HomeMy WebLinkAboutBuilding Permit # 2/29/2016Permit No#:
Date Issued:
LOCATION
PROPERTY OWNER
MAP
BUILDING PER IT
TO NI SF NORTH Al IDOVE
APPLICATION FOR PLAN EXAMINATION
Date Received
RTANT: Applicant must complete all items on this page
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Print I
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Print100 Yea ru ture yes no
PARCEL: 61-') (-1 ZONING DISTRICT: Historic District yesf no
Machine Shop Village ye no
TYPE OF IMPROVEMENT
PROPOSED/USE
Residential
Non- Residential
0 New Building
CI Addition
/. Alteration
0 One family
D Two or more family
No. of units:
0 Industrial
11 Commercial
0 Repair, replacement
0 Demolition
0 Assessory Bldg
0 Others:
0 Other
7
ru Floodplaine:tlan
'
a erOhe District,
OWNER: Name:
Address: /(:.-
Contractor Name: „),„„z,„,,,,,4,-/,„„4,,,,,
Email:
Address: / r-,-"/n- • „.! 4/-"/,'"
„/
Supervisor's Construction License:
DEScrIPTION OF
ORK TO BE PERFORMED:,
ilentification -. Please Type or Print Clearly
f/.. C... • c: 2—• 7 /04.:(.Phone y.‘"'")(
/
//Phone:
C.
) Exp. Date: /
Home Improvement License: Exp. Date:
/-
ARCHITECT/ENGINEER „ / I e Phone:
/
e et_e Reg. No.
Address:
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $
/
FEE: $
Check No.: / 66 (9
8,1
TE: Persons con tractin
Receipt No.:
ctors do not have access to the guamn und
contractor 4
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.
L
Permanent Dmnpster on Site
THE FOLLOWING SECTIONS F R (OFFICE USE SNLY
INTERDEPARTMENTAL SIGN OFF m U FORM
PLANNING & DEVELOPMENT Reviewed On Z/7'i Signature_
COMMENTS 0Pk1i 6ne_.5 -7 5(1-1,0. U ? v,� Le..s5
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision:
Comments
Water & Sewer Connection/Signature & Date
DPW Town Engineer: Signature:
Driveway Permit
FIRE DEPARTMVIENrT;. - Temp Dumpster on
Located at 124, Main Street
Fire Department signature/date
Located 384 Osgood Street
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Initial Construction Control Document
To be submitted with the building permit application by a
Registered Design Professional
for work per the 8th edition of the
Massachusetts State Building Code, 780 CMR, Section 107
Project Title:
Property Address:
Project: Check one or both as applicable:
Project description:
Date: l
A A
[1 New construction xisting Construction
LIMAI}- A Registration Number: Expiration date:
registered d ign professional, and I have prepared or directly supervised the preparation of all design plans,
computations and specifications concerning:
] Fire Protection [ ] Electrical
Architectural [ ] Structural
[ ] Mechanical
[ ] Other
,ama
for the above named project and that to the best of my knowledge, information, and belief such plans, computations and
specifications meet the applicable provisions of the Massachusetts State Building Code, (780 CMR), and accepted
engineering practices for the proposed project. I understand and agree that I (or my designee) shall perform the necessary
professional services and be present on the construction site on a regular and periodic basis to:
1. Review, for conformance to this code and the design concept, shop drawings, samples and other submittals by the
contractor in accordance with the requirements of the construction documents.
2. Perform the duties for registered design professionals in 780 CMR Chapter 17, as applicable.
3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and
quality of the work and to determine if the work is being performed in a manner consistent with the approved
construction documents and this code.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107.
When required by the building official, I shall submit field/progress reports (see item 3.) together with pertinent
comments, in a form acceptable to the building official.
Upon completion of the work, I shall submit to th
Enter in the space to the right a "wet" or
electronic signature and seal:
Phone number:
Building Official Name:
a `Final Construction Control Document'.
