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HomeMy WebLinkAboutBuilding Permit #491 - One High Street 1/22/2010TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: W1 Date Received Date Issued: IIA -PI to IMPORTANT: Applicant must complete all items on this nage LOCATION l W6" �" "[� 0 G b�x/r TMA Print PROPERTY OWNER MA-JAU�. it�1V Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no !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 Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Hi V\0r av1- v'LtH' 0-�.rz, err-V\DV&4- invt4, OV\ 3�d Identification Please OWNER: Name: Address: l 4A icA�-k CONTRACTOR Name:, 1. C- xi6J - or Print Clearly) ?a02 -q . &Ui Supervisor's Construction License: E;wOIB- Exp. Date:�5 l t Home Improvement . Date: ARCHITECT/ENGINEER xv Ma(nvl eMv'Le +hone: Address: 300 A STtZg5,:;-T, 02?A0 Reg. No. 4152� FEE SCHEDULE: BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ �'Gj. Aro, 00 FEE: $ DO Check No.: .12 9 Receipt No.: NOTE: Persons contra 'ng with unregistered ontractors do not have access to fu d Signature of Agent/O - Signature of contractor 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 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: FIRE DEPARTMENT - Temp Dumpster on site yes. Located at 124 Main Street Fire Department signatureldate COMMENTS Located 384 Usg000 Street �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 NOTES and DATA — For department use ❑ Notified for pickup - Date Doc:.Building Permit Revised 2008 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 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 ❑ 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: Doc.Building Permit Revised 2008 Location No. �/ ci / Date / � Z 1z TOWN OF NORTH ANDOVER .. y Certificate of Occupancy $ �'�s'••° E�� sAcMus Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # ")5(F4l Building Inspector w O W W GQ uuoov u O w° U w O P.4 a —coC/) w O Gs; o�G vi w p w w ww w w z , cn O cn CD �. c� h�o� r: r- % % o v v me •- _- � L O co t d L LU 3 � o E C cC, N C c �mm cn C m 4 C a NsL': A:: c O IOD O r4 �.mo 0 acs ®``'. y m m V y O Z +: ccc oo HQ a C : y O C CD : mz 3 m r0,~ W C =C, JZ t Wco . DQ 's •.Z O C .E V ti V m p ® C CLH a m� O-0 Z A o = �- z - O. z m 07 *� 0 z 1 01, U O v CD W W N The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Nalne (Business/Organization/tndividual): J. Calnan & Associates, Inc. Address: 1250 Hancock Street, Suite 302N City/State/Zip: Quincy, MA 02169 Phone#: (617) 801-0200 Are you an employer? Check the appropriate box: 0 I am a employer with 5 5 4. ❑ I am a general contractor and I employees (full and/or part-ti.tne).* have hired the sub -contractors '. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees 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.] t These sub -contractors have employees and have 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' insurance Type of project (required): 6. ❑ New construction 7. ❑ Remodeling R. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box Nl must also till out the section below showing their workers' compensation policy information. r Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. zContractors 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' camp. policy number. 1 ant an employer that isproviding workers' compensation insurance for niy emploj,ees. Below is thepolicy= and job site information. Insurance Company Narne: Ohio Casualty Insurance Policy # or Self -ins. Lic. #: XW053119614 Expiration Date: 101/2 010 Job Site Address: I HjAh G4-rV_,-b City/State/Zip: 1,1 PcVwoVQitr, IAN 01$4-T 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 Nainst the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the�51k for insur3yce coverage verification. do hereby rtif�utller tli/andf nalties of perjury that the information provided above is trite and correct. W-2ar3kM only. no not write in tltis area, to be completed by city or town official. City or Town: Perm it/License # IIvz to Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: ffnformation and ffnstrl1fleflQDns 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 entity, or any two or more of the foregoing engaged in a joint enterprise, 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 another who 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 has 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 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 certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to cavy 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 for 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' compensation policy, please call the Department at the number listed below. Self-insured 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 "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 permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a Iicense 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 424-07 Fax # 617-727-7749 