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HomeMy WebLinkAboutMiscellaneous - 22 BEACON HILL BOULEVARD 4/30/2018 22 BEACON HILL BLVD 2101058.&0011-0000.0 NORTN BUILDING PERMIT 0t'JUILD 06gtio TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION '" t 0 '° 1 Permit NO: Date Received .T.o•P""a`� CO SSACWU Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION i5.-qt.( Cly )yQ/ tVGf jt /ly(int PROPERTY OWNER Y��S / rint MAP 210 J��t PARCEL: ZONING NSTRICT: Historic District yes no Machine Shop Village ye no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer j� Me%?FCRI 10 F WORK TO BE PREFORMED: Identification Please Type or Print Clearly) OWNER: Name: Phone: a Address: CONTRACTOR Name: -..i 1f 1 Cid! �i '� Phone: � 0 Address:_( y Xcw C S Supervisor's Construction License: (�,5 °�37A35 Exp. Date: /;Z/p Lxll Home ImprovementLicense: Exp. Date: /go// ARCHITECT/ENGINEER Phone: Address: Reg. No. G FEE SCHEDULE.BULDING PERMIT.,$1Z00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ ( FEE: $ Check No.: Receipt No.:7 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund F ,_ignature of AgentJOwner Signature of contractor 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 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 ❑ Building Permit Application ❑ Certified Surveyed Plot Plan o 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 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 ❑ 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 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:Building Permit Revised 2008 Location &". 2 No. Date U Iv pGRTM TOWN OF NORTH ANDOVER ' Certificate of Occupancy $ Building/Frame Permit Fee $ AC NUS Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # r ( r 22981 Building Inspector 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 i COMMENTS HEALTH Reviewed on Signature CQMMENTS 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 FIRE DEPARTMENT -Tem_ p,Dumpster on site yes no Located at 124 Mein Street Fire Department sgnatureldate 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 The C'ommonwezlth of Massachusetts Department o f Industrial Accidents Office of.£nv,Cstigations 600 Rlashinaton Street Boston, AM 02111 www.rnass.g0V1&a Workers' Compensation Insurance Affidavit: guilders/Contractors/Electricians/Plumbers A ficant Informafion Please Print Lee-ibl Name(Business/organiza6an/Individual): J 1�)i lQ he- Address: J S� Wove. City/State/Zip:_ ///�TAUeh /Y Phone#: / V696D/6 Are you an employer?Check the appropriate box: [2. ❑ OL I am a employer with 4. I am a F7. pe of project(required):❑ general contractor and Iemployees(full and/orpart_time).* have hired the sub-contractors ❑N construction❑ I am a sole proprietor or partner- listed on the attached sheet x Remodeling ship and have no employees These sub-contractors have working for me in any capacity. workers' comp.insurance. g' ❑Demolition [No workers'comp.insurance 5. ❑ We are a corporation and its 9' ❑Building addition 3.❑ required.] officers have exercised their l0❑Electrical repairs I am a homeowner doing all work right of ex additions exemption per MGL 11.❑Plumbing repairs or additions myself, [No workers'comp, c. 152,§1(4),and we have no insurance required.]t employees. [No workers' 12.❑Roof repairs comp.insurance required.] 13•❑Other `a-n3' Brant that ch=>cs box 41 must also II]oet these tio:e_Iow ,jag�«- t Homeowner who submit this affidavit indicatingthey are d b worke s'comY..,,c,..—«:oc p^„licy=,cor.�on- eS' crag a(]work and thea hire outside couuacters must.submit a new affidavit indicating such. +Contmctots that cheek 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 the policy and--- job information Q Insurance Company Name: Policy#or Self-ins.Lic.