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Building Permit #880-11 - Bldg-7A-Groupe Schneider 6/21/2011
C?ao_ Permit NO: BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received, �v'tt�eo ,6�•ry�\ 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 _ T%j� / 'in'" 'l Yea' $r p tic Ulleilfv nib "G S{ A<; 4":. "4 i 4 rci ? 1 .' ,m Flood Iain : Wetlantls 4 A 9 IN atershel Dis#rict .�tkz pyo/ F. ,rE !�a „,, 7f C x '. '' "'zw-:* `a7*'3"' h?.., e k £ Y�Wa#mil(/,.ewer S-, '.�.� -.�fy M �„ r ,"k d .:^`� x'" '„G .'.$ a v� _";�sa-�' -s rin.,- �"% !$?b- ^ 4k $ .�. o"N ,i+ DESCRIPTION OF WORK TO BE PREFORMED: Ion or Ot � 0a L� 19-71d-011 we- wl' 11 40 X120 � Terl71 Cc' 4e.ider ,jech-lc &I 1 /-//,9h Stre.e-' ire /UorfA AA1Qj9Ve4- ReMOVAl cN�/f �� ova ��- ct%octf ��ag��//• Identification Please Type of Print Clearly) OWNER: Name: S c h h e tder Phone: CI7F-373 -9.- ARCHITECT/ENGINEER Mi'ck?oe I &Ou I ci Phone: 6 03 - ER3-�;32-6 Address:_1 9 dr-)Ve- 141hIS ,01034VgReg. No. FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. fis Total Project Cost: $ 2- 6 FEE: $ 2 Check No.: Receipt No.: -� 5'5° NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 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 DATE REJECTED DATE APPROVED 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 Watier & Sewer Connection/Signature & Date Driveway Permit Located at 384 Osgood Street �l Dimension Number of Stories: Total land area, sq. ft.: Total square feet of floor area, based on Exterior dimensions. 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 2 1 A —F and G min.$100-$1000 fine NOTES and DATA — (For department use ❑ Notified for pickup - Date Doc.Building Permit Revised 2007 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 o Building Permit Application o 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) u 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) o Building Permit Application ❑ Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses C3 Workers Comp Affidavit Li 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 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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 Location No. Date 7- 7--- "O*Tk TOWN -OF NORTH ANDOVER Certificate of Occupancy $ 5.2 Mus Building/Frame Permit Fee $ — Foundation Permit Fee $ Other Permit Fee TOTAL Check # 41 e-1 /-/ -> 242�t4 Building Inspector d Building Inspector co CD cr Go) EL Cl) CO2 c m o m C7 _v z H m•nC �• o y •.m m -So H .rt d o T C `C CD -I o o ti O --1 o o ®,y : CD p1 O �a o• � � : 'o~' 0 O n C y. C y n ca CD; CD Z yCD cm Q CL r CD CD Q CD Coo /0 p er . LU CL CA m O O C-) o a C v `D ►n H 7m0 CD (,� _� i CCD H : Z Q H H CD cr CD CD W co :\ 0 CD O CD ^^O ® D co w A WCD O O. Q CO) 0 _ W c co I v cn CD y CnCD •v Z Oq C!1 • o, CD •� C CD CL — C-) c2 CD CA 0 0 CCD b c C c o 41 { rD ° � O c Z w ° �:r, C CL ° (b n cn ° A tdrD oa pco~ d y H y � 41 { rD ° � O c Z w ° �:r, C CL t1 z (b n cn p r rb tdrD �J qN 0 0 y 0 Google Maps Page 1 of 1 To see all the details that are visible on the screen, use the "Print" link next to the map. Schneider Electric Equip. - www.grainger.com/Schneider-Electric - Get Electrical Supply from Square DA -bb; etan Report a problem http://maps.google.com/maps?rlz-- 1 T4GGLL_enUS345US345&um=1 &ie=UTF-8&q=sc... 06/16/2011 ZA m o. 5. im in L4 ZA m A ©' CERTIFICATE OF LIABILITY INSURANCE 8/30/2 0 ' 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 eertifieate holder is an ADDITIONAL INSURED, the policy(lies) 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 endorsements . PRODUCER Tebbetts Insurance Agency 4 Main Street Hollis NH 03049 NM1E Cr Seth TebbettS PHONE )465-3333 1 FAX No - (603) 791-4651 £ sethQtebbettsias.ccdn MUOU MCuomo 0000159 RMIRE14§1 AFFORDING COVERAGE NAICS INSURED Christian Delivery S Chair Seavice 18 Clinton Drive Hollis NH 83049 INSUR RA.Cit:izens Insurance Company of 31534 INsmme.11aanover Insurance Company.2292 RNsuRmc.CHARTIS INSURERD: RISK E 91suRERF: a,wcrcrauca L;r-m 1 1hICA f in I11ummi-m-Lui UIT.SUU Dy13 ocincrnar an tueco. 