HomeMy WebLinkAboutBuilding Permit #919-14 - 96 OLD VILLAGE LANE 6/11/2014BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#:_�Iq Date Received
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION 7'
Print
PROPERTY OWNER
Print 100 Year Struct6re
MAP PARCEL: ZONING DISTRICT: Historic District
Machine Shop Vi
P0
yes 0
yes no
yes , no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
El New Building
El One family
0 Addition
0 Two or more family
El Industrial
El Alteration
No. of units:
El Commercial
El Repair, replacement
D Assessory Bldg
El Others:
El Dem-olition
0 Other
El Septic 0 Well
D Floodpla,in 0 Wetlands
0 Watershed District
11 Water/Sewer
L)t--bL;KIP I IUN OF WORK TO 13E PERFORMED:
/ 9, �& VC q r- P Lo 0/ a.2 U \Ad.
Identification - Please Type or Print Clearly
OWNER: Name:& _ Q -0,5k Phone: (0 Z-0
Address:
Contractor Name:
I Address:
Supervisor's Construction Li
Home Improvement License:
ARCHITECT/ENGINEE
Ph
__-Exp. Date:
Date:—
Phone:
Address: Reg. No.
FEE SCHEDULE. BULDING PERMIT. MOO PER $1000.00 OF THE TOTAL ESTIMATED COSTBASED ON $125.00 PER S.F.
Total Project Cost: $ FEE: $ 0
� S,
Check No.:QG53 9-b -10-7301 Receipt No': CxJ
NOTE: Persons contrVting with —INYq!�tractors do not have access to the guarantyfund
,mn5g
§jgnature of Agtqt/Owne[)(
/, _SJg�re_of_66_ntractor
h
0
Plans Submitted 11 Plans Waived 11 Certified Plot Plan [I Stamped Plans El
TYPE OF SEWERAGE DISPOSAL
2
Public Sewer
Tanning/1\4assage/Body Art
Swhnining Pools
Well
Tobacco Sales
Food Packaging/Sales El
Private (septic tank, etc. El
"
Pennanent Dumpster on Site
I
� n'j "�Wbj C./,
- N
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
LANNING & DEVELOPMENT Reviewed On Signature_ 64.4 --
COMMENTS
ONSERVATION Reviewed on U Signature
COMMENTS
HEALTH
COMMENTS
Reviewed
Zoning Board of Appeals: Variance, Petition
Planning Board Decision:
Conservation Decision:
K,11
Comments
Comments
Signature
kit
Zoning Decision/receipt submitted yes
Water & Sewer Connection/signature & Date DrivewaV Permit
V'
DPW Town Engineer: Signature:
Located 384 USg00d btreet
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)
�L� . , Oe , k-6,�-1-c,— �O
LJ Notified for pickup Call Email
Date Time Contact Name
Doe.Building Pennit 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
,,e Building Permit Application
Ei 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
Li 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)
ij Copy of Contract
u Mass check Energy Compliance Report
La 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
Doe: Building Permit Revised 2014
TOWN OF i'90RTH ANDOVER
01TICEOF
]BUILDING DEPARTMENT
:1600 Osgood Street 13ifflding 20, -Silite 2-36
Noth Andover, Massachus etta 0 1845
Gerald A, Drown
Inspector of Bildings TelePlLone (M) 688-9545
F�x (978) 689-9542
HOMMMER-LICENSE tUNip
APPLICATION
DATE-
�OB
Street
�10VMDWNER
M QL
Name. homo Phone
Workf�ona
PRESENT MAILING ADDPESSL —SQ N A --I
0?=M
(-'i!V TL'!M. v- Z- 14- Y-
z9ap cod-,
Th15 current exemption for llomeoWn
are' Was eXtenaed to inoluda owue
,r -or
10, allo"y Such homeo - d dw
I Iffiels to e 31UR-P to tvO units -Or Tess and
acts as supervisor). I n9age an inftividllal-f�r hire -Who doesa'at possess a -license, provided that the ovMer
gae"O'ding (COdeSocilon.108.3.5.1)
DEFINITION OF R02VMOWNER
Pl'--TsOn(s) who -gvms a parcel of land on which helshe resiaes oriutendstoresida, onw�i . ch there i or is jute
bb1aon`orfw01aM1YsftuGtL1res. A person who comtracts more. thatone homD .uded to
0011sidered a homeowner, in. atwo-yearpeli6d shall not be
The Undersigned "homedwaor"assumes, responsibility forcompliances with the State 13uildiag Cc,
APPlicable codes, bY-Jaws, Mes and -regulations do and other
Thotmdersigued,,homeov,me
ce'rt,
'fies that
Miniinum inspection Procedures and re - he/she lmdergtauds the Tow*n of North AndoverBuilding Department
-requireinents, quiromeats and that he/she will c0n2P1Y With,said proceduras and
-UO1vM0WNP-RS SIGNATURE
A�PROVAL OF BUILDIRG oFFIcIAL
Revised 7.2009