#:7(�C V Expiration Date: Job Site Address (rcp /l l�U`(/QUI Attach a copy of the workers'compensation policy declaration awe rho City/State/Zip: p b (showing the policy number and expiration date). dot-C3 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 foam of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of statement maybe forwarded to the Office a Investigations of the DIA for insurance coverage verification I do hereby fy under the e s of perjury thrit the information Provided aba is true and correct Si store: � Phone#: CJ 0 Official use only. Do not write in this area, to be completed hj'cite or town official Cita'or Town: Permit/License# Issuing,Authority(circle one): I.Board of Health I Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumoine inspector 6. Other Contact Person: Phone Or: Information an- d 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=#ry,or any two or more of the foregoing engaged in a joint enterprise,and including tiie 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 apamx ents and who resides therein,or the occupant of the dwelling house of another who employs persons to do mainte;=rance,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 cosapliance 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 uncal 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 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:turned to the city or`u3aJn that the applicsLLon for the permit or license is being requested,not the Depa*lment.of Industrial Accidents. Should you have any questions regardinL g the law or if you are required to obtain a workers' compensation policy,please call the Department at the.numbe;r listed below. Self-insured companies should enter their self-insurance license number an 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 tfmat must submit multiple permit/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 perimits 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 allThe Department's address,telephone.and:faxnumber... The Commonweal& of Massachusetts Degarlment of Industrial Accidents Office of Investigations 600 Washington S,tn=t Boston,MA 021.11 Tel. #617-72.7-4300 M-ft4Q6 or 1-977-MASSAFE Fay: #617-7-217-7749Revised�-26-QS vry v,-mass.-aov/dia AC4RD� CERTIFICATE OF LIABILITY INSURANCE WI29/aO10 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION �ooucER FAX ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE )eAngel i 5 Insurance Agency. Inc. HOLDER.THIS CERTIRICATE DOES NOT AMEND,EXTEND OR ZS3 Merrimack Street ALTER THE COVERAGE AFFORDED 8Y THE POLICIES BELOW✓• 11 Methuen, MA 01844 INSURERS AFFORDING COVERAGE NAIc _ —. -- _ ----— INSURERa; National Grange Mutual Ini Co 42 AsuREo ]aures Ga11a9her Construction --...— -- — -- — - �- INSURERB� Atlantic Charter Ins Co ....._. 3SZ Howe Street _ ...._.....-_.__.. ._.... Methuen,, MA 01844 INSURER C� INSURER E....... .... .--... INSUaER D'...___... _.... ;,OVERAGES _ ANY REQUIREMENT,TERM OR CONDITION OF ANY BE ',.ISSUED 10 AC OR OTHER DOCUAAENT W 7M RESPECT WHICH ITHIS CERTDIFICATE MAY BE SUED OR DIN (uWY PERTAIN THE INSURAS�E AFFOROED 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, Fr ,� LAY a IRATI Llaass d OF II URRA IICE POLICY NUMBER DATE M (YVYY GATE MMIDDMIYY �NTR NS P_REIAISES(Ea octurtnce).,��.. �(),00 pQNEMLLIABELITY MPT45Z3Z 06/10/2009 � 06/10/2010 'EACI,pccuRRENcE; S 11 �"=,000 -- MED Exp(Any cns Ver %-" " OOQ.Q IIAFMi�TOR IF X iC.OMMERCIAL GENERAL LIA911.ITY I II I �. qpn} { 10 00 ' CLAIMS MADE I X•••I OCCUR I P@RSUNPL 8 A[lV MJURY I'mo 0 r - GENERAL AGGREGATE000 11)00 _ _.... PRDDucTI -coMPros GENL AGGRE(VITE LIMIT APPLIES PER: . POLICY PRO LOC AUTOMOBILE LIABILITY 1 I COMBINED SOCCIdIN" IMMT ANY AUTO 1 LY INJIIRY AlL OWNED AUTOS l EOOI e!f4011) leer P __ SCHEDULED AUTOS HIRED AUTOS (PetSO ar INJURY s (Pet rdaM1 NON•OWNEDAUTOS -` —...—._..— _...._-._. PROPERLY CIAMApE g (PeracadenI) AUTO ONLY•E_A_ACCIDENT GARAGE LIABEIdTY EA ACC Z I OTHER THAN �_-_. ....._._.... 1 ANY AUTO AUTO ONLY! ACG'S E_ACI•I OCCURRENCE $ ,.......... EXCESS I UMBRELLA LIABILITY AGGREGATE S OCCAJR �CLAIMS MADE DEDUCTIBLE - -- - .— S RETENTION S WORKERS GOMPENSATON WGtlQ0131908 05/17/2009 05/1 /2010 ...-LT Lfm S ....LER •._ P. AND EMPLOYERS'LIABIVI F.L.EACH ACCIDENT S .. _. 