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HomeMy WebLinkAboutBuilding Permit # 6/4/2015 FORTH BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION _ p Permit No#: yup Date ReceivedSRA rep �gSSgCHUS �y Date Issued: .� IMPORTANT: Applicant must complete all items on this page I LOCATION 15-6 -,4v,-n V Print PROPERTY OWNER Qaskz-f- Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes O Machine Shop Village yes 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 .,f a3,�, i?'"�i'.., �x+r x„'` ..r �sy✓r '.a'��$`F&.�f �.-,Gni`,�`�`�r'%. Fl � � ;,.*fi r reps r✓�„,rr+� x,?�+?�,��,.��` �`' `` Y�; ffi.,, x � F r�l ,s .:�-.n ;'-.�,'`� .li�,:;�j.' j t �,.r. xt�. ,,�..: �n �f�s,�:x-.r"� a.,o-.,Fio'a'Y... f,� "�3"?...',: ,.x ,.�r .✓�:x... t. ,.x.� '. � 9 +�i s�`f.. ., x,.<ar .1' .=- =s'.;.�c3 ��-� 9rrr-2Y.,r:.,�fr ..y`�'�,.9��r 3'"c �.,. ,% 1�,z✓t�i .� z ;.. ': �'.�✓��...,, � .>. K .,r .;ay �;r`,�F�a''.;,.. .,_/>� ...t o"�'�l,�rr�..x�,,,�.xr.r.�r r.�r r'±�,�� i rrs�� r% /'�:...; � x"r r... r,�rr•-,� �c r.. ,;,.,:' DESCRIPTION OF WORK TO BE PERFORMED: Ao(al 2 (,.L 5,-s -Pyv n-- o ff- b46.,V a"Irl new b aI c"y�P 'V 4"W s A -�--a ��,I.�e✓t/ ��(o( 2 si�,Ls iln haks�bsl7op> (�hclprGn�v„dl -�-e�c��i.�-fz,r- nrws�G,,�s qnc� 2 �vrl-�S�s' Gth� i-enrn�r Identification- Please Type or Print Clearly OWNER: Name: pA 43oslc-e4, Phone: -706a Address: ?-15- E 54, .ev q6s 01814, Contractor Name: S�,eQ1� Cakis4 v- F,h Phone: lQa 3 ?y'1 3a 1 Email: Address: 1 i2a+, fZ,,vlcl�e A04 63L-1(. ( Supervisor's Construction License: C 5 - (v` o`l Exp. Date: 1 1212a 1� Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ 1 U , 0 0 FEE: $ E Receipt No.: Check No.: p NOTE: Persons contracting with unregistered contractors do not have access to the guar ty fund T FORTH _t own of It Andover so r -W_ 0 ®O Y n O LAKE h ver, ass, COCHICHEWICN y1' S � BOARD OF HEALTH R IT LD Food/Kitchen Septic System THIS CERTIFIES THAT BUILDING INSPECTOR ,,,\\ ... Foundation has permission to erect .......................... buildings on ....... .�.I........ .. .tom.. .. . .� Rough to be occupied as ..AAA,.This, ... �� . .. k Rough. .. . .. . . . .. ... .. ... ... .. provided that the person acceptpermit shall in every respect confor t the s 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final ITE I ® ELECTRICAL INSPECTOR 1CW LESS T I S Rough Service ............ ........ .. ...................... :,w.= ,, ........ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildin 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 Approvedthe Building Inspector. Burner Street No. Smoke Det. t r7 A EXECUTIVE OFFICES 875 EAST STREET TEWKSBURY, MASSACHUSETTS 01876-1495 978-851.8000 May 4, 2015 To Whom It May Concern: Seppala Construction Inc. is authorized to provide construction services to add a sandwhichjsalad case in the Market Basket store located at 350 Winthrop Ave., North Andover, MA.This job will be issued to Seppala Construction on a time and material basis. If you have any questions I can be reached at 978- 640-8117. Normand Martin Facilities Manager Planning& Development The Commonwealth of Massachusetts Department oflndustriaiAccidents i{ 1 Congress Street Suite 100 Foston, MA 02114-2017 www mass.govIe is NVurkers' Compensation InsuranceAffldavit:Builder s/C ontr actor s/Flectridans/Plumb ers. TO BE FrLED WITH THE PERMITTING AUTHORITY. Applicant hiformation Please Print. Legll)ly Name (Buaneee/Organization/Individual): Seppala Construction Co.,Inc. Address: 153 Hunt Hill Road City/State/Zip: Rindge, NH 03461 Phone#; ws-$ss-3011 Are you an employer?Check theappropriate box: Type of project(required): 1. Iamaemployerwith employees(full and/orpart-time).