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Home My WebLink AboutBuilding Permit #1279-2016 - Building 27-Apt. 1 Royal Crest Drive 6/8/2016' QyOr2Yy BUILDING PERMIT OFSZLED /b��.o TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION o _ * h . - t� . > Permit No#• Date Received DRQ°RarEo PP"`•c� �SsgCHU Date Issued: I ORTANT:Applicant must complete all items on this page LOCATION tONER Print PROPERTY cM P Print 100 Year Structure yes Fno MAP PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑ Alteration No. of units: ommercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 0 _e El❑ Well ❑-Floodplain ❑Wetlands ElWaferShed'District 0 Water/Sewer _ DESCRIPTION OF W RK TO BE PERFORMED: U I r G0 I entification- Please Type or Print Clearly OWNER: Name: Phone: - U -a�� 2 Address: QO t to ye_ �_ � -•e�-�1 Contractor Na Gr w ) w Phone: Email: n o v Address: 2 tl 2� Supervisor's Construction License: (' S G �-� Exp. Date: Z� 7 Home Improvement License: / Exp. Date: 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: $ Uay•y o FEE:$_ '`�% Check No.: 6 Co; Receipt No.: . NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Plans Submitted ❑ Plans Waived ❑ Certified Plot Flan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL = Public Sewer ❑ Tanning/Massage/Body Art ❑ Swiirnning 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 e U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENT'S CONSERVATION Reviewed on Signature COMMENTS (HEALTH 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 Town Engineer: Signature: Located 384 Osgood Street FIREDEI? ARTI�IENT�- TerripjDumpsfe .-p n Isite. Locatedjatti124iwifiikeet ; f Fi_�e Departrnent,si d `` __ gnatu �/date _ -- -- COMMENTS �., Dimension Number of Stories: Total square feet of floor ar,a, 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 DANCER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department case) 0 Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 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 OTE: All durnpster permits require sign off from Fire Department prior to issuance of Bldg Permit 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/Cross Section/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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit 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 2012 IECC Energy code Engineering Affidavits for Engineered products j ®TE: 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:Building Permit Revised 2014 I � NORT1y Town of 3 n p .. `' �► No. * _T = W. C'o;;N.-. h * ver, Mass0(a A- 1-1114, coc"Icnew,cw 7,QS 4ATED U BOARD OF HEALTH Food/Kitchen PERM- IT T LD Septic System ^..C..Q.............................. ,,,,,,,,,,,,............................ BUILDING INSPECTOR THIS CERTIFIES THAT .... .. .......................... has permission to erect ............ buildings on tiara - . ... Foundation .............. .. . . ... ..... Rough to be occupied as ......... ... ....ao-�t w.....Coo0i . ....................................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONST TION Rough Service ..... .. ..... ... . ........ .... ..... Fina BUILDING I ECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. Smoke Det. The Commonwealth ofmassachusefts z , Department of IndustrialAcczclents a d X Congress Street,Suite 100 t Boston,M4 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Ele ctricians/Plumbers. TO BE FILED WITH THE]PERMITTING AUTHOWTY. A licaut Information Please Print Legib Name(Business/Organization&dividual): o. .Address: City/State/Zip: y 4-t-v1 Phone#: Areyou an employer?Cheektlie appropriate box: Type Of project(xgquir®d): 1.FIT am a employer with employees(M and/or part-time).* 7. ElNew construction 2.❑I am a sole proprietor or partnership and have no employees V✓orldng for me in 8. Remo deliYig any capacity.[No workers'comp.insurance required] 9. ❑Demolition 3.❑I am a homeowner doing all work myself[No workers'comp..insurance required.]t 10F1 Building addition 4.E]I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11:❑Electrical repairs or additions proprietors with no employees. 12.h Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contraotors listed on the attached sheet. ❑ 13. Robfrepairs These siib-contractors have ei4loyees and have workers'comp,insruance.t �—yam 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.�!"ther 0/ 152,§1(4),and we have no,employees.[1To workers'comp.insurance required.] 