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HomeMy WebLinkAboutMiscellaneous - Health Department 16 Royal Crest DriveLIL COMMONWEALTH OF MASSACHUSETTS North Andover BOARD OF HEALTH Cornerstone ---- --------------------------------------------------------------------------------------------------- NAME 16 ROYAL CREST DRIVE --------------------------------------------------------------------------------------------------------- ADDRESS IS HEREBY GRANTED A PERMIT Trench Permit NUMBER BHP -2017-0363 FEE $100.00 Trench Permit - Excavation to expose existing foundation & footing at bldg 12 to allow for repair of foundation drainage & waterproofing This permit is granted in conformity with the Statutes and ordinances relating thereto, and expires ----------------July-20, 2017 ---------------- unless sooner suspended or revoked. April 20, 2017 ------------------------------------ ----------- I ----------------- BOARD OF -------------------- ------------------------------ HEALTH ------------------- -------- -9 --- i y -------------------- -------------------------------------------- BOARD OF HEALTH CHAIRMAN ---------------------------------------------------------------- COMMONWEALTH OF MASSACHUSETTS North Andover BOARD OF HEALTH Cornerstone ---------------------------------------------------------------------------------------------------- NAME 16 ROYAL CREST DRIVE ---------------------------------------------------------------------------------------------------- ADDRESS IS HEREBY GRANTED A PERMIT Trench Permit NUMBER BHP -2017-0363 FEE $100.00 Trench Permit - Excavation to expose existing foundation & footing at bldg 12 to allow for repair of foundation drainage & waterproofing This permit is granted in conformity with the Statutes and ordinances relating thereto, and expires----------------Jul-Y-20,--2-0-1-7 ---------------- unless sooner suspended or revoked. April 20, 2017 r _ ---------- ---------- BOARD OF HEALTH CHAIRMAN --------------------------------------------------- BOARD OF ---------------- --------------------- ---------- HEALTH �� i�,,,r------------ --------------------------------------------------- --------------------------------------------------- of "O ,T 4 1y 7828 O Town of North Andover HEALTH DEPARTMENT ,SSAGHUS CHECK #: A/0 6 DATE: LOCATION: r� H/O NAME:1�"�G� CONTRACTOR NAME: Type of Permit or License: (Check box) $ ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5Inspector $ ❑ Title 5 Report $ Other: (Indicate) T fe.Ii Gh $� q ro Initials White - Applicant Yellow - Health Pink - Treasurer t t. TOWN OF NORM ANDOVER Permit Number NORTH AN -DOVER, MASSACHUSETTS 01845 Date Issued Expiration Date G6\,qS11D Vv 91�o Jackie's Law — Permit Applicatib���'`N Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seg.(as amended) THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION Name of Applicant Cornerstone Land Consultants, Inc. Phone Cell Street Address 2 Bridgeview Circle, Unit 2 (978)433-8100 City/Town MA ZIP Tyngsboro 01879 I Name of Excavator (if different from applicant) Phone Cell Street Address Heider Building Assoc. (978)851-2652 (978)606-1435 P.O. Box 217 City/Town MA ZIP Tewksbury 01876 Name of Owner(s) of Property Phone Cell Street Address AIMCO North Andover, LLC 16 Royal Crest Drive City/Town MA ZIP North Andover 01845 Permit Fee Received No Y Other Contact Description, location and purpose of proposed trench: Please describe the exact location of the proposed trench and its purpose (include a description of what is (or is intended) to be laid in proposed trench (eg; pipes/cable lines etc..) Please use reverse side if additional space is needed. E*CAvA'*t TO EtocPOSE E?4STO-J6i FOUQb4Tk*Q1 . LTi �--I AT T—;0j1 uDitc-1 12 Ta A u.cw P.. 1MPA-u2 CIF F u tv't,Az l bN rNZA4w1A-ee a 4 Insurance Certificate #: 0 L-' (-Ao ,7>c15o44o �\ / re c� Corner �o/v, lcot-rjr,4 /?es4 Name and Contact Information of Insurer: TF,, Cq"i8 ,44 25 _ 959 C • Polis Expiration Date: Dig Safe #: Name of Competent Person (as defined by 520 CMR 7.02): James A. Heider Massachusetts Hoisting License # HE -033993 License Grade: 2A Expiration Date: 14 �U BY SIGNING THIS FORM, THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY THAT THEY ARE FAMILIAR WITH, OR, BEFORE COMMENCEMENT OF THE WORK, WILL BECOME FAMILIAR WITH, ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED, INCLUDING OSHA REGULATIONS, G.L. c- $2A, 520 CMR 7.00 et seq., AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS AND REGULATIONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR SUCH WORK WILL COMPLY THEREWITH IN ALL RESPECTS AND WITH THE CONDITIONS SET FORTH BELOW. THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE PERMIT AND THE EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF THE OWNER, AND ALSO, FOR THE DURATION OF CONSTRUCTION, AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIPALITY TO ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONFORMITY WITH THE CONDITIONS ATTACHED HERETO AND THE LAWS AND REGULATIONS GOVERING SUCH WORK. THE UNDERSIGNED APPLICANT, OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO REIMBURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY THE MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED THEREUNDER, INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE LAW AND CONDITIONS OF THIS PERMIT, INSPECTIONS MADE TO ASSURE COMPLIANCE THEREWITH, AND MEASURES TAKEN BY THE MUNICIPALITY TO PROTECT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO COMPLY THEREWITH INCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURES DEEMED NECESSARY BY THE MUNICIPALITY. THE UNDERSIGNED APPLICANT, OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND, INDEMNIFY, AN I���THE MUNICIPALITY AND ALL OF ITS AGENTS AND EMPLOYEES FRO AND ALL LIABIL , CAUSES OR ACTION, COSTS, AND EXPENSES RESULTING FROM ARISING OUT OF ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPE Y DURING THE WORK CONDUCTED UNDER THIS PERMIT. DATE EXCAVA OR SIGNATURE (IF DIFFERENT) DATE OWNER'S SIGNATURE (IF DIFFERENT) DATE: 2 1 P a g e CONDITIONS AND REQUIREMENTS PURSUANT TO G.L.C.82A AND 520 CMR 7.00 et seq. (as amended) By signing the application, the applicant understands and agrees to comply with the following: In M iv. vi. No trench may be excavated unless the requirements of sections 40 through 40D of chapter 82, and any accompanying regulations, have been met and this permit is invalid unless and until said requirements have been complied with by the excavator applying for the permit including, but not limited to, the establishment of a valid excavation number with the underground plant damage prevention system as said system is defined in section 76D of chapter 164 (DIG SAFE); Trenches may pose a significant health and safety hazard. Pursuant to Section 1 of Chapter 82 of the General Laws, an excavator shall not leave any open trench unattended without first making every reasonable effort to eliminate any recognized safety hazard that may exist as a result of leaving said open trench unattended. Excavators should consult regulations promulgated by the Department of Public Safety in order to familiarize themselves with the recognized safety hazards associated with excavations and open trenches and the procedures required or recommended by said department in order to make every reasonable effort to eliminate said safety hazards which may include covering, barricading or otherwise protecting open trenches from accidental entry. Persons engaging in any in any trenching operation shall familiarize themselves with the federal safety standards promulgated by the Occupational Safety and Health Administration on excavations: 29 CFR 1926.650 et.seq., entitled Subpart P `Excavations". Excavators engaging in any trenching operation who utilize hoisting or other mechanical equipment subject to chapter 146 shall only employ individuals licensed to operate said equipment by the Department of Public Safety pursuant to said chapter and this permit must be presented to said licensed operator before any excavation is commenced; By applying for, accepting and signing this permit, the applicant hereby attests to the following: (1) that they have read and understands the regulations promulgated by the Department of Public Safety with regard to construction related excavations and trench safety; (2) that he has read and understands the federal safety standards promulgated by the Occupational Safety and Health Administration on excavations: 29 CMR 1926.650 et.seq., entitled Subpart P "Excavations" as well as any other excavation requirements established by this municipality; and (3) that he is aware of and has, with regard to the proposed trench excavation on private property or proposed excavation of a city or town public way that forms the basis of the permit application, complied with the requirements of sections 40- 40D of chapter 82A. This permit shall be posted in plain view on the site of the trench. For additional information please visit the Department of Public Safety's website at www,mass.gov/dps 3 1 P a g e Summary of Excavation and Trench Safety Regulation (520 CMR 14.00 et sea.) This summary was prepared by the Massachusetts Department of Public Safety pursuant to G.L.c.82A and does not include all requirements of the 520 CMR 14.00. To view the full regulation and G.L.c.82A, go to www/mass.gov/dps Pursuant to M.G.L. c. 82, § 1, the Department of Public Safety, jointly with the Division of Occupational Safety, drafted regulations relative to trench safety. The regulation is codified in section 14.00 of title 520 of the Code of Massachusetts Regulations. The regulation requires all excavators to obtain a permit prior to the excavation of a trench made for a construction -related purpose on public or private land or rights-of-way, All. municipalities must