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HomeMy WebLinkAboutBuilding Permit #512 - Suite 68 3/7/2008BUILDING PLKMI I TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: Date Received -01, 1— �SSACHL' T TYPE OF IMPROVEMENT ❑ New Building ❑ Addition 12 Alteration ❑ Repair, replacement DI Demolition PROPOSED USE Residential ❑ One family ❑ Two or more family No. of u6its: ❑ Assessory Bldg _ ❑ Other Non- Residential ❑/Industrial _ [� Commercial ❑ Others: DESCRIPTION,OF WORK TO B PREFORMED: �. Identification Please TXpe or Print Clearly) OWNER: Name: Phone: ARCHITECT/ENGINEER &x,c oet F - ` Phone:' Address: /�/7 CeffEK- lir(( Sl' \c�IC nYt�uyh Reg. No. FEE SCHEDULE: BULDING P, RMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED O� 0 PER S.F. Total Project Cost: $ %w FEE: $ Check No.: Receipt No.: � NOTE: Persons contra g wito egisttered contractors do not have access to ua/r�a� fu ndq Location 7S I Ae, s� No. , Date " b NaRTM } TOWN OF NORTH ANDOVER 3?� .o` r « Certificate Occupancy $ /o v — of ;� s°•^°' Eta 4CNu5 Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check #/ 3// 21602 Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanningfmassage/Body Art ❑ Swimming Pools ❑ i 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 ❑ o COMMENTS �� DATE R JE TED DATE APPROVED CONSERVATION ❑ . ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ !rMENTS / Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/signature Date Located at 384 Osgood Street Driveway Permit Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. I 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 A1r)TFC and r)ATA _ (Fnr HAnartment usel VK ❑ 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 CC.S.L. oPhoto Copy Of H.I.C. An OLicense Copy of Contract ❑ Floor Plan Or Proposed Interior Work o 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 ❑ Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses u Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o 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) ❑ Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses Li Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract ❑ 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 submitted with the building application Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 The Commonwealth of Massachusetts Department of Indus&ial Accidents Office of Investigations 600 Washington Street .Boston, ALA 02111 f' www.m.ass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: Citv/State/ZID: plinnP fi- Are ayou an employer? Check the appropriate box: 1.0 I am a employer with � 4. 0 I am a general contractor and I � employees (full and/or part-time).* have hired the sub -contractors 2. lu l I am a sole proprietor or partner- listed on the attached sheet ship and have no employees These sub -con -tractors ,have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp• insurance. required.] 5. We are a corporation and its 3.0 I am a homeowner doing all work officers have exercised their . myself. [No workers' comp. right of exemption per MGL insurance required.] t 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. 0 Building. addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13.0 Other _1y al,p�,�U WELL cnecKs oox Fi must atso nll out the section below showing their workers' compensation policy information. t Homeowner; 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: Policy # or Self -ins. Lic. #:' Job Site Address: Expiration Date: City/State/Zip: 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 Investieations of the DIA for insurance coverage verification. Ido hereby certify under the pains •and��ne aloes of perjury that the information provided above ys true gnd correct i� -� �,� not write in this area, to City or Town: or town official, Permit/License # Issuinb Authority (circle one): 1. Board of health 2. Building Department 3. City/Town Clerk 6, Other Contact Person: 4. Electrical Inspector 5. Plumbing Inspector Phone #: 1-- ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID $ DATE(MM/DD/YYYY) AM&AM-1 1 03/04/08 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Samuel J. Durso Insurance Agcy ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Charles S. Randone HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 198 Massachusetts Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. North Andover MA 01845 Phone:978-682-5175 Fax:978-794-0313 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Safety Insurance Company 33618 X COMMERCIAL GENERAL LIABILITY INSURER B: The Hartford AM & AM Masonryfiini DBA Anthony M. Manc INSURER C: National Grange Mutual 14788 , 203 Grandville Lane North Andover MA 01845 INSURER D: INSURER E: CLAIMS MADE a OCCUR COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR INSIRC TYPE OF INSURANCE POLICY NUMBER DATE MM/DD POLICY EXPIRATIO DATE MM/DD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1000000 