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Home My WebLink AboutBuilding Permit #463-11 - 1705 Turnpike Street 12/2/2010TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION i Permit NO: L _ff" Date Received Date Issued: J Arg I IMPORTANT: Applicant must complete all items on this pate LOCATION a\. ^ Print PROPERTY OWNER L _U, K%Y\L CnpKq // Print MAP NO: PARCEL: 0�-%ONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE I Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ! 0 Two or more family ❑ Industrial 0 Alteration. No. of units: Ee6ommercial Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic, ❑ Well ❑Floodplain p Wetlands ❑ WatershedE > strict.. t D;Water/Sewer - DESCRIPTION OF WORK TO BE PERFORMED: Please Type or Print Clearly) OWNER: Name: Phone: c CJQ k Address: \�� `,��_ ��[�..olC��G� C��,IS('� CONTRACTOR Name: A 1, Yy irw— Phone: r — (z Address: .\. -\c I' kc: () Supervisor's Construction License: Home Improvement License: ARCH ITECT/ENGINEE %IlaiEx p .Date: Exp. Date: Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT. • $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cost: $ (o ,, 52�CFEE: $ Check No.: 0p- Recei t No.: NOTE: Persons contr -ting with unregistered contractors do not have access to the guar my fund Si nature€o en Qwner _Signature of'contractor- , _ v Plans Submitted ❑ Plans Waived 11 Certified Plot Plan Stamped Plans 11 TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site El THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS I CONSERVATION COMMENTS HEALTH COMMENTS v DATE REJECTED DATE APPROVED ❑ ❑ Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comme Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: FIRE DEPARTMENT - Temp Dumpster on site Located at 124 Main Street Fire Department signature/date COMMENTS i Located 384 Osgood Street yes no 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 Doc:.Building Permit Revised 2008 I Building Department The following is a list of the required forms to be filled out for the aropppria« NV,,,,,< <U uC vuanea. Roofing, Siding, interior Rehabilitation Permits ❑ Building Permit Application Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/0r C.S.L. icenses ig) Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpstiier 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/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 ConstrucA tion (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 sp Icial permit was required the T own Clerks office must stamp the sion from the Board of Apeals that the appeal period is over. The applicant must then get this recorded t the Registry of DeedsclOne copy and proof of recording , must be submitted with the building application Doo: Doc.Building Permit Revised 2008mi Location Y No.Yjg� 3 72/z Date Zd —2-1:7D NORTry TOWN OF NORTH ANDOVER • OL i �a Certificate of Occupancy $ 14, Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee TOTAL Check do 23760 Building Inspector O z. I F c c as c c sa o = L :.0 O C i.. O C m C p i :EQ CJ co c ;Ec ' c.. . o 0 o� m cm c v L db: o N cm R a _m N O N m _ c.vL om � N Z COO C Q,cs m o � V y O 'COD Z C � O y." C H y m C F- W C .teas t . 2 isCA C.t A C :.; W •� v� v CM V co 0-049.s y C. o 32 = CIOW A ` N C. . m E a LA L N 0 N C 0 cm co cr- OI C m O Of C �C N m t O Z O J O T co O O U a) L O Ov Z CD O U CO) C F_ w CO) O G _ y �E O CL ~ +=+ F O � 0CD co 0 IO c�a w° J) CMa w° a�' U u. v a w a O cn w C a w wcd cA z cn cn c c as c c sa o = L :.0 O C i.. O C m C p i :EQ CJ co c ;Ec ' c.. . o 0 o� m cm c v L db: o N cm R a _m N O N m _ c.vL om � N Z COO C Q,cs m o � V y O 'COD Z C � O y." C H y m C F- W C .teas t . 2 isCA C.t A C :.; W •� v� v CM V co 0-049.s y C. o 32 = CIOW A ` N C. . m E a LA L N 0 N C 0 cm co cr- OI C m O Of C �C N m t O Z O J O T co O a) L O Ov Z CD O � CO) C O Om CO) O G _ y �E O.0 m m CL ~ +=+ � O � 0CD co 0 0 o a a CMa CO) C C3 c cv Cc v J .