www.mass.gov/di.a V�CERTIFICATE OF LIABILITY INSURANCE 1012( 2009 PRODUCER Phone: 781-681-6656 Fax: 781-681-6686 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION The Driscoll Agency, Inc. 93 Longwater Circle P.O. Box 9120 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. *SAMPLE* Norwell MA 02061 POLICY EFFECTIVE DATE MMIDD POLICY EXPIRATION DATE MM DD INSURERS AFFORDING COVERAGE NAIC # INSURED J. Calnan & Associates, Inc. President's Place, No.Tower 3 INSURERA:Nat' 1 Fire Ins Co of Hartford 20478 INSURER B: Everest National Insurance Co INSURERc:Ohlo Casualty Insurance Co. 1250 Hancock Street INSURER D: Quincy MA 02169 INSURER E: 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. INSRDD' LTR WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE *SAMPLE* POLICY NUMBER POLICY EFFECTIVE DATE MMIDD POLICY EXPIRATION DATE MM DD LIMITS A GENERAL LIABILITY INS2095325239 10/1/2009 10/1/2010 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE ( RENTED PREMISESS Ea occurrence) $ 100,000 CLAIMS MADE FX_1 OCCUR MED EXP (Any one person) $ 5,000 PERSONAL BADV INJURY $ 1,000,000 X Tri(, Contra( tical GENERAL AGGREGATE $2,000,000 X Inc . X, C, U GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $2,000,000 POLICYFXPRO- LOC A AUTOMOBILE LIABILITY ANY AUTO SAP2095325225 10/1/2009 10/1/2010 COMBINED SINGLE LIMIT (Ea accident) $1000000 BODILY INJURY $ (Per person) X ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY $ (Per accident) X X HIRED AUTOS NON -OWNED AUTOS PROPERTYDAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EAACC $ ANY AUTO AUTO ONLY: AGG $ $ EXCESS/UMBRELLA LIABILITY 71C8000071-91 10/1/2009 10/1/2010 EACH OCCURRENCE $10,000,000 X I OCCUR F—I CLAIMS MADE AGGREGATE $ 10,000,000 $ DEDUCTIBLE $ RETENTION $ 0 CWORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE XW05 3119 614 10/1/2009 j 0 j 2 / / 010 WC sTATU OTH- X TORY LIMIT -SIX I ER MA RI CT N E.L. EACH ACCIDENT $500000 OFFICER/MEMBER EXCLUDED? ❑ (Mandatory in NH) E.L. DISEASE - EA EMPLOYE $500000 If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $500000 A OTHER INS2095325239 10/1/2009 10/1/2010 Leased or Rented $100,000 Conractor Equipment DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Evidence of insurance for work performed within the Insureds scope of normal business operations. Notice of cancellation provision is 30 days, except 10 days applies for non-payment of premium. CERTIFICATE HOLDER CANCELLATION -� n ACORD 25 (2009/01) © 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD OF created with pdfFactory Pro trial version www.pdffactory.com SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE *SAMPLE* CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO USA SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25 (2009/01) © 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD OF created with pdfFactory Pro trial version www.pdffactory.com '� �i;t.•acftu�rtt. - Defuirtmcnt of Public `afm Bom-d of Buildin-, Regulation. and `tandardk Construction Supervisor License License: CS 56087 Restricted to: 00 STEPHEN M TERRENZI 12 ENDICOTT STREET NORWOOD, MA 02062 Expiration: 3/5/2011 ( nuiii.a,nr Trx: 12500 14oRTh TOWN OF NORTH ANDOVER oe `e`•o ' 0� OFFICE OF BUILDING DEPARTMENT 400 Osgood Street North Andover, Massachusetts 01845 D. Robert Nicetta, Building Commissioner Telephone (978) 688-95454 Fax (978)688-9542 CONTROL CONSTRUCTION - SECTION 116.0 M.S.B.C. CERTIFICATE OF ENGINEERING/ARCHTTECTURE BULDING INSPECTOR TOWN OF NORTH ANDOVER 400 OSGOOD STREET NORTH ANDOVER MA 01.845 I Carolyn Hendrie HEREBY CERTIFY THAT THE BUILDING CONSTRUCTED AT 1 High Street DOES CONFORM IN ALL RESPECTS TO THE MASSACHUSETTS STATE BUILDING CODE AND APPLICABLE FEDERAL REGULATIONS FOR THE FOLLOWING: Building 14, 3rd Floor Renovation for Converse, Inc. AUTHORIZED SIGNATURE: DATE: December 21, 2009 REGISTRATION: 4823 NOTE: ENGINEER "WET STAMP" MUST BE AFFIXED TO THIS FORM Control Constntction fonn revised 1 1 J 5 2004 ��a CNF. c, 4'623 rit t - ( TO BOARD 01 API'I:ALS 688-1541 CO NSI_ RVA 1'1ON 688-9530 1 II,AL [if 688-9540 ('I ANNING 688-t>535 TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT 400 Osgood Street North Andover, Massachusetts 01845 D. Robert Nicetta, Building Commissioner Telephone (978) 688-95454 Fax (978)688-9542 CONTROL CONSTRUCTION -SECTION 116.0 M.S.B.C. CERTIFICATE OF ENGINEERING/ARCHITECTURE ' BULDING INSPECTOR TOWN OF NORTH ANDOVER 400 OSGOOD STREET NORTH ANDOVER MA 01845 I, Carolyn Hendrie .HEREBY CERTIFY THAT THE BUILDING CONSTRUCTED AT 1 High Street DOES CONFORM IN ALL RESPECTS TO THE MASSACHUSETTS STATE BUILDING CODE AND APPLICABLE FEDERAL REGULATIONS FOR THE FOLLOWING: Building 14, 3rd Floor Renovation for Converse, Inc. AUTHORIZED SIGNATURE: DATE: December 21, 2009 REGISTRATION: 4823 NOTE: ENGINEER "WET STAMP" MUST BE AFFIXED TO THIS FORM Control Construction Form revised 11.15.2004 C• 4,523 TO BOARD OF APPEALS 688-9541 CONSERVATION 688-95330 11LALTII 688-9540 PLANNING 688-9535