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, L!TRR OF INSURANCE AWLTYPE sve POLICY NUMBER POLICY LIMITS GENERAL LIABILITY EACH occuRRENcIs S 1,000,000 A X COMMERCIAL GENERAL LIABILITY CLAIMS MADE Q OCCUR Sr 4844353-43 /1/2010 /1/2011 PREMISES Ea $ 100,000 MED EXP one person) S 5,000 PERSONAL& ADV INJURY S 1'000,000 GENERAL AGGREGATE $ 2,000,000 GENLAGGREGATE LIMIT APPLIES FEILPRODUCTS-COMPIOPAGG 7X PR POLICY LOC $ 2,000,000 $ AUTOMOBILE X LIABILITY ANY AUTO COMBINED SINGLE LIMIT IEa ac idem $ 1,000,000 BODILY INJURY(Perperson) $ A ALN-OWNmAlITOS 716909 !1/2010 /1/2011 BODILY INJURY (Per accident) $ SCIiEDULEDAUT06 PROPERTY DAMAGE (Paraockimt) S HIREDAUTOS NON-OWNEDAUTOS Uninsuredm*WtstcwrMned $ 1,000,000 Meftal paymelds S 5,000 UNIBREIUlUA6 OCCUR EACH OCCURRENCE $ 4,000,000 JXRETENTION EXCESS UAB CLAIMS -MADE AGGREGATE $ 4,000,000 DEDUCTIBLE S 10 000 $ B 0844365-03 /1/2010 /1/2011 S (',, VJORKERS AND � FLITY Y!N ANYPROPM15TORWARRtERID(ECUTIVE OFFICEt1MEMBERE(CLUDED? El (MandztoryinNH) If yyaass�� describe under DESCR PnON OF OPERATIONS below NIA 9870539 /1/2010 /1/2011 WIC STATU• OTH- ER EL EACH ACCIDENT $ 11000,000 EL DISEASE -EA EMPLOYE $ 1 000 000 EL DISEASE -POLICY LIMIT $ 11000,000 DESCRIPTION OF OPERA71ONS I LOCATIONS I VFRICLE$ (Attach ACORD I t. Additional Rrm dm Sehedt ft Amore space Is raa$ted) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCq i BEFORE THE EXPIRATION DATE THEREOF, NOTICE VALL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHOREDREPRE$ENTATiVE ISeth Tebbetts/SAT ACORD 25 (2009109) 01988-2009 ACORD CORPORATION. All rights reserved. INS026 poosos) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): C J-1s5h jjl Vdi' erl +Cha/h Snryi1z, -1;,7e-. Address: 7 rn ity/State/Zip: N11 AJ -6 q9 Phone #: Z-03 -8,33- 5326 Are you an employer? Check the appropriate box: 1. [ I am a employer with ,9 4. ❑ I am a general contractor and I employees (full and/or part-time).* ❑ I am a sole proprietor or partner- 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 have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.$ 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 1.1.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. Other 'Ft-kI45' *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. 1 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: CA r h 5 Policy # or Self -ins. Lic. #: WG q976 5 3 9 Expiration Date: Job Site Address: 1 ITIq ki SJ1ece� City/State/Zip: IV, AA Daye.*- 14A als4�' 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 against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations 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, 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 #: 18 Clinton Drive, Hollis, NH 03049 603-882-1234 or 603-881-8833 fax 1-888-RENTENT www.intents.com email: sales@intents.com. GREG B CORPORATE CHEFS I 22 PARK RIDGE ROAD L L HAVERHI.LL TEL: (978) 373-9522 MA 01835 ORDER CONFIRMATION 16690-2 Pg: 1 EVENT DESC: LOBSTER BAKE EVENT DAY: TUESDAY DATE: 06/28/2011 EVENT TIME: DELIVERY: MON 06/27/201.1 PICKUP: WED 06/29/2011 SALES PERSON: JT PO#: ( y ORDER DATE: 04/26/2011 �Q 7 TERMS: NET 10 DAYS JA f Af FAX: (978) 975-9494 GREG (978) 373-9522 I IBELECTRIC H 1 HIGH STREET I NO. ANDOVER NH P QTY ITEM DESCRIPTION PRICE TOTAL 1 40'X 120' WHITE FRAME TENT(KT)--STAKED ON PAVEMENT 2,640.00 2,640.00 ' 80 FEET OF SOLID SIDEWALLS(BEHIND STAGE FOR PROJECTION) 1.00 80.00 1.20 FEET OF MESH SIDEWALLS (60' ON EITHER SIDE OF STAGE) 1.10 132.00 8 8' LONG X 14" HIGH BLACK STAGE SKIRT 8.00 64.00 1 STEPS FOR STAGE (15" HIGH) 25.00 25.00 1 08'X 16' STAGE (15" HIGH) 280.00 280.00 350 CHARCOAL "FAN BACK" FOLDING CHAIRS 1.25 437.50 10 8'X 30" BANQUET TABLES 8.00 80.00 44 5' ROUND TABLES 8.25 363.00 2 4' ROUND TABLES 8.00 16.00 12 l2' TENT FAN(CLAMP ON SIDE.POLES) 40.00 480.00 4 50' WHITE EXTENSION CORD. WITH PLUT EVERY 10 FEET 20.00 80.00 3 EXECUTIVE PORTABLE TOILET W/SINK 160.00 480.00 1 25% SET UP / BREAK DOWN FEE FOR TABLES/CHAIRS 224.13 224.13 1 FILL HOLES IN TAR 45.00 45.00 1 TENT PERMIT 150.00 150.00 SPECIAL INSTRUCTIONS: SUB TOTAL: 5,576.63 PLEASE SIGN CONTRACT AND RETURN FOR OUR RECORDS. THANK YOU FOR YOUR ORDER. 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