� •C co O CDZ C. V C cc C C C. Q� ul W W 19 W N From: Peggy A. Stevenson At: Eastern States Insurance Agency, Inc. FaxID: To: Inc. Date: 12/2/2010 01:50 PM Page: 2 of 2 OP ID: PS ACORO" CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 12/02/10 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 781-642-9000 Eastern States Insurance 781-647-3670 Agency, Inc. I 50 Prospect Street Waltham, MA 02453 CONT NAMEACT A,Or Ext): (A/, No): E-MAIL ADDRESS: PRODUCER ALPRI-1 CUSTOMER ID#: INSURER(S) AFFORDING COVERAGE NAIC # INSURED A.L. Prime Energy Consultant INSURER A: CNA Insurance Companies Inc. I INSURER B: Ace Property & Casualty 319B Salem (Street Wakefield, MA 01880 INSURER C: Peerless Insurance Company 24198 INsuRER D :General Star Indemnity Co. INSURER E 12/01/10 INSURER F DAMAGE TO RENTED PREMISES Ea occurrence $ 100,000 COVERAGES I CERTIFICATE NUMBER: 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 MAYHAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSR S 8 WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY TCP2082441295 12/01/10 12/01/11 DAMAGE TO RENTED PREMISES Ea occurrence $ 100,000 CLAIMS -MADE Fx_1 OCCUR MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 Contractual Liability Include GENERAL AGGREGATE $ 2,000,000 ffI GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGS $ 2,000,000 POLICY PRO- LOC JECT . $ C AUTOMOBILE LIABILITY ANY AUTO ( BA8355277 12/01/10 12/01/11 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 BODILY INJURY (Perperson) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ X X SCHEDULEDAUTOS HIRED AUTOS PROPERTY DAMAGE $ (Per accident) $ X NON -OWNED AUTOS UMBRELLA LIAB FF0,CUR EACH OCCURRENCE $ 4,000,000 AGGREGATE $ D EXCESS LIAB AIMS -MADE IXG379730 12/01/10 12/01/11 DEDUCTIBLE S Auto $ ONLY $ RETENTION $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y!❑N C46388938 12/01/10 12/01/11 X WC STATU- OTH- TORY LIMITSER E.L. EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDE D9 (Mandatory In NH) N/A E.L. DISEASE -E4 EMPLOYEE $ 1,000,000 If 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, If more space Is required) RE: Permit CERTIFICATE HOLDER CANCELLATION EVIDENC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Evidence of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2009/09) ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial.Accidents Office of Investigations 600 Washington Street Boston, HA 02111 www.mass.gov1dia Workers' Compensation Insurance Affidavit: Biiildexs/Contractors/FIectricians/JPlumbers .Applican�Juformation Please Print Legibly . r Name(B.usiness/Organization/Tndividual): Address: \ S(,Ne_cn S� Phone#: 725\ 'at -IC,, (�aok Are you an employer? Check the appropriate box: 1. [01 am a employer with. 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. z ship and have no employees These sub -contractors have working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] i workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL 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. ❑ Building addition 10.❑ Electrical repairs or additions 11. F1 Plumbing repairs or additions 12.2foof repairs 13.❑ Other *Any applicant that checks box 41 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 anew 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. Insurance Company Name: fc&a�Ae �6. � u� St �CGc1c L f� Q A t—V Policy # or SeIf-ins. Lic. #: , CL��p 'ani Expiration Date: X a i 1 �1 lb - � I ( I Job Site Address:�1t�'�E1Ca��,5�- 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 ofthis statement may be forwarded to the Office of Investigations of the DIA, for insurance coverage verification. I do hereby Phone #: 'penalties ofperjury that the information provided above is true and correct. Official use orgy. Do not write in this area, to be completer) 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. EIectricaI Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: J VT CO LO 0 m J X U (9 w g }W m WO H LL — Z a x W -� ,, r . :.4 k � ;. a .. r