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HomeMy WebLinkAboutBuilding Permit #054-2011 - One High Street 7/13/2010 BUILDING PERMIT Of NORTH 1 4ts�ao 4aa 1•A TOWN OF NORTH ANDOVER o APPLICATION FUR PLAN EXAMINATION Permit N0: Date Received 4To'����, IO CHUS�� Date Issued: �3 4SS� IMPORTANT: Applicant must complete all items on this page Ge,,{r,,Ve V'S P LOCATION 1 -1�1A�1 S `Get / o�-EM kVxAD\1,ey, (1h ptg+S' Pr, t PROPERTY OWNER VA0,Vx5uY t nve'7- MC v4-6 Print MAP NO: 6 q PARCEL: O/ ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Additi I Two or more family Alteration No. of units: 2Comrr�e�riaD Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORM: MY bF 0 OWNER: Name: Identification Please T pe or Print Clearly) OTT rnki, F�AA1,16 Phone: Address: W61A 5C , to Aqk1Q0VfA MA 01*4-6' CSA-P-ve,'I�vv-e vtu CONTRACTOR Name: ,-j NA 1AA Vi 4 Ke_4.,OG, I vac, Phone: &1-7 W Address: -3t , SA-e— -30L-O [Q UW\C\/ OA O Lt &1 Supervisor's Construction License: G&OS"7 Exp. Date: 3 S it Home Improvement License: Exp. Date: 0:�0LV-akyY-\ -Kt ARCH ITECT/ENGINEER&Ly4ma-on 4A_tn,4-\e,-r NOS one: l'1 - 35`?V -0+G-0 Ili Address: 3t c> 4, STf-eX_'T", Wix l �, I-AA n22iOReg. No. $ Z3 T I - FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ J�]h l FEE: $ 06 , 00 Check No.: 3/f(4/1 Receipt No.: O�l5 NOTE: Persons contracting with unregistered contractor's-do not have access to-aa guarantyfund Signature of Agent/Owner Signature of contractor Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL I 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 t 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: Located 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date 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 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:Building Permit Revised 2008 Location No. L2�C— p4t Date 711,dl" NORTH TOWN OF NORTH ANDOVER 3? OL • i � Certificate of Occupancy $ sACMUs<� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 3Z/ka �l 2 wilding Inspector flf ttO RTy TOWN OF NORTH ANDOVER mss, °* o OFFICE OF BUILDING DEPARTMENT ; 400 Osgood Street North Andover,Massachusetts 01845 c�tu � D.Robert Nicetta, Telephone(978)688-95454 Building Commissioner 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 1, 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 , Selected Renovations to Floor 2 - Archive Room for Converse, Inc. AUTHORIZED SIGNATURE: DATE: July 9, 2010 REGISTRATION: 4823 10 ED Q?C NOTE: ENGINEER"WET STAMP" MUST BE AFFIXED TO THIS FORM ov-4 C fit,' "i. o 23 io M Control Construction Form revised 11.15.2004 4TH of y P BOARD OF APPEALS 688-9541 CONSERVA'3.ION 683-9530 HEALTH 688-9540 PLANNING 688-9535 ~-- (4r- 2 �►� v-� t40RTH TOWN OF NORTH ANDOVER d��Y so bp.� O4 OFFICE OF o p BUILDING DEPARTMENT 400 Osgood Street North Andover,Massachusetts 01845 �$SRCFkt75�•� D.Robert Nicetta, Telephone(978)688-95454 Building Commissioner 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 1, 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 , Selected Renovations to Floor 2 - Archive Room for Converse, Inc . AUTHORIZED SIGNATURE: DATE: July 9, 2010 REGISTRATION: 4 8 2 3 ED AiC- N T : ENGINEER WET STAMP" MUST BE AFFIXED TO THIS FORM i,jN C. o . fip 0 o cy N 23 $ eTo l: J� Control Constriction Form revised 11.15.2004 of% BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 1lEAL`CH 688-9540 PLANNING 688-9535 1 o� tto RT►, TOWN OF NORTH ANDOVER ,•', a,b�0 OFFICE OF BUILDING DEPARTMENT *Po e 400 Osgood Street North Andover,Massachusetts 01845 D.Robert Nicetta, Telephone(978)688-95454 Building Commissioner 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 , Selected Renovations to Floor 2 - Archive Room for Converse, Inc. AUTHORIZED SIGNATURE: DATE: July 9, 2010 REGISTRATION: 4823 Eo 4/eC. NOTE: ENGINEER"WET STAMP" MUST BE AFFIXED TO THIS FORM .�4a.�" C.yF1G��i CIS 23 W, . Control Construction Form revised 11.15.2004 ' a�TH of 0 BOARD 01 APPEALS 688-9541 CONSERVATION 688-9530 1IEAL'I'I-1 688-0540 PLANNING 688-9535 ORTH Town of And 0 No. '7/j //0 L A K E dover, Mass., CCC NICKEwICK 7�ADRATED SS BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THISCERTIFIES THAT......... . . .. .. EE^` ........................................................ Foundation has permission to erect..............:.:....................... buildings on ....�....... .. ...�. `. .S....................................................... Rough fil/IaPJ�(� Chimne to be occupied as A#40. r� ... q0 �� y provided that the person accepting 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 CONSTRUCTION STARTS Rough Service BUILDING Gam=^ 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 FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE S 1 D E Smoke Det. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' 600 Washington Street Boston, MA 02111 www.mass.govAlia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/individual): 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: Type of project(required): LM I am a employer with 55 4• ❑ I am a general contractor and I employees(full and/or part=time). * have hired the sub-contractors 6. ❑ New construction 2.