Homeowners Exemption
.13DARD OF AIPEALS'688-9541 CO3\TSERVA-fl0N 689-9530 MALTH 689-9540
PLANNING 689-9535
The Commonveafth ofMassachuseft
Deparftne-nt of1kdifsNq1,4cc!d&fs
Office ofluvesfigations
60 0 Washington Street
Boston, MA 02111
vmmuss.govIdia
Workews' Compewation Ymurance Affidavit: BuRders/Contr.actorslElectri , clans/Plonbers
A ormation Please Print LeAk
pplicant 1hf
Name (Business/Oxganizationftdi-vidual)' I
2�
City/Statc/Zp: Phone #;
Are voix an employer? Check ffie appropriate box:
F1 I am a employer with _ 4. F] I am a general contractor and I
empl aes &H and/or have hired the sub -contractors
OY part-time
2.E] I am a sole proprietor or Pfftner-
ship and'lavano.employeos�
worling for me, in any capacity.
[No work -ors, comp. ;Jisurauco
requRed.]
I am a homeowner 40ng all work
myself. LEO workays, comp.
insurancareqa1re4.1 Ti
listed on the attached shoot.
These sub -contractors have
workers' comp. insurance.
5. El We are a corpora�on and its
officers have exercised.1heir
.Tight of exemption per MGL
c. 152, §1(4), and we have no
employe6s. [No workers,
comp. insurancereqaired.]
Type of project (reqidred):
6. E] Now construction
7. [] Remodeling
S. E] Demolition
9. Building addition
1011 Electricalrepairs or additions
ll.[] Plumbiagrepairs or additions
l2.Q RoDfr6pairs
is.0 other
"Any applicant that &ecks box M must also fill out the section be16wsho-wmgtfte1rW0r1C6r3' COMPMMUOILP011GYMolmatloll.
fi-Torneownersw1io submit ihisaffldavitfndicathit�,,Yk�dgingaUworR and then hire outside contractors must submit a now affidavit indicaffigsiibb.
TCoutractD.rg that checkthis box must attached mialddiflonal, sheet sfiowingtho name of the sub: -contractors and their workers' comp.polloyinformation.
fam an employer aaaspoviding workers'compensation insuranceformy employees. Be-loW 1�s thepolley andjoh site
information.
Insuxance, Company N
Policy # or Self -ins. f-io.
RTiration Date:
lob Site Address: -Pity/State/Zip:
Attach a copy of the workers' compensation -policy aeclaration page (showing the policy number and expiration date)
Failmato, secure coverage.as regpiredunder Section 25A ofMGL o. 152 can leadto theimposition of crimlaal penalties of a
Rue up to $1,500.00 and/or one-year Mprisonment, as wellas civilpenalties in the form of a STORWORK ORDER and aflae
ofupto$250.00 a day against the, violator. Be advised that a copy of this statementmay be, forwarded to the Office of.
Investigations of the DIA for insurance coverage verification.
eandeoyeet,
.palhi�andjpenaftles qfperju.-y Mat the infoTmationprovide
fdo herelby ceyttp
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers, compensation for thek employees.
Parsua�t to this statute, an enz
,ployee is defffied as ..every person Tri the servic of o er d a yco t
express or Implied, oral or wxitten.,, 0 an th un or n iitrac ofir1ra,-
An employeiis defined as "an individual, partnership, association, colpoxation, or other legal entity, oranytwoormoye
of the f6r6jolug engaged in ajoint enterprise, and including the, 10gal.76FOsentativas of a:deceased emplo
ya; or the
redelv6r or'. taistee'6f an individual, -partnership, askciation or other legal entity, employing em�ployees. jjo��aver th6
owner of a dwelling house having notmore than three apartments and who resides therek, or Me, occupant of the
dwellinghousa of another who employs persons to do maintenance, construction orrepair workon su6h dwelling house
or on the grounds or building appurtenant thereto shall. not becauso of such emploYment be deemedto be an employer.,,
MGL chapter 152, §25C(6) also states that "every state or lo'cal lie-ensing 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 -acceptable evidence Of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states'Weithor the commonwealth nor any of its political sub divisions shall
enter into any contract for the p erfortnanco ofpublic work until acceptable evidence of complipco, with the insurance
requirements of this chapter have beenpresented tat the GQatractiug authority."