Ito
Bui ii •Eal Use Only
Permit No.: Date:
Version 06 11 2013
The Commonwealth of Massachusetts
Departme-nt of Industrial Accide- nts
Office of Investigations
600 Washington Street
Boston,11171 02111
www.mass.govalia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information
Name (Business/Organization/Individual):
Address:
City/State/Zip:
Phone #:
())"!
<4.
Please Print Legibly
Are you an employer? Check the appropriate box:
,
1.Li I am a employer with .., 4. El I am a general contractor and I
employees (fill and/or part-time).* have hired the sub -contractors
2. 111 I am a sole proprietor or partner- listed on the attached sheet. I
ship and'have no employees These sub -contractors have
working for me in any capacity. workers' comp. insurance.
[No workers' comp. insurance 5. El We are a corporation and its
required.] officers have exercised their
3.n I am a homeowner doing all work right of exemption per MGL
myself. [No workerscomp. c. 152, §1(4), and we have no
insurance required.] t employees. [No workers'
comp. insurance required.]
Type of project (required):
6. New construction
7. El Remodeling
8. El Demolition
9. El Building addition
10.0 Electrical repairs or additions
11.0 Plumbing repairs or additions
12jIlJ Roof repairs
13.0 Other
!Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information,
Homeowners who submit this affidavit indicating they eie doing all work and then hire outside contractors must submit a new affidavit indicating such.
TContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policy information.
ain an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:.
?' 64'
l.
4")
Policy # or Self -ins. Lie. it: ) (4/ Expiration Date:
Job Site Address: /( e- 0: 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 requiredunder Section 25A of MGL o. 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 of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certN) under the pains andpenalties of perjury that the information provided above is true and correct.
Signature:
Phone if:
74'
r.
Date:
Official use only. Do not write in this area, to be completed by c10) or town official.
City or Town: Permit/License #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone if:
A CCJIZ C TIFIC T •F LI .ILITY I
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11-115 CERTIFICATE 15 .15SUED AS A MATTER OF iNFORMATION ONLY AND, CONFERS NO R.10FII5 N-141 F CFRTIFICATF HOLDER. 1i-f4
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER ThIE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT C0N5T11U11 A CONTRACT BETWEEN IRE ISSUING IPUIhRISI, ALItHORZED
PRESENTATIVE OR PRODUCER, AND ME CERI1RCATE HOLDER
IMPORTANT: If the certificate holder Is an ADDITIONAL. INSURED-. the policyties) mit be endorsed. If SU OGMiON IS WAIVED, subject to
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M.P. Rohorts =nuurancu.- Agonay
1060 OrgocO
North Andov z, MA 01845
DCWCIERT CONSTRUCTION CO., INC
616 13;8 SEX STREET
LAN -FENCE MA 0 1 8 4 L
COVERAGE a
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CERTIFICATE HOLDER
CANCELLATiON
OZZY PROPERTIES INC' 1600 0SGCC'
811* L.D.2 DUNDEE OFFICE PARK 1-7iC
ITAYNDPIR STATION LLC DUNDEE
REDSORTNC LLC HERITAGE PLACE L.
i?,70 ANO R•11.9
ACORD 25(20111;55)
Pi
SHOULD ANY OF THE 411.10VC DC SCRIBED PCLIC ME BF CANCELLED BEFORE
TIC Lx.piRAITIONI DATE THEREOF, NOTICE 'PELL EE DEUVERED
ACCORDANCE WITH THE POLICY PROW:210HE .
A!J1HC.2ED !RE 1;zESE'I4rATTE
El:CRP-LEI P. ROBERTS
'6195B-2010 ACORD CORPORATION, MI rights rosermd,
The ACORD 41a me and logo aro regi*tered rnirkr,;c..if ACORD
Fax: (603) 45B- 0 90 '101-
e
Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CS-048040
Construction Supervisor
TADEUSZ DOWG`IERT
175 BRADY AVE
SALEM NH 03079
Commissioner
Expiration:
10/29/2017