❑ I am a sole proprietor or partner_ listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition working for me in airy capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp, insurance.: u req 1ired. 5. F1We are a corporation and its 10,F] Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LF❑ Plumbing repairs or additions myself. No workers' comp, right of exemption per MGL [ p• � 12.❑ Roof repairs c. 152, 1(4),an w v � insurance required.]t 5 d e have e no q ] 13.❑ Other employees. [No workers' comp. insurance required.] *Any applicant that checks box#1 must also till out the section below showing their workers'compensation policy information- *Homeowners who submit this affidavit indicating they are doing all work and[hen 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. 1 ant an employer that is providing workers'compensation insurance for my entpl�l-ees. Below is the policy and jab site information. Insurance Company Name: Ohio Casualty Insurance Policy#or Self-ins.Lic.#: XW05 3119 614 _ Expiration Date: 10 1 2 010 Job Site Address: [ t4J C< A �T City/State/Zip: VA.4 J0 y ir't_ 4 O 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 tine 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 Investigations of the DIA for insurance coverage verification. 1 do Hereby cerci ut to pains and penalties of perjtcry that the information provided abo e is true and correct. Sianature - Date: Iq- J 4.66, 20 tO Phone M 9i (p_ Q 5�01 04�O a Official use only. Do not write in this area,to be completed by city or town of fciaL City or Town: Permit[License# 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#: information and Rnstructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an emplovee 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 steal I 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-contractors)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 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 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 a2propriate 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 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 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 4-24-07 Fax# 617-727-7749 www.mass.gov/di.a , 11,1 O CERTIFICATE OF LIABILITY INSURANCEF5/18/2010 DATE /YYYY) `� PRODUCER Phone: 781-681-6656 Fax: 781-681-6686 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION The Driscoll Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 93 Longwater Circle HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P.O. Box 9120 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Norwell MA 02061 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA:Nat'1 Fire Ins Co of Hartford 20478 J. Calnan & Associates, Inc. INSURER B:Continental Casualty Co. 20443 President's Place, No.Tower 3 1250 Hancock Street NsuRERc:Everest National Insurance Co Quincy MA 02169 INSURERD:Ohio Casualty Insurance Co NSURERE:Amer Int' l S ec Lines Ins. Co 126883 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' POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR N TY F DATE MMIDD DATE MM/DD A X GENERAL LIABILITY C2095325239 10/1/2009 10/1/2010 EACH OCCURRENCE $1,000, 000 X COMMERCIAL GENERAL LIABILITY DAMAGE ( RENTED PREMISESS Ea occurrence) $300, 000 CLAIMS MADE Fx_]OCCUR MED EXP(Any one person) $ 5, 000 X Inc!. Contractual PERSONAL&ADV INJURY $1,000, 000 GENERAL AGGREGATE $2,000, 000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000, 000 POLICY X P� LOC B X AUTOMOBILE LIABILITY SAP2095325225 10/1/2009 10/1/2010 COMBINED SINGLE LIMIT X ANY AUTO (Ea accident) $ 1, 000, 000 ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ C X EXCESS/UMBRELLA LIABILITY 7108000071-91 10/1/2009 10/1/2010 EACH OCCURRENCE $ 10, 000, 000 C X I OCCUR F—I CLAIMSMADE Per Project Agg 10/1/2009 10/1/2010 AGGREGATE $ 10, 000, 000 DEDUCTIBLE $ X RETENTION $$10, 000 $ D WORKERS EMPLOYCOMPENSATION ILIT WC STATUYIN XW053119614 10/1/2009 10/1/2010 X TORY LIMITS OER AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE❑ E.L.EACH ACCIDENT $500, 000 OFFICER/MEMBEREXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500, 000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $500, 000 OTHER Limit $1,000,000 E Pollution and CPPL8088097 10/1/2009 10/1/2010 SIR $25,000 Professional DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/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 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 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 Massachusetts - Department of Public Safeo Board of Buildint, Re-ulations and Standards Construction Supervisor License License: CS 56087 Restricted to: 00 STEPHEN M TERRENZI 12 ENDICOTT STREET NORWOOD, MA 02062 Expiration: 3/5/2011 -01mmiaimier Tr#: 12500