Applicants
Please fill out the workers, c i
ompensallon affidavit completely, by chec;l�ng tho boxes that apply to your situation and, if
.Uece,gsa*� supply sub-contractor(s) name(s), address(es) andphono munber(s) along with their cortificate(s) of
insurauco. Limited Liability Companies (LLQ or Limited Liability Partnerships (LLP) with no employees other than the
members or p�rtnars, are not required to carry workers' compensation insurance. If an LLIC orLLP does have
61UP10YOPS,apolicyisrequired. Be advised thattfii� affidavit maybe submitted to the Department of Industrial
Accidents for con&ma�tlonof hisurance coverage. Also be sureto sign and date the affidavit. ile affidavit should
be, r0tumcdto the city or town that th6 applicatign for the permit orlicenso is being reqaaAqqnot the DopJartment of
Industrial Accidents. Shouldyou have any questions regarding the law orif you are requriedto obtain a*arkersl
con�pcnsatlonpoliqy, please call the Department at the -number listed below. Scif-insured companies should outer their
self-insurance, license nmnber on the appropriate lino.
City or Town Officials
Please, be sure that tho affidavit is complete andprinted"legibly. The Department has provided a space attho bottom
of the affidavit for you to fill out in tha event the Office of Invo tig ons ha o co t t yo gr g p t.
8 at! st n ac u re a din the a plican
Please, be -sure to fill inthe pennit/license, number whichwiff be used as a reference number, In addition, an applicant
thatj�ustsubmitmultipla permit/license applications ia any givenyearneed only submit one, affldavit indicaffig cutr6nt
policy hafonnation (if necessaty) and under "Job Site Address" the applicant shouldwrite "afflocations 1u_____�(cjty or
tow,r)." A: 6o,
py dthe afff davit that has been offloially stamped or marked by the city or town may be provl4d to the
applicant as Proof that a valf d affidavit -ii on RIO �Or fUtWO Pelmits or licenses. Anew afff davitm�stbo MeLd out each
year. Where a �oma owner or citizen is obtaining a license oi�enuft not related to any business or commercial venture
(i.e. a dog license orpermitto burn leaves afti.) said person is NOT required to complete this affidavit.
The Office Of TllVeSggations . wouldlike, to thankyouin advance for your cooperaflon and shQuld yqu have auyguestio�s,
please do not hesitE6 to give us a call.
The D op artmenes address, telephone ajad fax number:
Tho Cm -moa
DPT aximent of Indu*ial Accidenta
office of IRVOWO-001mg
6bQ Wa�blggtm
B C) Ston, 9-A 02111
TOL # 617-7-2Z49,00 W 406 QX- 1-877�WASWI g
Revised S -26 -OS Fay,# 617-727-7749
2
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North Andover MIMAP
June 11, 2014
79 OLD VILLAGE L N
125 OLD VILLAGE LN
059.0-0058
059.0-0059
046.0-0090
059.0-0060
89 OLD VILLAGE LN
046.0-0088
0 9.0-0064
103 OLD VILLAGE
LN
046.0-0089
0 .0-0092
4
76 OLD VILLAGE LN 58 OLD VILLAGE LN
059.0-0063
260'
40
-4
01A - '86 OLD VILLAGE LN 059.0-0062
114 OLD VILLAGE LN 119,
059.0-0061
96 OLD VILLAGE LN —
100 OLD VILLAGE LN 046.0- 0 095
046.0-0093
046.0-0094
64�'.' 008
Rail Line
Interstates
Horizontal Datum: MA Stateplace Coordinate System, Datum NAD83,
Roads
I: i Easements
q4ORTN
16'.
6 0
Meters Data Sources:, The data for this map was produced by Merrimack
Valley Planning Comm ssion (MVPC) using data provided by the Town of
North Andover. Additional data provided by the Executive Office of
Environmental Affaim/MassGIS. The information depicted on this map is
for It for
0 MVPC Boundary
C310unicipal Boundary
0
p-
planning purposes only. may not be adequate legal boundary
definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER
MAKE NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING
S
0 Parcels
4lL
THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY
OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT
C' Hydrographic Features
0
ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF
-- Streams
THIS INFORMATION
.1 Wetlands
CHUS
C2 Exempt Lands
1" 94 ft
Print
Ownerl OSULLIVAN FAMILY TRUST
Owner2
C/O EDNA ROSA
Address
96 OLD VILLAGE LANE
PropertyID
046.0-0095-0000.0
Lot Size
27442.8S
Fiscal Year
2013
Land Use Code
101
Last Sale Date
41208
Book/Page
1076
Total Valuation
$474400
Building Type
CL
Year Built
1969
Finished Area
2355 sq. ft.
