPRESENTATIVES. AUTH REPRESENTATIVE_�— ACORD 25(2001/08)1 of 2 #S215305/M215165 /ew/ rV7/� WR001 0 ACORD CORPORATION 1988 Board of Building Regulations and Standards b One Ashburton Place - .Room 1301 Boston, Vlaswhusetts 02108 Home hnprovemer Ctractor Registration Registration: 155890 ,_.;,, :.~'.: pi• ,,E __ =;`:-' "� "� 'v.. ..... Type: Individual �w :.^. .. t. ry�j ,�r MARK Expiration: 5/1512009 Trli 255443 AUDETTEUDETTE ,� � � :__ -� MARK A .�<: �'�,_���� ' gg . 18 HIGH RD. NEWBURY, MA 41951 DPS-CA1 Update Address and return ca .Marls reason for change. 9GM o5/D6PC84sG rd Address � Renewal F-1 Employment F-1 Lost Card �e •�,,,ow;,kueal�la v�✓�cra/�.rurB.Cl� Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Re$_Istr;t[ >ii':_145890 Board of Building Regulations and Standards ..Nm rte 1512U09 Tr# 255443 One Ashburton Place Rm 1301 Boston,Ma.02108 r hR )4dual MARK AUDETTE� ; err ') MARK AUDETTE' 18 NIGH RD. NEWBURY,MA 01951_ A4,*.il*ator Not valid without signature T 'd XFi3 13r?J3SLJ1 dH WHa T : T T LOOZ 92 ReW ` FORTH '9 T0 0 : Andover No. -� ©L .,over, Mass . p o COC MIC ME WICK V ORATED BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING.INSPECTOR THIS CERTIFIES THAT (... .......W LtM�11��.... .....40 .! . . A..h� ' ......... .. Foundation has permission to erect........................................ buildings on ..............9 ........ . .. / �A..640 ....................... Rough to be occupied as.. Chimney provided that the p son accepting this permit shall in every respect conform to the terms of the application on file in Final 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMr r EXPIRES IN 6 MONTHS Final ELECTRICAL INSPECTOR UNLESS CONSTR N STARTS Rough Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. SEE REVERSE SIDE Smoke Det. The Commonwealth of Massachusetts Department of Industrial Accidents I ?.. Office of Investigations 600 Washington Street t BOstoiz , MA 02111 www-mass.gov/dia Workers' Compensation Insurance.Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibiy Name (Business/Organization/individual): , r eU�b � PAC Address: �� K I`t City/State/Zip: V Phone #: —�-� Are you an employer?Check the appropriate box: 1.❑ I am a employer with 4. ❑ I am a general contractor and IF7. [] roject(required): employees(full and/or part-time).* have hired the sub-contractors w construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet ode' ship and have no employees These sub-contractors have olition working for me in any capacity. workers'comp. insurance. o workers' comp. insurance 5. 9• ❑ Building addition [N p. ❑ We are a corporation and its required.] officers have exercised.their 10:❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No.workers' comp. c. 152, §1(4),and we have no 12.[] Roof repairs insurance required.] t employees. [No workers' com . in 13.❑ Other p surance required.] *An a licant that checks Y o box#1 must also fill out the section below showing then workers'compensation policy information. +t'lUIl1CUlVne[s WIIG silbnlll thlS ai�.'davit£lld'eat£r£t Uie-A al'c uu£Ii-0 ii+Ctrk and then hire outside eonlriiclors Ifnlsl submit a now atiltiavit indicatmg such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.Policy information. I am an employer that is providing workers'compensation insurance for vq'employees. Be information. low is the policy and job site ---� Insurance Company Name: Policy#or Self-.ins. Lic.#: J Z Expiration Date: e2 Job Site Address: City/State/Zip: 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 an 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. Be advised that a copy of this.statement may be forwarded.to the Office of Investigations of 1A for i nce coverage verification. 1 do hereby c nder a d ehaldes of perjury that the information provided above is true and correct Signature: Date: OF Phone#: �c7 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association, corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and includiri.g the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit,to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptatile evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority.". Applicants Please fill out the workers'compensation affidavit compi etely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractors)name(s), address(es) and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. Theaffiidavit should be returned to the city or town.that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the nurnber:iisted below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/hcense number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)." A copy of the affidavit that has been officially starnped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn'leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to.thank you in advance for your cooperation and should you have any questions, -please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26=115. Fax 4 617-727-7741 wwvt.mass.gov/did