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HomeMy WebLinkAboutBuilding Permit #883-13 - Building 24 Schneider 6/8/2013TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION y'� Permit NO: g - � Date Received Date Issued, J�,Jz IMPORTANT: Applicant must complete all items on this page ILL zr -Jr em 03 i 1• - .00 RT Yt I V,N E W L ld Te,.S 100kYvaaoO'istr56f6 P� fit . Y yes 4 T I H figtbric-QD ri M4ch'ihe'Sh- p) 49p,riot yq!�) - - - - TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Building El One family 0 Addition El Two or more family El Industrial 0 Alteration No. of units: El Commercial 11 Repair, replacement D Assessory Bldg l�Others: 0 Demolition El Other iv ❑'S.eptic Will f z WFFI&odplaih� EIN01i a. t 0 r,5- h etllDistrct V'V or(- DESCRIPTION OF WORK TO BE Ft--Kl-UKMtIJ: 0 bo (A *I- C4 12 ( we wt %/ /00 X 12o qP74-e 20'x 30` -red i -n 7'Ae p4rkik, lWe Se-kneldv- Cler-756-,(L teem ova f c.,v /// be o ;-1 �/�/1� ..- -- Identification Please Type or Print Clearly) OWNER: Name: � le eAY& Phone: Address:.Z �'j6 114A e.0 AvC>,O Vv, - G T 0 N RAQ N?irqq Ch �i:4 -r--4%/ L -h Aol up- 0, n' f ffip.q �_q n I P"I ARCHITECT/ENGINEER Phon 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: $ FEE: $ Check No.: Receipt No.: 0 NOTE- Porvnn.v rnntrarting with unregistered contractors do not have access to the guaranty fund Igo., Ore"40T. Plans Submitted [I Plans Waived El Certified Plot Plan El Stamped Plans Ll 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 CONSERVATION Reviewed on Signature COMMENTS ; "`'ALTH Reviewed on Signature COMMENTS Zoning 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 DPW Towi., Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMI=NT - Temp Dumpster on site yeas no Located at 124.Mair)'Street Fire De partmenf-signatu"re/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 ® Notified for pickup Date Doc.Building Permit Revised 2010 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 u Building Permit Application u Workers Comp Affidavit u Photo Copy Of H.I.C. And/Or C.S.L. Licenses u Copy of Contract u Floor Plan Or Proposed Interior Work u Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks u Building Permit Application Li Certified Surveyed Plot Plan u Workers Comp Affidavit u Photo Copy of H.I.C. And C.S.L. Licenses u Copy Of Contract u Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) a Mass check Energy Compliance Report (If Applicable) o 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 u Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o Mass check Energy Compliance Report o 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 subm:¢ted with the building application Doc: Doc.Bui?ding Permit Revised 2012 Location No. Date (C:�� Check # �7?14-� TOWN OF NORTH ANDOVER Certificate of Occ upancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Building Inspector J WCL Q m O t Y y O LCL E a0+ �n N O_ �V) cr b ZZ Z m O O Y f0 7 11 0 OC 41U C E U LL O a Ln Z m 2 J d % t to 5 LL o V IA c .F LU LU L b311 K i N @ LL O a0 V) N Q t :3 LL d WC G CLa 'L 0 LU LL O m Z Y O N }' 41 D O1 COC Ln ' M 0 C O H c :v W n •� . to � }: Z og.- �Z E o - �o v : J y � O Cl) H �� V/ u �Noof�Q- 0 � O CO QJ E •: Lm a Z H Cl)_ U) LLI o — o 0 0 �_ H _ Cl) �n = a Z t t o LLI 0 U N 0 o r- 0) . 'N 3 c W J c x: CL m © to p •y o Q L�mo oto V m w W C •o +�+ O O .r LL •N a to C o .�� Z w N umiEv =V O W 0 N CL FE N� •p c 0 0 F- .� ��+ CL 0 V > ti v c.