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Home My WebLink AboutBuilding Permit #93 - Bldg-7A-Groupe Schneider 7/31/2009Permit Date Issued: BUILDING PERMIT, TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received IL 0 TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial <Q&�gx No. of units: qLo:m=merdaI R ,epzLr,1.*Iacement Assessory Bldg dt�hers CDemolit0n) Other ;,floodplain Wetlands' Qrs Wat hed Dikridi` Water/Sewer UtbUKIF I 1UN OF WORK TO BE PREFORMED: 1*;Vz1r1,61f.1 11CO&.0 A0A1,e OO -,C z& Identifidation Please Type or Print Clearly) OWNER: Name: F�� ti-- t5,,,� Phone: 11 Tb q 9,�? "5 IS' Address: 7 CONTRACTOR.'Name.- Phone:, CA i��'l Address:` Supervisor's Construction -License. 0165L641 Exp. Date: Home Improve"merit License:— --Exb. Date.-*' ARCH ITECT/ENG I NEER b�A+P,, �k��Av7ic) Phone: %— 7 -- Address: 15oc, A, sTq-6ej, t3t T , r�(, o %;U C) 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: $ - FEE: $ Check No.: O?F 09 -7 Receipt No.: c29 P Z6 NOTE: Persons contractin;,w�th un!�egistered contractors do not have access to th,�.,guqrantyfun—d 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 DATEAPPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS Reviewed on Signature HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes - Planning Board Decision: el Comments Conservation Decision: Comments Water & Sewer Co'nnection/signature & Date DriveWay Permit DPW Town Engineer: Signature: Located 884 Osgood Street FIRE DEPARTMENT J-1�1. T-6ft'.'Durn - ,on sJte ves J no 'pster ocated at 124 Main Streeta, /da Fire De.iiartmebt �signat6re tW 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 21 A —F and G min.$100-$l 000 fine NOTES and DATA — (For department use) El Notified for pickup - Date . . .. . . . ................ -.- . . . . . . . ... . ... . . . . ................................................... . . .. . ..... . . . . . . ... . ..... .......... .............................. . .... ............................................. . ............ Doe.Building Pennit Revised 2009 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 Lj Building Permit Application L3 Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses a Copy of Contract u Floor Plan Or Proposed Interior Work zi Engineering Affidavits for Engineered products NOTE: All dump'ster 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/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (if Applicable) • Mass check Energy Compliance Report (If Applicable) Li 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) L3 Building Permit Application u Certified Proposed Plot Plan Li Photo of H.I.C. And C.S.L. Licenses u Workers Comp Affidavit Li Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (if Applicable) D Copy of Contract zi Mass check Energy Compliance Report L3 Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit I 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 2008 Location A, No. 91 f Date I — " - -/ - f TOWN OF NORTH ANDOVER Certificate of Occupancy $ .1.1 CHUS Building/Frame Permit Fee $ 671— Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# -/)(rO�7 222'/ 6 /01 B uil'64 inspector cn m m m m m X cn m CA a m C2 cop) CO) Cl) 10 .0 CD cwj Z ca CD r— sm CD CD CD C:L cr =r CD CD Q CD CD co) CD CO) CD .co) 0 10 CD z PC.** CD CD w 0010 *10 =r --4 Z-1 0. Im m ca a cr CA :10 CO3 CL a 0 a Cl) to n -% m CD CA C2 CL CD �* z =r -w 0— CA -P CD -- -n =r CL -0 CL 0= FR CD =r 10 cwoj 0 mc =r W co CA CD CO 0 cl) z:s. CD CL C=.r CD C42 0 CD CO CA cr z C/) CL CL CO2 9D 'iic I Cco, CA —4* 90) 4� CCD CRO ci� cm C& nc, co, Cm CD C=, m m INEMB- MEMEL C/) El 0 C/) " z to c ni 0 ;z 0 r- C/) (D �T" 0 r- CA z n zr, CD go cn cn Irl 0 0 rA rA 9 z 0 0 omi 0 9 1 0 49i CD pi D. Robert Nicetta, Building Commissioner TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT 400 Osgood Street North Andover, Massachusetts 0 1845 Telephone (978) 688-95454 Fax (978) 688-9542 CONTROL CONSTRUCTION — SECTION 116.0 M.S.B.C. CERTIFICATE OF ENGINEERING/ARCHITECTURE BULDING INSPECTOR TOWN OF NORTH ANDOVER 400 OSGOOD STREET NORTH ANDOVER MA 0 1845 1, Carolyn Hendrie 'HEREBY CERTIFY THAT THE BJJILDING CONSTRUCTED AT 1 High Street DOES CONFORM IN ALL RESPECTS TO THE MASSACHUSETTS STATE BUILDING CODE AND APPLICABLE FEDERAL REGULATIONS FOR THE FOLLOWING: Offices for Converse, Inc. - Demolition only AUTHORIZED SIGNATURE: DATE: July 29, 2009 REGISTRATION: 4823 NOTE: ENGINEER "WET STAMP" MUST BE AFFIXED TO THIS FORM Control Construction Fonn revised 11. 