* 7, ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8, remodeling any capacity.[No workers'comp.insurance required.] 3.❑I am a homeowner doing all work myself.[No workers' comp.insurance required.]t 1. ❑BuildDemoing 4.[:]1 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition ensure that all contractcros eitherhave workers' compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13,❑ p Roof re airs These sub-contractors have employees and have workers'camp.insurance.$ 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and wehaveno employees.(No workers'comp.insurance required-] *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. I 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 most provide their workers' camp.policy number. I atrt aro employer that is providkg workers'compensation htwancefor OV employees Below die policy Mul,Job site hLrormatloft. Insurance Company Name: Ohio Security insurance Co. Policy##or Self-ins,Lia#: XWS553587M Expiration Date: 01/01/2016 \Job Site Address: 350 Winthrop Avenue City/State/Zip:North Andover, MA Attach a copy of the workers'compensation policy 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. 1d hereby cern,mader'the palrs=dpenaldes gf'pedury flint the t'Ylformation provided above is true and correct. 5i` tltllre Date t Phone#: 603-899-3011 Official use only. Do not write in this ewer4 to be completed by city or town q ffleial City or Town- Permit/lAcense# Issuing Authority(drde one): 1. Board of Health 2.Building D epartment. 3. City/Town Clerk d.Electrical Inspector 5.PlMnbingInspector 6.Other Contact Person: Phone#: '4 CERTIFICATE OF LIABILITY INSURANCE 5/5/2015 Y' 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 endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).. PRODUCERYvette Fanaras NAME: Infantine Insurance PHONE IA/C (603)669-0704 I FAX AIC Na 603-669-6831 P. O. Box 5125 6012 .yvette@infantine.com INSURERS!AFFORDING COVERAGE NAIC X Manchester NH 03108 INSURERA:American Fire & Casualty 4066 INSURED INSURERB:West American Ins Co 44393 Seppala Construction Co. , Inc. INSURERC:Peerless Ins Co, 24198 153 Hunt Hill Road INSURERD:Ohio Security Ins Co 24082 INSURER E: Rindge NH 03461 INSURERF: COVERAGES CERTIFICATE NUMBER:2015/2016 Master REVISION NUMBER: 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 WTH 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, EXCLUSIONSAND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE INSR VM POLICY NUMBER .MMJDDfYYYY MMA)DIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COM MERCIAL GENERAL LIABILITY PREMISESIE oerurrence $ 300,000 A CLAIMS-MADE D OCCUR X KA55358735 /1/2015 1/1/2016 MED EXP(Anyone person) $ 5,000 PERSONALRADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATELIMIT APPLIES PER: PRODUCTS-COMP/OPAOG $ 2,000,000 POLICY I X I PRO X LOC S AUTOMOBILE LIABILITY COM B;NEDSINGLE LIMIT $ 1,000,000 B X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BAWS5350735 /1/2015 1/1/2016 AUTOS AUTOS BODILY INJURY(Per accident) S X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS er acc(dent S X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 10,000,000 C EXCESS LIAB CLAIMS-MADE AOOREGATE $ 10,000,000 DED I X I RETENTIONS 10,OOC X S05535B735 /1/2015 1/1/2016 $ D WORKERS COMPENSATIONNIn STAT.. OTN- AND EMPLOY ERS'LIABILITY YIN X 0 YLIMTS X ER ANY PRO PRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 OFFICERIMEMBER EXCLUDED? [N] N/A (Mandatory In NH) wS 5 53 5 873 5 ./l/2015 1/1/2016 E.L.DISEASE-EA EMPLOYE $ 500,000 If yes,describe under DESCRIPTION ate: NH,MA VT NY SCOF OPERATIONS below tE.L.DISEASE-POLICYLIM IT $ 500,000 DESCRIPTION OF OPERATIONS f LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Various Work It is agreed and understood Market Basket Store #12 and DSM II LLC are named as additional insureds with respects to General Liability and Umbrella when required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Market Basket Stare #12 ACCORDANCE WITH THE POLICY PROVISIONS. 350 Winthrop Avenue North Andover, MA 01845 AUTHORIZEDREPRESENTATNE Jim Harrison/BYM �^�'' ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 gotou),oi The ACORD name and logo are registered marks of ACORD ACo CERTIFICATE OF LIABILITY INSURANCE 5i5 2oDD5 Y) �- 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(ies) 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 NAME: Yvette Fanaras Infantine Insurance PHONE (603}669-0704 AJC No FAX 603-669-6831 P. O. Box 5125 E-MAIL .yvette@infantine.com INSURER(S)AFFORDING COVERAGE NAIC H Manchester NH 03108 INSURERA:American Fire & Casualty 4066 INSURED INSURERB:West American Ins Co 44393 Seppala Construction Co. , Inc. INSURERC:Peerless Ins Co 24198 153 Hunt Hill Road INSURERD:Ohio Security Ins Co 24082 INSURER E: Rindge NH 03461 INSURER F: COVERAGES CERTIFICATE NUMBER:2015/2016 toaster REVISION NUMBER: 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. LTR TYPE OF INSURANCE INSR VWD POLICY NUMBER 'MMJDDIYYYY MMJDDJYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMA(31:10 RENT E X COMMERCIALGENERAL LIABILITY PREMISES(Ea_oc_rurrence $ 300,000 A CLAIMS-MADE OCCUR KA55358735 /1/2015 1/1/2016 MED EXP(Anyone person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERALAGGREOATE $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPJOPAGO $ 2,000,000 POLICY I X I PRO- I X LOC $ AUTOMOBILE LIABILITY OMEKiEDSINGLE LIMIT(Ea $ 11000,000 B X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BAW55358735 /1/2015 1/1/2016 BODILY INJURY(Per accident) $ AUTOS AUTOS XX NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident $ X I UMBRELLA UAB X OCCUR EACH OCCURRENCE $ 10,000,000 C EXCESS LIAB CLAIMS-MADE AGGREGATE $ 10,000,000 DED X RETENTIONS 10,000 US055358735 /1/2015 1/1/2016 $ D WORKERS COMPENSATIONinrrrSTATI- OTH- AND EMPLOYERS'LIABILITY y J N X LI I S X PER ANY PRO PRI ETORJPARTNERJEXECUTIVE E.L.EACHACCIDENT $ 500,000 OFFICERIMEMBER EXCLUDED? NIA (MandatoryinNH) WS55358735 /1/2015 1/1/2016 E.L.DISEASE-EA EMPLOYE $ 500,000 If yes,describe under tate: tTH DESCRIPTION OF OPERATIONS below rliA rVT rNY r5 C E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if snore space is required) RE: Permit - Market Basket Store #12, North Andover MA CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The Commonwealth of MassachusettsACCORDANCE WITH THE POLICY PROVISIONS. Department of Industrial Accidents 1 Congress Street, Suite loo AUTHORIZED REPRESENTATIVE Boston, MA 02114-2017 Jim Harrison/BYM (I r--rCwwr ACORD 25(2010/05) ©1988.2010 ACORD CORPORATION. All rights reserved. INS026(201005),01 The ACORD name and logo are registered marks of ACORD f,ZVt Massachusetts -Depariment of Public Safety �Ot Board of Building Regulations and Standards Construction SuperN isor License: CS-106509 BENJAMIN KUUSiST( � 65 NH RT 119 '' " Rindge NH 0346f expiration 01/18/2016 Commissioner