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Home My WebLink AboutBuilding Permit #782 - Bldg-7A-Groupe Schneider 7/1/2008BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: W2- . Date Received DESCRIPTION OF WORK TO BE PREFORMED: l®' X zIS`' Please Type or Print Clearly) OWNER: Name: Phone: 9�F= 9 7`-- 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: $ z�S FEE: $ Check No.: 116 -To Receipt No.: �;?/2r-7 NOTE: Persons contractiZwunregistered contractors do not have access to the guaranty fund r Signature of Agent/Owner Signature of contractor/��Z� Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS 1-1 J 0 DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED IN 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 ❑ Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments :1 1. Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit Located at 384 Osgood Street 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.s100-$1000 fine 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 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 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 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 %f /�'�` No. 7,f Date TOWN OF NORTH ANDOVER TOTAL $ �: Check # %/G D 2 i 289 tsuil ing Inspector P , Certificate of Occupancy $ �'� s'•••° tt� 4CMU 5 Building/Frame Permit Fee. $ 3y Foundation Permit Fee $ Other Permit Fee $ TOTAL $ �: Check # %/G D 2 i 289 tsuil ing Inspector P R o 5 m S 5 5 -n o � o �, D m z 0 5 5 v 5 � cn �' � o �� 5 5 Z �' �2 WDA 5 S 5 5 od SL o � cn �' a« �,�rn 51 z0 5 5 D� C. W — Z 0° Z -m-Iv O n CD Z fJ 5 5��' �' �o�NN. CL m DeoCD M 5 5 -,j �z O �� 3 3 �Qa) f D D 0 � z0 x � � n 00 -n f CD rt_ � N cD M o-0 z D �: 0 o b =v ^' �. -* Q co m 3 o s'uc rr �x ai x * � ��_a m CD i O 0 0 cr 5 Cl)a 0 z =� N Mn 5 m0 cn ' �'Z�0 U) -•, ., n a) a �`D�Z< Z D m 0� �D 5 5 cn _ �D0� :r 2) CD07o0( �CD_j< Z C p CD 3 < f D O= C o cn r m cn o 5 5 .� -� C �(D . m H -SC 0� 5 5 ° v_ � = � 0- cn m� co �2) Cn CD Q( =D Z� o 5 CD _ c o r -., m -n A A r Z r � Q. z 5m =.;o �W nO 3 CD _ mcn� N 5 5� o�� CL5m `° C Z 5z �o a, , � CD % S 0 �. Q. fD' �' m v �/•� 5 50 5 0 ; 2 0 O o S 50 � �� A �� 5 5 5� � a) N z 3 Lu N 5 00 5 5N CD Cr a S 5 5 � 'CL C 5 5 5 5 5 The Connnonwealth of fassachuseas DeparIMent of Industrial Aecidents C�Rce oflit vestigations ' 60t7 IYashbigaton Street Roston,.MA 02111 1 wWw.nlass.go1r/d!a Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plluml;�(!1::;i :in c. -ant Information _ Please PriniI Lel?:fall Nallie LBusiness.oi-Qanization:lndividual): Addre!::,s:_— City/State/Z:ip: 1A i1/1 C 17 -e -S Phone #: Are your an employer? Check the appropriate bo:c: I . K-1 arra a employer with Q—� -O 4. ❑ 1 am a general contractor and I eml:Aoyees (full and/or part-time)." have hired the sub -contractors 2. ❑ 1 ani a sole proprietor or partner- I fisted on the attached sheet. ship and have no employees "These sub -contractors have working for me in any capacity. Workers' comp. insurance. [No workers' comp. insurance S. ❑ V e are a corporation and its required.) officers have exercised their 3.11 1 ain a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §](4), and we have no insurance required.]'t employees. [No workers' cxamp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 4. ❑ Building addition 10.❑ Electrical repairs or a:..dd itiom I l .❑ Plumbing repairs or add irions 12.❑ Roof repairs r 'Any applicant that checks box # 1 must also fill out the section b-:1a•w showing their workers' compensation policy information. -� t Homeo%,-wrs who s.ibmit this affidavit indicating they are doing all work: and then hire outside contractors must submit a new affidavit indicating ,scot'! i. Contractors that cheek this box must attached an additional. sheet showing the name of the sub -contractors and their workers' comp. policy infor eLtion I ani an eirrployer that is providimg workers' coniperu ation insurance for my employees. Below is the policy acrd job :ri; i;! informatiat r. , Insurance orripany Name: Policy # or;self-iris. �Liic. #: Job Site Address: !