100,000 ANY PROPRIETORIPARTNER)FXECUTME _1 ( I E.L.DISEASE•EA EMPLOYEES 100,000 B OPFICER/MEMBER EXCLUDED? --,_ -•-- — -- -'•-�-' "' In E.L.DISEASE•POLICY LIMB i S00 100 M lar 48wiEe u dBr $i'tCwL PROVISION$hclow OTHER OESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES 1 O(CLUSIONS ADDED BY ENOORSEMEM 15PECIAL PROVISIONS ertificate is issued in the interest of the named insured and Certificate holder listed below• ertificate is subject to conp&ny conditions and exclusions. lames Callagher is excluded rom Workers compensation coverage. CERTIFICATE HOLDER CANCELLATION SMTE TD ANY O.TME ABOVE INSURER ILL EN09 BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF.THE ISSUING ENSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE MOLDER NAMED TO THE LOFT.BUT FAILURE TO 00 SO SMALL IMP056 NO OBLIGATION OR UABILITY OF ANY II UPON THE INSURER.ITS AGENTS OR Town of N Andover REPRESENTATIVES, 1600 Osgood Street AUTNORR@DREPRESGNTATVE O.J.0 Building 20-236 N Andover. MA 01845 David Se al TEL ACORD 25(2009101) FAX: 978.688.9542 ®1988-2008 ACORD CORPORAT ON. All rights reserved. The ACORD name and logo Sre registered marks of ACORD Page No. of Pages JIM GALLAGHER CONSTRUCTION 352 Howe Street METHUEN, MASSACHUSE'T'TS 01844 (978)686-8163 . PROPOSA ITT IJ Jy� C P /(�/ as D DATE ! V 10B NAME CITY, STATE AND ZIP CODE JOB LOCATION ARCHITECT DATE OF PLANS ::�: JOB PHONE We hereby submit specifications and estimates for: __._.........................................................................................................._......._.......,.......................................... _............:............................_............. ........... ................._._..._...................,....... .. ............................................................ .......................... _._...._.........................: .................................... ............... ............I.................. ............ ....... ...... 1i........... ....................................... ................ .. _ _ _ _110L I y _ _ .......... ........................... 0 � _ ..... ...... ................. . ...................... .......................... _................. ..................... ............ .......... .................... o ©d ........................._......._._............._............ ............................. ...................................... ................ __._......................... ...... _...... ...... ................... ...._.._............._.._................................................_...................._............................._............................ St f rlapor hereby to furnish material and labor —complete in accordance with above specifications, for the sum of: Payment to be made 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 deviation from above specifica• Authorized tions involving extra costs will be executed only upon written orders,and will become an Signature extra charge over and above the estimate.All agreements contingent upon strikes,accidents Lworkers nd our control.Owner to carry fire,tornado and other necessary insurance. te:This proposal may be re fully covered by Workmen's Compensation Insurance. with b us if not accepted within days.— _//�l 1 Y ru�ro �l—The above prices,specifications �ns are satisfary and are hereby accepted. You are authorized Signature / r rk as specified.Payment will be made as outlined above.ptance: Signature NORTIy '9 0" . 0 f Andover , O No. - _ dover, Mass., d COC HIC HE WICK DRATE D BOARD OF HEALTH PERMIT .. T D Food/Kitchen Septic System, BUILDING INSPECTOR THIS CERTIFIES THAT 2 � .....'A %Q....................YYt..J....... ............. .............. ""r""" ""' Foundation ... ...... .... ... has permission to erect...............:........................ U1. Ings on . •......... _...... .. .................�.�... ....................... Rough to be occupied as....... ......... ............ ....•I ........s. ........��.MNR6.....✓............... Chimney Chi provided that the person accept this permit shall in every respect conform to the terms of the application on file in Final 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CON ST1.7 T S Rough ...................................................................... ................. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. Burner FIRE DEPARTMENT Street No. IL SEE REVERSE SIDE Smoke Det.