'kAny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. fi Homeowners who submit#his affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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. lfthe sub-contractors lrave:employees,they miist provide their workers•'comp.policy number.' fain an employer that is p'iavid1hg workers'compensation insurance for my employees.'Below is the policy and yob site information. //�� Insurance Company Name: to G r fin — Policy#or S elf-ins,Lic.#:= i1/cj U 1 L' Expiration Date; /v fob Site Address: - r z l G �o�7 ` 14 City/State/Zip: Attach a copy of the wor rs'compensation p olicy declaration.page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. f do hereby cert' nder liepai, s ndpenaldes ofpeiyury that the information provided above is true and correct. Signature: Gt j!J Date: Phone#• C 7— 43 r2 2 Z. 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 G.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, expxes's or implied,oral or written." ' An employer is defined as"an in'dMdual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enferprise,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 anotherwho 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 lias 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,iiisurance - 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=contractors)name(s),address(es)and-phone number(s)along with their certificates)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 fox 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' compensatioii policy,please call the Department at the number listed below. Self-iii'sured 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 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. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"fob 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 proofthat 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 buin leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.#617-•727-4900 ext.7406 or 1-877-MASS.AFE Fax#617-727-7749 Revised 02-23-15 wWW.mass.gov/dia Massachusetts Department of Public Safety.. Board of Building Regulations and Standards License: CS-065281 F Construction'Supervisor i PAUL BRUNO 109 CHESTNUT STREET LYNNFIELD MA 1646 i + a Commissioner. Expiration: 09/28/2017 I ' t �1 ® ill AC4 RO CERTIFICATE OF LIABILITY INSURANCE 4i4i o�) 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 REPR ENTATIVE 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 endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NCOANEACT Jean Sullivan, CIC, AIS Burgip, Platner, Hurley Insurance Agency, LLC PHONE (617)472-3000 Fax (617)472-7248 14 Frpnklin St. EMAIL . 'as@b hins.com INSURERS AFFORDING COVERAGE NAIL S Quincy MA 02169 INSURER A:Banover Insurance Company 2292 INSURED iNsuRERa:Safety Indemnity Insurance Co 33618 8 & M Restoration & Contracting, Inc. INSURERCAcadia Insurance Company 218 Paris St INSURER D: i INSURER E: Bast Poston MA 02128 INSURER F: COVERAGES CERTIFICATE NUMBER aster Cert 2016-17 REVISION NUMBER: THIS I 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 CERTIOICATE 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. LR A D 8 POLICY EFF POLICY EXP LT LIMITS LTR TYPE OF INSURANCE POLICY NUMBER GENERAL LiAsurY Y N EACH OCCURRENCE $ 2,000,000 DAMAGE TO REM I tu B COMMERCIAL GENERAL LIABILITY PREMISES Me occurrence $ 500,000 A CLAIMS-MADE ®OCCUR HN8997647 /17/2016 /17/2017 MED EXP one n $ 10,000] PERSONAL&ADV INJURY $ 2,000,0001 GENERAL AGGREGATE $ 4,000,090' GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 4,000, 0 0 B POLICY PRO LOC $ AUTOMOBILE LIABILITY Y Y EaMBINED SINGLE LIMB IAaccident) 1 000 000. B ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED 6208157 1/6/2015 11/6/2016 BODILY INJURY(per accident) $ AUTOS AUTOS X HIRED AUTOS % NON-OWNED PAUTOS er P accient)DAMAGE $ PIP-Basic $ 8 000 R UMBRELLA LIAOX OCCUR Y N EACH OCCURRENCE $ 5,000,000 A EXCESS LIAR CLAIMS-MADE AGGREGATE $ 5,000,000 DED g I RETENTION$ URN9055121 /17/2016 /17/2017 $ (` WORKERS COMPENSATION jI % WC STATU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE K MIA E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? _20-20-003740-03 /10/2015 /10/2016 (Mandatory In NH) E.L.DISEASE-EA EMPLOYE9$ 1,000,000 It yes,describe under DESCRIPTION OF OPERATIONS below E_L DISEASE-POLICY LIMIT 1$ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,H more space is required) Contract # 18122-422094-CPe-00002; Property Name- Royal Crest Estates(North Andover); AIMCO North Andover LLC is additional insured per written contract CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN AIMCO North Andover LLC ACCORDANCE WITH THE POLICY PROVISIONS. 50 Royal Crest Drive North Andover, MA 01845 AUTHORIZED REPRESENTATIVE