/ a - /z/ (p ��% -��a 7 Expiration Date: Aj 9 U City/State/Zip: Attach a copy of the workers' compensation polity declaration page (showing the policy number and expiration d;! Failure to secure coverage as required under Section _) 5A of MGL c. 152 can lead to the imposition of criminal penalties .),fa fine up to 911,500.00 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. Ido Irereb)- certif , under the pains and penalties of perjuty that the information provided above is true and correct. Signature: L Date: #: Official Use on/r. Do not write in this area, to be cesirrpleted by cirl, or town official. CRY or T'own: Permit/License # Issuing ,A athority (circle one): 1. Board. of !Health 2. Building Department 3. City/Town Clerk - 4. Electrical Inspector 5. Plumbing Inspector 6. Other • A00RD,_ CERTIFICATE OF rcItKYAKI LIABILITY INSURANCE DATEaMmDjyyyy) PRODUCER 10/03/07 USI Ins. Services of MA, Inc. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 12 Gill Street Suite 5500 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, PO Box 4043 GENL AGGREGATE LIMIT APPLIES PER: EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Woburn, MA 01888-4043 GENERAL AGGREGATE 12 000 000 INSURED POLICY PEO- LOC INSURERS AFFORDING COVERAGE NAIL # Peterson Party Center, Inc. INSURERA St. Paul Fire and Marine Insurance C 24767 139 Swanton Street AUTOMOBILE LIABILITYBINDERMA00200328 INSURER e: North River Insurance Co. 99999 Winchester, MA 01890-1918 10/03/08 INSURER C: Commerce & Industry Insurance Compan 19410 ANY AUTO INSURER D: - COVERAGES INSURER E: 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 MAY PERTAIN, WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SU POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN BJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS REDUCED BY PAID CLAIMS. OF SUCH -TR NSR A TYPE OF.INSURANCE GENERAL LIABILITYBIND POLICY NUMBER POLICY EFFECTIVE DATE MM/DDlYY POLICY EXPIRATION DATE MM/DD/YY LIMITS X COMMERCIAL GENERAL LIABILITY BINDERCK00219639 10/03/07 10/03/08 EACH OCCURRENCE $1 000 000 X NON -OWNED AUTOS CLAIMS MADE R OCCUR BODILY INJURY DAMAGE TO RENTED $100000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES/ EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS Re: Insured's operations renting equipment for business & social functions, including erecting tents. Statutory cancellation of Workers Compensation is 10 days. GSA -Boston Courthouse, BCMA LCC, Urban Retail Properties, their affiliates and designees are additional insureds on General Liability. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 40 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR ACORD 25 (2001/08) 1 of 2 � #S177924/M177923 AGDCD 0 ACORD CORPORATION J88 MED FRCP (Any one person) $5000 PERSONAL d ADV INJURY $1 000 000 GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 12 000 000 POLICY PEO- LOC PRODUCTS - COMP/OP AGG $2,000,000 A AUTOMOBILE LIABILITYBINDERMA00200328 10/03/07 10/03/08 ANY AUTO COMBINED SINGLE LIMIT ALL OWNED AUTOS (Ea accident) $1,000,000 X SCHEDULED AUTOS BODILY INJURY X HIRED AUTOS (Per person) $ X NON -OWNED AUTOS BODILY INJURY (Per accident) S PROPERTY DAMAGE GARAGE LIABILITY (Per accident) $ O ANY AUBRELrTJ.L AUTO ONLY - EA ACCIDENT g OTHER THAN EAACC $ B - EXCESSAIMITY BINDER5530892346 AUTO ONLY: AGG $ X OCCUR10/03/07 MS MADE 10/03/08 EACH OCCURRENCE $5000000 AGGREGATE $5 000,000 DEDUCTIBLE $ X RETENTION $10000 $ C WORKERS COMPENSATION AND EMPLOYERS' UASIUTY BINDERWC5310744 10/09/07 10/09/08 $ X WC STATU- OTH- ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L. EACH ACCIDENT 1500,000 Yes describe under S PRO SPECIAL PROVISIONS below ' E.L. DISEASE - EA EMPLOYEE 5500,000 OTHER E.L. DISEASE -POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES/ EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS Re: Insured's operations renting equipment for business & social functions, including erecting tents. Statutory cancellation of Workers Compensation is 10 days. GSA -Boston Courthouse, BCMA LCC, Urban Retail Properties, their affiliates and designees are additional insureds on General Liability. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 40 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR ACORD 25 (2001/08) 1 of 2 � #S177924/M177923 AGDCD 0 ACORD CORPORATION J88 Board of Building Regulations and Standards Construction Supervisor License License: CS 60219 Birthdate: 4/27/1954 Expiration 4/27/2009 Tr# , 11766 - Restriction: 00 MARK TRAINA 33 HANFORO RD STONEHAM, MA 02180 Commissioner r� I� CA M co W x o o O w a v v1- U P-4ow W O w O cG ..0 U G w � ua w Q. p a G w a O W W p w v (n �+ G w' v � O c�4 � G x z w W G � cn z i cn Q o cn E Q. N O N C O �a O) m cm C m `o cm c N m t O Z O CD zoo M� w U 12 .Z4 P4 O CD L O Z co CL O CO) I C c' CO) O M rcoQ CD m m CL I--� .00D CD c � 0 0 L to O d CL �a c Ce C .cc EL O CO2 2m c co CL V y ev c c _c 0. 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