15.2004 BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-95540 PLANNING 688-"-35 D. Robert Nicetta, Building Commissioner TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT 400 Osgood Street North Andover, Massachusetts 0 184 5 Telephone (978) 688-95454 Fax (978) 688-9542 CONTROL CONSTRUCTION — SECTION 116.0 M.S.B.C. CERTIFICATE OF. ENGINEERING/ARCHITECTURE BULDING INSPECTOR TOWN OF NORTH ANDOVER 400 OSGOOD STREET NORTH ANDOVER MA 0 1845 1, Carolyn Hendrie -----.,HEREBY CERTIFY THAT THE BUILDING CONSTRUCTED AT 1 High Street DOES CONFORM IN ALL RESPECTS TO THE MASSACHUSETTS STATE BUILDING CODE AND APPLICABLE FEDERAL REGULATIONS FOR THE FOLLOWING: Offices for Converse, Inc. - Demolition only AUTHORIZED SIGNATURE: DATE: July 29, 2009 REGISTRATION: 4823 NOTE: ENGINEER "WET STAMP" MUST BE AFFIXED TO THIS FORM Control Construction Fonn revised 11.15.2004 BOARD OF APPEALS 688-9541 CONSERVATION 688-95330 HEALTH 688-9540 PLANNING 688-9535 k) *kORTN TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT 400 Osgood Street rib North Andover, Massachusetts 0 1845 D. Robert Nicetta, Building Commissioner Telephone (978) 688-95454 Fax (978) 688-9542 CONTROL CONSTRUCTION — SECTION 116.0 M.S.B.C. CERTIFICATE OF ENGINEERING/ARCHITECTURE BULDING INSPECTOR TOWN OF NORTH ANDOVER 400 OSGOOD STREET NORTH ANDOVER MA 0 1845 1, Carolyn Hendrie THE BUILDING CONSTRUCTED AT 1 High Street Y CERTIFY THAT DOES CONFORM IN ALL RESPECTS TO THE MASSACHUSETTS STATE BUILDING CODE AND APPLICABLE FEDERAL REGULATIONS FOR THE FOLLOWING: offices for Converse, Inc. - Demolition only AUTHORIZED SIGNATURE: DATE: July 29, 2009 REGISTRATION: 4823 NOTE: ENGINEER "WET STAMP" MUST BE AFFIXED TO THIS FORM Control Construction Form revised 11.15.2004 BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 goaktof Buildi-6g.R,&Olitio-fi�s�-Aiid;'Sfaiidgrdt Construdidn SUpem, Uidepise, s �4 t , le A626 TrW. 98269 R I .A DANIEL CHAR 16B CHESTNUT STONEF(AM, MA 021,80 itbifimiisiofier The Commonwealth ofMassachusetts 13, Department ofindustrial Accidents Office otinvesfigations 600 Washington Street, 7hFloor Boston, Mass. 02111 Workers' Comeensation Insurance Affidavit: Building/Plumbing/Electrical Contractors jApplicant information: Please PRINT le0bly J. Calnan & Associates, Inc. address: 1250 Hancock Street, Suite 302N city Quincy state: MA zip: 02169 phone# 617-801-0200 1 1 work site location (full address): F-1 I am a homeowner performing all work myself. Project Type: El New Construction ORemodel F-1 I am a sole vronrietor and have no one working in any cai)acitv. F-1 Building Addition am an em loyer providing workers' compensation for rn)� R _emilloy es working on this ob. com anvname: J- Calnan & Associates, Inc. ,address: 1250 Hancock Street, Suite 302N I �cjty: Quincy, MA 02169 i)hone#: 617-801-0200 f I insuranceeo. Ohio CasualtV GroulD nolicv# XWO (06) 53119614 H I am a sole proprietor, general contractor, or homeowner (circle one) and have hired the contractors listed below who have the following workers' compensation polices: i company name: . I ;address: Icily: phone #: �insurance co. Policy # :company name: �address: !city: phone #: �insurance co. 1policy # [Att-�k additional sheet if necessa Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of $100.00 a day against me. I understand that a copy of this statement nlxnb forwarded to t4*pfflce oflnvestigationsof the DIA for coverage verification. I do hereby Print name �perjury that the information provided above is true and correct. Date official use only do not write in this area to be completed by city or town official