Assessor Map
NorthAndoverAssessorMap46-26x36.pdf
More Info:
Click here for Assessor website
Water Tie: VILLAGE—LANE-0096.pdf OLD
VILLAGE—LANE-0096.pdf
Page I of 1
http://mimap.mvpc.orgINorthAndoven-nimaplldentify.aspx?datatab=ParcelBasic&id=O46.... 6/11/2014
Client#: 65690
I Z 11111RA-1r, P
ACORD,. CERTIFICATEOF LIABILITY INSURANCE
FDATE (MMIDDNM)
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED 13Y THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
1 6/02/2614
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.
I
IMPOFITANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the tenns 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
People's United Ins. Agency CT
One Goodwin 6quare
Hartford, CT 06103
860 524-7600
CONTAcT Karen Dispo
NAME:
H
I C�N E., IFAX
LA N E,): 860 524-7660 (AIC No): 860 722-7728
E-MAIL
ADDRESS: KD!sipio@rcknox.com
INSURER(S) AFFORDING COVERAGE NAIC #
INSURER A: American Casualty of Reading PA 20427
INSURED
NAMCO LLC
100 Sanrico Drive
Manchester, CT 06040
INSURER B: Commerce and Industry Insurance 19410
INSURER c: First Liberty Insurance Corp 335H8
INSURER 0: Continental Casualty Company 20443
COMMERCIAL GENERAL LIABILITY
X COA
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: RFVISInN NUMRFR-
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 13Y 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
LT
TYPE OF INSURANCE
ADDLSUBR
INSR
WVD
POLICY NUMBER
POLICY EFF
(MMIDDNWY)
POLICY EXP
(MMIDDffYM LIMITS
A
GENERAL LIABILITY
6012699384
D6/01/2'014
06/0112015 EACHOCCURRENCE $11000000
COMMERCIAL GENERAL LIABILITY
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PRE ES 1:000:000
CLAIMS -MADE OCCUR
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MED EXP (Any one person) s5,000
PERSONAL & ADV INJURY $1,000,000
GENERAL AGGREGATE s2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG s2,000,000
POLICY 0 PRI
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$
D
AUTOMOBILE LIABIL17Y
6012699370
6/0112014
MBINED INGLE LIMIT
06/01/2015 (CEO .. dents S1,000,000
X ANY AUTO
BODILY INJURY (Per person) $
ALL OWNED SCHEDULED
AUTOS AUTOS
BODILY INJURY (Per accident) $
NON -OWNED
X
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HIRED AUTOS AUTOS
PR tDAMAGE
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$
B
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BE44196638
06/01/2.014
06/01/2015FACH OCCURRENCE s20.00O.00O
EXCESS LIAB
CLAIMS -MADE
AGGREGATE s20,OOO,OOO
DED I X1 RETENTION$110000
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$
c
WORKERS COMPENSATION
WCJZ914275780213
09/3012'013
1OTH-
09/30/2014X 1TW3CRSyTuATmUhs I IER
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETOR/PARTNERiEXECUTIVEr---I
E.L. EACH ACCIDENT $11,000,000
OFFICERIMEMBER EXCLUDED? I NJ
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tL- DISEASE - EA EMPLOYEE $1000 1 000
S6 describe und r
D RIPTION OF OPERATIONS below
DISEASE -POLICY LIMIT 0;1000
D
Direct Damage
RMP5087052655
06101/2014
06/0112011 $55,977,000 Per Occ
Property
DESCRIPTION OF OPERATIONS /LOCATIONS I VEHICLES (Aftach ACORD 101, Additional Remarks Schedule, if more space is required)
Physical Damage Deductibles; Comprehensive and Collision:
$2,000 (heavy, extra heavy and tractors)
$1,000 (PPTs, trailers, ligqt and medium weight trucks)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Evidence of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
I ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
,04& ok*d,��OAAW
1988-2010 ACORD CORPORATION. All rights reserved.
ACORD L25 (2010105) 1 of I The ACORD name and logo are registered marks of ACORD
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Location 6� C)
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TOWN OF NORTH ANDOVER
Certificate of Occupancy
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee
TOTAL
Check #YZ2c)53"-�0-1
2 6' 7
Building Inspector