establish a local permitting authority for the purpose of issuing permits for trenches within their municipality. Trenches on land owned or controlled by a public (state) agency requires a permit to be issued by that public agency unless otherwise designated. In addition to the permitting requirements mandated by statute, the trench safety regulations require that all excavators, whether public or private, take specific precautions to protect the general public and prevent unauthorized access to unattended trenches. Accordingly, unattended trenches must be covered, barricaded or backfilled. Covers must be road. plates at least 3/4" thick or equivalent; barricades must be fences at least 6' high with no openings greater than 4" between vertical supports; backfilling must be sufficient to eliminate the trench. Alternatively, excavators may choose to attend trenches at all times, for instance by hiring a police detail, security guard or other attendant who will be present during times when the trench will be unattended by the excavator. The regulations further provide that local permitting authorities, the Department of Public Safety, or the Division of Occupational Safety may order an immediate shutdown of a trench in the event of a death or serious injury; the failure to obtain a permit; or the failure to implement or effectively use adequate protections for the general public. The trench shall remain shutdown until re -inspected and authorized to re -open provided, however, the excavators shall have the right to appeal an immediate shutdown. Permitting authorities are further authorized to suspend or revoke a permit following a hearing. Excavators may also be subject to administrative fines issued by the Department of Public Safety for identified violations. Summary of 1926 CFR Subpart P -OSHA Excavation Standard This is a worker protection standard, and is designed to protect employees who are working inside a trench. This summary was prepared by the Massachusetts Division of Occupational Safety and not OSHA for informational purposes only and does not constitute an official interpretation by OSHA of their regulations, and may not include all aspects of the standard. For further information or a full copy of the standard go to www.osha.gov. Trench Definition per the OSHA standard: o An excavation made below the surface of the ground, narrow in relation to its length. o In general, the depth is greater than the width, but the width of the trench is not greater than fifteen feet. Protective Systems to prevent soil wall collapse are always required in trenches deeper than 5', and are also required in trenches less than 5' deep when the competent person determines that a hazard exists. Protection options include: o Shoring. Shoring must be used in accordance with the OSHA. Excavation standard appendices, the equipment manufacturer's tabulated data, or designed by a registered professional engineer. o Shielding (Trench Boxes). Trench boxes must be used in accordance with the equipment manufacturer's tabulated data, or a registered professional engineer. o Sloping or Benching. In Type C soils (what is most typically encountered) the excavation must extend horizontally 1 'h feet for every foot of trench depth on both sides, 1 foot for Type B soils, and 1/4 foot for Type A soils. o A registered professional engineer must design protective systems for all excavations greater than 20' in depth. continued 4 1 P a g e • Ladders must be used in. trenches deeper than 4'. o Ladders must be inside the trench with workers at all times, and located within 25' of unobstructed lateral gravel for every worker in the trench. o Ladders must extend 3' above the top of the trench so workers can safely get onto and off of the ladder. • Inspections of every trench worksite are required: o Prior to the start of each shift, and again when there is a change in conditions such as a rainstorm. o Inspections must be conducted by the competent person (see below). • Competent Person(s) is: o Capable (i.e., trained and knowledgeable) in identifying existing and predictable hazards in the trench, and other working conditions which may pose a hazard to workers, and o Authorized by management to take necessary corrective action to eliminate the hazards. Employees must be removed from hazardous areas until the hazard has been corrected. • Underground Utilities must be: a Identified prior to opening the excavation (e.g., contact Dig Safe). o Located by safe and acceptable means while excavating. o Protected, supported, or removed once exposed. • Spoils must be kept back a minimum of 2' from the edge of the trench. • Surface Encumbrances creating a hazard must be removed or supported to safeguard employees. Keep heavy equipment and heavy material as far back from the edge of the trench as possible. • Stability of Adjacent Structures: o Where the stability of adjacent structures