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HomeMy WebLinkAboutBuilding Permit #14 - 99 MIDDLESEX STREET 7/6/2007 NORTH BUILDING PERMIT aFt��.o �e�'�'p �� 4` ' TOWN OF NORTH ANDOVER o L APPLICATION FOR PLAN EXAMINATION Permit NO: G Date Received �,y"�R,T , SSACHU`�E Date Issued: Q' IMPORTANT: Applicant must complete all items on this page WE dal MAIC xt 1XCEL 3 �C TR„�T hllO�tkIS1"Rl T TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial 20'Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 5 ttc I la ` C g lc dpa n aVY( tta ds � l ”c 7 1 ft z � a DESCRIPTION OF WORK TO BE PREFORMED: !CeV­AACe_ Com%n&�M C.e n VAc t c q Identifica ion Please Type or Print Clearly) C3 OWNER: Name Falv'1 k -.vinY1 ,..iCC\ascckl1d Phone: ('7� Address: 4K CX3� CT lPhorl Y9; ,.. ; d 3l ?ervISOt�S stt tctio t��tse z. xo H, lrnpr ert�er Ll�er� e� 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: $ , 6UC , cc-, FEE: $ Check No.: Receipt No.: 0371 NOTE: Persons contr cting it unreged contractors do not have access to the guaranty fund Signature of Agent/Owner ignature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED C ED DATE APPROVED O ED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS 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 ❑ honing 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 Located at 384 Osgood Street Fli lh'kr"1EPAR tVIENT�-Ter p�umpste:on sjte yes no ¢ai ertsign11! Fte ep ' y COMlIENTS,. 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 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 o 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 Addition Or Decks ❑ Building Permit Application L3 Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses o 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 New Construction (Single and Two Family) o Building Permit Application Li Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit L3 Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) L3 Copy of Contract o Mass check Energy Compliance Report o Engineering Affidavits for Engineered products 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:INSPECTIONAL SERVICES DEPARTMENTMITORM07 Revised 2.2007 Location 7 / 'ell u AA SIA No. Date0 7 JI NORTH TOWN OF NORTH ANDOVER 4L Certificate of Occupancy $ Building/Frame Permit Fee $ S7 s�cMus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ nn Check #o + 2G � � � 7 Building Inspector The Commonwealth of Massachusetts Department of Industrial Accidents Ogee of Investigations 600 Washington Street Boston, MA 02111 i Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers u des/Contrac Applicant Information tors/Electricians/Plumbers Please Print Le ibl Name(Business/organization/Individual): Address: City/State/Zip 1E�'�� 7� ?c� �.(•- Phone#: �i Aree Y n employer?Check the appropriate box: 1 31 am a employer with 'a�- 4. ❑ I am a general co Type of project(required): employees(full and/or part-time).* have hired the sub-co ntractorsl 6• ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet._ ship and have no employees ?• Remodeling These sub-contractors have working for me n any capacity, workers'COMP. ' 8• E]Demolition [No workers'coin . ' P ��OC' 9. E]Building addition p insurance �5. ❑ We are a corporation and its required.] officers have exercised their 10•0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemptibti per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp, c. 152 1(4), insurance required.]t employees. )'ando workers, no [N 12.0 Roof repairs comp.insurance required.] 13•❑Other *Any applicant that checks box#I must also fill out the section blow showing their workers'compensation policy information. t Homeownas who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicatings 1Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. such. Ifo an employer that is providing workers'compensation insurance for my employees: Below is the policy and'ob site information. . J Insurance Company Name: ( Policy#or Self-ins. Lic.#: Expiration Date: / rJ Job Site Address: P Attach a copy of the workers'compensation policy declaration a e City/State/Zip: tV,• yl �C��p�j (�`� �� ng Failure to secure coverage as required under Section 25A of MGL . 52 caned to the imposition e policy bof criminal penaer and l ti datea r fine up to$1,500.00 and/or one-year imprisonment.as well as civil 1 penalties of a of a STOP Of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded t��RDce of d a fine Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true S i nature and correct (� a Date Phon #: ZS O lcial use only. Do not write in this area,to be completed by city or town ufj9ciai: City or Town: Permit/License# Issuing Authority(circle one): I. Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ACORD� CERTIFICATE OF LIABILITY INSURANC DATE E 07/06/2007 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION NORTH ANDOVER INSURANCE AGENCY, INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 9 WAVERLY ROAD ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. NORTH ANDOVER MA 01845-2415 INSURERS AFFORDING COVERAGE INSURED INSURERA:CITIZENS INSURANCE CO Michael Rodden INSURER B:HANVOER INSURANCE 47 Prescott Street INSURER C:AMERICAN INTERNATIONAL GROUP INSURER D: North Andover MA 01845— 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. INSR TYPE OF INSURANCEPOLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LTR DATE MM/DD/YY DATE MM/DD/YY LIMITS A GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X �TLAIMSMADE ERCIAL GENERAL LIABILITY FIRE DAMAGE(Any one fire) $ 300,000 FX OCCUR ZBN 8605683 02/01/2007 02/01/2008 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ 2,000,000 POLICY JECT LOC B AUTOMOBILE LIABILITY ADN 8336670 07/16/2006 07/16/2007 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS / / / / BODILY INJURY X SCHEDULED AUTOS (Per person) $ 100,000 HIRED AUTOS / / / / BODILY INJURY NON-OWNED AUTOS (Per accident) $ 300,000 PROPERTY DAMAGE (Per accident) $ 100,000 GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO / / OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS LIABILITY / / / / EACH OCCURRENCE $ OCCUR FICLAIMSMADE AGGREGATE $ $ DEDUCTIBLE RETENTION $ $ WORKERS COMPENSATION AND / / / / TORY IMITS DTH- EMPLOYERS' ERLIABILITY X E.L.EACH ACCIDENT $ 100,000 C WC1760133 01/01/2007 01/01/2008 E.L.DISEASE-EA EMPLOYEE $ 100,000 E.L.DISEASE-POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER ADDITIONAL INSURED;INSURER LETTER:_ CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT TOWN OF NORTH ANDOVER FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OFA PON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE NORTH ANDOVER MA 01845- ACORD 25-S(7/97) ©ACORD CORPORATION 1988 W TM INS025S(ssio).oi ELECTRONIC LASER FORMS,INC.-(800)327-0545 Page 1 of 2 ` NORTIy Town of And o dover, Mass., If, COCMI-...':K V^ �OOATED PPG �� �7 4 BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System "00 • • BUILDING INSPECTOR THIS CERTIFIES THAT........ ... o. ` ..G........ C � . . . . oundation SO has permission to erect ....................................... buildings on ...... . ......... .. ....�.. .. .5�... Rough to be occupied as f..' *.. w.�.....� I. 5.........-..... 5�4*14.. ........... . . Chimney Ch' provided that the person accepting this permit 23i�ect conform to t e terms of the application on file in Final this office, and to the provisions of the Codes angpto 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 ., 70 PERMIT EXPIRES IN 6 MONTHS Final ELECTRICAL INSPECTOR. UNLESS CONSTRUCTION ARTS Rough ......... ......##/ . Service L G INSPE 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.