C X COMMERCIAL GENERAL LIABILITY MPK27389 03/23/08 03/23/09 PREMISES (Ea occurence) $ 500000 CLAIMS MADE a OCCUR MED EXP (Any one person) $ PERSONAL &ADV INJURY $ 1000AOO GENERAL AGGREGATE $ 2000000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OPAGG $2000000 POLICY 7 PRO- JECT 71 LOC AUTOMOBILE LIABILITY A ANY AUTO 2430636 09/11/07 09/11/08 COMBINED SINGLE LIMIT $ (Ea accident) ALL OWNED AUTOS X SCHEDULED AUTOS BODILY INJURY $ 100000 (Per person) X HIRED AUTOS X NON -OWNED AUTOS BODILY INJURY $ 300000 (Per accident) PROPERTY DAMAGE $ 100000 (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE RETENTION $ $ WORKERS COMPENSATION AND X TOR IMITS TF ER $ EMPLOYERS' LIABILITY E.L. EA HACCIDENT $10000001 ANY PROPRIETOR/PARTNER/EXECUTIVE 08WECRJ5941 p3 /23/08 03/23/09 Oyes,de/MEMBER eunder EXCLUDED? H yes, describe under E.L.DI ASE-EAEMPLOYEE $ 1000000/ SPECIAL PROVISIONS below E.L. DIS E - POLICY LIMIT $ 10000 Q OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Masonry CFt?TICICAT= unl MCM NORTHI3 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN Town of North Andover NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL 384 Osgood Street IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR North Andover MA 01845 REPRESENTATIVES. A mrD R ESENTATIVE _ ACORD 25 (2001/08) ©ACORD CORPORATION IARR IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 26 (2001108) Nk. m m m m mm v. 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O • 43 • Ul 0'-- - -- t i AM & AM MASONRY 203 Granville Lane North Andover, MA 01845 (48) 686-2034 PROPOSAL SUBMITTED TO GARY DMD PHONE 978 794 0010 DATE I 3/4/08 STREET 1 APPIAN WAY JOB NAME CITY, STATE AND ZIP CODE WESTPORT), MA_ 0186'6 JOB LOCATION ANDOVER STREET No ANDOVER ARCHITECT JJOB PHONE We hereby submit specifications and estimates for: SCOPE of WORK DEMOLITION OF EXISTING OFFICE SPACE. REMOVAL OF CEILING TILES CARPETING CABENITS AND WOOD PETITIONS. RESTUD FOR DENTAL CUBICLES SHEETROCK AND PAINT. C APPF.T AND CEILING TILE TOTAL: $52,500.00 DEPOSIT: BALANCE: p r"PrIfir hereby to furnish material and labor — complete in accordance with above specifications, for the sum of: Payment to be as follows: dollars ($ ). All material is guaranteed to be as specified. All work to be completed In a workmanlike manner according to standard practices. Any alteration or devia- tion from above specifications involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado and other necessary insurance. Authorized Signature , Title owner NOTE: This proposal may be withdrawn by us if not accepted within days. Alliptan i of propusai— The above prices, specifi- cations and conditions are satisfactory and are hereby accepted. You are auth- orized to do the //work as specified. Payment will be made as outlined above. Buyer ` 4G r (_- '> ! f Signature Signature Signature + _ Date of Acceptance G i AM & AM MASONRY 203 Granville Lane North Andover, MA 01845 `Y;F/ OW 686-2034 PROPOSAL SUBMITTED TO PHONE I DATE 31 DMD 978 794 0010 I 3/4/08 STREET I JOB NAME 1 APPIAN WAY CITY, STATE AND ZIP CODE WESTFORD., MA_ 01866 JOB LOCATION 451 ANDOVER STREET No ANDOVER ARCHITECT j JOB PHONE We hereby submit specifications and estimates for: SCOPE OF WORK DEMOLITION OF EXISTING OFFICE SPACE. REMOVAL OF CEILING TILES CARPETING CABENITS AND WOOD PETITIONS. RESTUD FOR DENTAL CUBICLES SHRETROCK AND PAINT, CARPET AND CEILING TILE TOTAL: $52,500.00 DEPOSIT: BALANCE: P FrOV08p hereby to furnish material and labor — complete in accordance with above specifications, for the sum of: dollars ($ ). Payment to be as follows: All material is guaranteed to be as specified. All work to be completed lr a workmanlike manner according to standard practices. Any alteration or devia- 1 Authorized Signature tion from above specifications involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Title owner Owner to carry fire, tornado and other necessary insurance. NOTE: This proposal may be withdrawn by us if not accepted within days. ,c urptamp oft1ropus l — The above prices, specifi- cations and conditions are satisfactory and are hereby accepted. You are auth- Signature orized to do the work as specified. Payment will be made as outlined above. Buyer 6" % c' bemA— Signature Signature Signature Date of Acceptance The Commonwealth of Massachusetts Department of Public Safety k451 1618 Chapter 143, General Laws, ended Loca 'ndover Street, North Andover MA Capacity: 2000 Pounds Speed: 125 Feet per minute State ID#: 210-P-3 F. T. #: 7 032080 Issued on: 11/26/2007 F. F.:IV I AA Expires: Apply for Re -inspection Thomas G. Gatzunis 60 days Prior to Expiration Date. Commissioner WRiN IN CASE OF ACCIDENT NOTIFY (617) 727-3200 AT ONCE. AFTER 5:00 PM & WEEKENDS, CALL (508) 820-2121 REPORT UNSAFE CONDITIONS TO BUILDING MANAGER / OWNER Z N °D Op, Z 0O D Z m ;o r m D "! pp`, l! N \ N O W C p W co � 3. o 6 A A p 03 CT o oCp o WN .nor G O c °Q v CD � N O C m CD � N N � O v m