is endangered by creation of the trench, they must be underpinned, braced, or otherwise supported. o Sidewalks, pavements, etc. shall not be undermined unless a support system or other method of protection is provided. • Protection from water accumulation hazards: o It is not allowable for employees to work in trenches with accumulated water. If water control such as pumping is used to prevent water accumulation, this must be monitored by the competent person. o If the trench interrupts natural drainage of surface water, ditches, dikes or other means must be used to prevent this water from entering the excavation. • Additional Requirements: o For mobile equipment operated near the edge of the trench, a warning system such as barricades or stop logs must be used. o Employees are not permitted to work underneath loads. Operators may not remain in vehicles being loaded unless vehicles are equipped with adequate protection as per 1926.601(b)(6). o Employees must wear high -visibility clothing in traffic work zones. o Air monitoring must be conducted in trenches deeper than 4' if the potential for a hazardous atmosphere exists. If a hazardous atmosphere is found to exist (e.g., 02 <19.5% or >23.5%, 20% LEL, specific chemical hazard), adequate protections shall be taken such as ventilation of the space. o Walkways are required where employees must cross over the trench. Walkways with guardrails must be provided for crossing over trenches > 6' deep. o Employees must be protected from loose rock or soil through protections such as scaling or protective barricades. 5 1 P a g e Request Number: 20171100229 Date 03/13/2017 Time 07:50 Latitude: Longitude: State: MASSACHUSETTS Municipality: NORTH ANDOVER Address / Intersection: 12 ROYAL CREST DR Nearest Cross Street 1: MERRIMACK COLLEGE Nearest Cross Street 2: STATE HWY 114 Additional Information: Nature Of Work: INSTALLING FOUNDATION DRAIN Area Of Work: 50 RADIUS AROUND THE BUILDING AND 75 BEHIND THE BUILDING Area Is Premarked: Y Start Date: 03/16/2017 Start Time: 08:00 Caller: JAMES HEIDER Title: MGR Return Call: Fph-ne#- 978-851-2652 Fax#: 978-455-2670 Alt. Phone#: 978-606-1435 Email Address: JIMHEIDER@HOTMAIL.COM Contractor: HEIDER BUILDING ASSOC Address: P O BOX 217 City: TEWKSBURY State: MA Zip: 01876 Excavator Doing Work: HEIDER Member Utility List Code Abbreviation Name EG CMAGAS COLUMBIA GAS OF MASSACHUSETTS ME NGRDEL NATIONAL GRID ELECTRIC-MASS ELEC SE VERIZN VERIZON N� COMCAS COMCAST ON ONTARG ON TARGET LOCATING RJ VERIZN VERIZON • There may be non-member utilities in the area that you need to notify. • Electric and other companies may not mark lines they don't own or maintain. You may want to contact them for more information. • The excavator is responsible to maintain markings placed by member utilities... -Accmtf CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDNYYY) 4/4/2017 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 CONTACT Cindy Valiton W.E. Noyes & Son Insurance Agency, Inc. 73 Front St PHONE (978)425-9595 FAX (978)425-9160 IC.AIC No E-MAIL ADDRESS: P.O. BOX 1248 Shirley MA 01464-1248 INSURERS AFFORDING COVERAGE NAIC # INSURERA Essex Insurance Company INSURED INSURERB:Hartford Underwriters Ins. Co. Cornerstone Land Developers, Inc. INSURER C: PO BOX 657 INSURER D: 61 Main St INSURER E: Pepperell MA 01463 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1661355046 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. INSR LTR I TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/D /YYYY1 LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $ 50,000 MED EXP (Any one person) $ 10,000 3EA5422 6/10/2016 6/10/2017 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY [�] PRO- ❑ LOC JECT GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OPAGG $ 2,000,000 Employee Benefits $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY Per accident $ ( ) NON -OWNED HIRED AUTOS AUTOS - PROPERTY DAMAGE Per accident $ $ X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 2,000,000 A EXCESS LIAR X CLAIMS -MADE AGGREGATE $ 5,000,000 DED I X I RETENTION 10,000 $ MAPXS00005504 6/10/2016 6/10/2017 B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVEE.L. OFFICER/MEMBER EXCLUDED? F_� (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A 6S60UB-OG12678-7-16 6/18/2016 6/18/2017 PER OTH- STATUTE ER EACH ACCIDENT $ 1,000,000 _ E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Property Name - Royal Crest Estates (North Andover) Contract # 21319 - 428089 - CPe - 00001. Coverage includes owner as additional insured as expressly nominated under the insurance provisions of the contract. AIMCO NORTH ANODVER, LLC. 50 ROYAL CREST DRIVE NORTH ANDOVER, MA 01845 ACORD 25 (2014/01) INS025 r2menrn SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Ted Noyes/CVALIT < - c C2—I ©1988-2014 ACORD CORPORATION. All rights reserved. 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