� w ti O Z 0 V/ 0 .E i O v n. V .y r U ccs .0 _m Q. r—W L.: d N 01- 0:2 H � CD 00 O CL Q. �Q C _I O Z U) LLIG ra H 19W W 19 W U) O CERTIFICATE 4F LIABILITY' INSURANCEF9/m5/2012ID°""�`' INSR k. �--� 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 certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsemeft A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements). PRODUCER CONTACT Lnci Fitzpatrick Tebbetts Insurance Agency P.O. Box 848 PHONE(603) 4653333 F'C (603)465-6800 E40UL.ADDRIM.luci@tebbettsins.com 3 Market Place Hollis NH 03049 INsu AFFORDING COVERAGE NAIC 4 INSURER A:Citizens Insurance C2Mny of 31534 INSURED Christian Delivery & Chair Service Inc. D/S/A Christian Party Rental 18 Clinton Drive Hollis NH 03049 IN RE B -iHanover Insurance C2MERM 22292 msunRc:Commerce and Industry Insurance 15172 INSURER D: INSURER E : INSURER : Liuvin- CAUES CFIZTIFICATF NI IMRFRCL7795n1357 otxnernu us 119mm92. 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. INSR TYPE OF INSURANCE Au WON POLICY MB D EFF IQAWALIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS M/wI- fX DccuR V0844363 /1/2012 /1/2013 EACH OCCURRENCE $ 1,000,000 DAMAqE TOPREMEff- rremm$ 100,000 MED EXP (AM one $ 5,000 PERSONALS ADV INJURY $ 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: :� POLICY PRO jEcT El LOC PRODUCTS -COMPIOPAGG $ 2,000,000 $ A AUrOMOBILELIAWLn'Ya x ANYAUTO AALLOSNED SCHEDULED HIRED AUTOS AUTOS AU.IOS WNED 0716909 /1/2012 /1/2013 I LIMIT 1 000,000 BODILY INJURY (Per persan) E BODILY INJURY (Per aeddent) $ P tPereodderiDAMAGE $ EIeE $ B X UMBRELLA LUIS EXCESS LIAB OCCUR CLAIMS -MADE L844365 /1/2012 /1/2013 EACH OCCURRENCE $ 4,000,000 AGGREGATE a 4,000,000 DED X RETENTI N $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORRARTNERIEXECUTIVE YIN OFFICERIMEMBER EXCLUDED? (Mandetoly to NH) D es, IPTIOeunder DESCRIPTION OF OPERATIONS below NIA 009870539 /1/2012 /1/2013 X WC STA X OTFh ER E L EACH ACCIDENT $ 110 0 000 E.L. D SE- EA EMPLOYEE S 1,000,000 E.LDISEASE- POLICY LIMIT S 1,000,000 OESCRIPnON OF OPERATIONS ILOCATIONS I VEHICLES (Attach ACORD 101. Additional Remerka Schedule, H more space I8 requRed) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Seth Tebbette/Lt7CI ACORD 25 (2010105) ®1988-2010 ACORD CORPORATION_ All rlehf* ranarvod IN9025 ronvm-nnt Tho Armon narna anti !neon ara ranlafarari m2pire of Ar ewn 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 Applicant Information Please Print Legibly Name (Business/Organization/Individual): r'/S48 li'Ver 'ryl J�rf. DhlS1r7�4N Jct1'� /f� `l Address: !/'1 f�1 �i^1 Ve City/State/Zip: Il 15 / /V// g�r9 Phone #: �0�3 �883� •�.�'Z Are you an employer? Check the appropriate box: 1. Elam a employer with _V 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed 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 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 1011 Electrical repairs or additions 11. El Plumbing repairs or additions 12.❑ Roof repairs 13. flier Tf? *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t 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 their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. - I Insurance Company Name: L Gl�I/y!t'^� t=.ZyeQ'u�►X ZK Policy # or Self -ins. Lic. #: WCDO9 874:0? Expiration Date: / 2 0/3 Job Site Address: ! �� City/State/Zip:/Ay do ivP!^. 111M Attach a copy of the workerscompensation 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 yperjury that the information provided above is true and correct Phone #: 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 #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, 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 residers 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, §25C(6) also states that "every state or local licensing 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 "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." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation 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. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials _ 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 t6 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. In addition, an applicant that must submit multiple-pemik/license applications in any given year, need only submit`one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address; telephone qnd fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-72.7-7749 www.mass.gov/dia 6/17/13 Google Maps To see all the details that are visible on the Goo,qle �Sc,�?elg . 6"e-- screen, use the "Print" link next to the map. https:Hniaps.g oog I e.com/maps?i e= U TF-8&q=schnei der+electric+north+andover&ftp 1 &g 1=us&hq=schneider+electric&hnear=0)(89e3064551 dac259:0)6332f84... 1/1 (.Gertif lucre of f fame ReeUtance 40 REGISTERED ISSUED BY. Oate treated or APPUCATION AZTEC TENTS manufactured CONCERN No. 490 ALASKA AVENUE O?l2006 TORRANCE, CA 90603 CAL COJM F,4f0A1 (310)328.6060 This is to cerdfy that the materfals described below hereof have been Name retardant !rested (or are inhatu entry nonflammable). FOR t.WRI.STW PAMREM%AW ADDRESS 18 MMON DRIVE CITY HOLDS STATE _ NH, 08048 Certification is hereby made that. (check "a" or "b') (a) The articles described below this certificate have been treated with a flame retardant chemical approved and registered by the State Fire Marshal and that the application of said chemical was done In confor- mance with the laws of the State of Caiifomis and the Rules and Regulations of the State Fire Marshal. Nameof chemical used .»»..» ..._.».»...».»»............ Chem. Reg. No.......».»...»».».» Meathod of application...».»...»»».»..............-».............».....» »» ... »» ..�». ». » ® (b) The articles described below hereof are made from a flame -resistant fabric or material registered and approved by the State Fire Marshal for such use; Fabric has been tested and Passes NFPA701-96. Trade name of flame -resistant fabric or material used.. . Reg. No. ...... t :til,P1....... The Flame Retardant Process UsedINILL MOT .... Be Removed by Washing cwm; trod David Bradley Chuck Miller - President CUSTOMER ORDER NO. 8159657 ITEMS MANUFACTURED: 1.100'X40' (2 PC.) SERM 2M TP- ULTRA WWW & 201r40'(1 Pr-) QW TOP ONLY- ULTRA MOE k Z0k80' (1 PG) QWIKTOP ONLY- ULTRA inns PDF created with pdfFactory trial version www.gdffactory.com C.I.ertifirate of if fame Reziqtance REotSTERED ISSUED BY- Date treated or APPLICATION AZTEC TENTS manufaawed CONCERN No. age ALASKA AVENUE MUMTORRANCE, CA 90603 CAt F419M (310)328.6060 This Is to *01fY that the mateAais described below hereof have been name retardant treated (or are Inher- enNy nonflammable). FOR CHRISTIAN PAMRENTALS ADDRESS is CLAff" DRIVE MY HOLLIS sTATE NH, 03M Certification is hereby made that. (check "a" or "b') F -1(a) The articles described below this certificate have been treated with a flame retardant chemical approved and registered by the State Fire Marshal and that the application of sold chemical was done In confon mance with the laws of the State of Callfomis and the Rules and Regulations of the State Fire Marshal. Name of chemical used ...»..»....»»..»...».»»..._....... Chem. Reg. No.......»._...»». »» Meathod of applicatlon...».»»......»._...»........._».».........».».»» »»» ...».» ».. _ ».._ ® (b) The articles described below hereof are made from a flame -resistant fabric or material registered and approved by the State Fire Marshal for such use; Fabric has been tested and passes NFPA701-96. Trade name of flame -resistant fabric or material used.. . Reg. No. ...... MW...... The Flame Retardant Process Used *7u: NOT.... Be Removed by Washing David Bradley Chuck Miller - President NNW MMM or PROW M�Wft� Tft CUSTOMER ORDER NO. R159657 ITEMS MANUFACTURED: i- i00WIV (2 PC j SEMM 2000 TPS• ULTRA wHnr 2-2 R M411 INWH E 205180'(? PCa QWIKTOP ONLY- ULTRA - x3o PDF created with pdiFactory trial version www.r)dffactory.com