city or town: F� check if immediate response is required contact person: (m�iscd Scpt. 2003) # Q L-7 IN01 02-49 permit/license # E]Building Department ElLicensing Board ElSelectmen's Office EjHealth Department phone#; [:]Other Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted 6om the "law", 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 including 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 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license orpermit 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, 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. I I Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation. Please supply company name, address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confin-nation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit 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 number listed below. I City or Towns 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/license number which will be used as a reference number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you 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,7th Floor Boston, Ma. 02111 fax #: (617) 727-7749 phone #: (617) 727-4900 ext. 406 ACQRD - __ CERTIFICATE OF LIABILITY INSURANCE IIAT_ 10 1212008" PRODUCER (781) 681-6656 FAX: (781) 681-6686 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION The Driscoll Agency, Inc. 93 Longwater Circle ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. TYPE OF INSURANCE P.O. Box 9120 Norwell MA 02061 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURERA:Nat'l Fire Ins Co of J. Calnan & Associates, Inc. INSURER 8: Everest National President's Place, No.Tower 3 INSURERci0hio Casualty Insurance 1250 Hancock Street INSURER 0: Quincy MA 02169 f�MiMaA^ INSURERE: I THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REOUIREMENT, 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 SU13JECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEE RE12UQED By PAID CLAIMS. INSR LTR ADD11 iNsRn TYPE OF INSURANCE POLICY NUMBER ILICY EFFECTIVE DATE (MMIDD(M POLICY EXPIRATION DATE (MWDDfM LIMITS GE ERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 300,000 PREMISES (Ea occurrence) $ X COMMERCIAL GENERAL LIA131LJTY A 7 CLAIMS MADE FX_1OCCUR INS2095325239 10/1/2008 10/1/2009 MED EXP (Any one Person) $ 5,000 PERSONAL 4, ADV INJURY $ 1,000,000 X Inc. Contractual __ Includes GENERAL AGGREGATE $ 2,000,000 A.Cweners Protective GEN1 AGGREGATE LIMIT APPLIES PER: PRQDQCT8 - COMP/OP AGG $ 2,000,000 B. X, C, U ROi F I LOG POLICY FX PE J C AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 X ANYAUTO (Ea accident) A ALL OWNED AUTOS SAP2095325225 10/1/2008 10/1/2009 BODILY INJURY SCHEDULEDAUTOS (Per parson) BODILY INJURY HIRED AUTOS NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Peraccident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EAACC $ ANY AUTO AUTO ONLY: AGG S EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ 10,000,000 AGGREGATE S 10,000,000 OCCUR CLAIMS MADE S [�RETEIVTION DEDUCTIBLE 71CS000071-81 10/1/2008 10/1/2009 $ $10,000 S C WORKERS COMPENSATION AND X STA U OTH- Y Ij ITj ER EMPLOYERS' LIABILITY E.L. EACH ACCIDENT S 500,000 ANY PROPRIETOR/PAITTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? XW053119614 10/1/2008 10/1/2009 E.L. DISEASE - EA EMPLOYEE $ 500,000 It yes, describe under E.L. DISEASE - POLICY LIMIT S 500,000 SPECIAL PROVISIONS kjaw (NA, CT) A OTHER INS2095325239 10/1/2008 10/l/2009 Leased/rented Contractors Per Item $100,000 Equipment DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS ***Please refer to attached addendum*** Evidence of insurance for work performed within the Insureds scope of normal business operations. Notice of cancellation provision is 30 days, except 10 days applies for non-payment of premium. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE SANIPLE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO 00 SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Pennis Driscoll/GJM 4fo� I&uv ACORD CORPORATION 1988 4 -11