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Home My WebLink AboutBuilding Permit #199 - 1060 OSGOOD STREET 9/14/2009 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION r P !� emit N0:( Date Received Date Issued: -0 IMPORTANT: Applicant must complete all items on this page LOCA JON 104 0 Print PROPERTY OWNERZ o1ji i v . �►'7 r�t z `1 L 1, C Print MAP NO: S� 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: Identification Please Type or Print Clearly) 9 OWNER: Name: Phone: Address: ' CONTRACTOR Name: Z&/J Phone Address: <�� Supervisor's Construction License:_Z� co f Exp. Date: r/%� o7d/`/ Home Improvement License: 14: �1ejf Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. c9-✓ Total Project Cost: $ Q C' FEE: $ ,- Check No.: / Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access tot a guaranty fund Signature of Agent/Owner W Signature of contractor Plans Submitted Plans Waived Certified Plot Plan Sta , ped 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 Hr'ALTH 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 I 0 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 lz7Ge o o �� No. 6 Date NOR.h TOWN OF NORTH ANDOVSR O AL � A j Certificate of Occupancy $ �a Building/Frame Permit Fee $ O r MU Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 5 I 224i1 B bilding Inspector NORTH Town of tAndover No. / 99 dover, Mass., COC MIC KE WICK y�. .1�ADRA TE D P"? �5 S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System / BUILDING INSPECTOR THIS CERTIFIES THAT........../.&"............. ... / . .............l .. .... ... .................................................................. Foundation has permission to erect........................................ buildings on ..... D..�r.. ..........60�r�.Q.c ...r'/.................2 Rough to be occupied as....P . ��.....�f.Ov ... l y .t...... ... /........... Chimney 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 (DO _ UNLESS CONSTRU STARTS Rough Service ....... .........................................................:. .. ....................................... BUILD SPECTOR 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 SIDE Smoke Det. t tare tbmrrronrvealfh U, of Massacherse ' f De�artrrre�tt of fndustrid Aa derrt, iRr' .� Of`Fee of Inp stiaations 6017 If,-asjIin;tnn Street B&&Oft, M4 02111 Workers, Compenation fusiurance �� amass gov/di4 , A 'cant Information A�d�vit: Sunders/Contractors/Eiedrit:i$ns/Pitzmbers Please Print Leeibf Name(Businrss�OrrgaoizafioMndividual): Adexress: . CrtylState/Ztg, phone #; . • Are you an employer?Clreek.the a .PP ro P'��boz: I:Q I,lima mn io er P Y with trmc, 4. Q have a.--cal ral contractor and I . of Protect(t'egairedj: emPlOyeos(full and/or� 2. 1 errt.asolc 1 hired the strb-carttiat ors ❑New construction . propnetor or pm tn.r- listed on the attached sheet 3 7. ship and have no employe These Q Remod„fin working for mein a stL&contractors have g ffiry capacity. workers' con insurance, Q Demolition [No workers comp•insurance.. 5. required.] Q We M.L.sra corporation and its 9• Q But'lding addition 3•❑ Iain a homeowner doing all work O�� xerc s have eised their 10.[]EIe."trical repairs or additions myself[No•w.ork�s'co t�of exemption per MGL 11.E]PIurttb' ng insurance ' 'c' L'52, §1(¢l,and,we have no rcpatra or additions .=Pjyees [No workors' 12.0 Roof repairs '�Y amumm ti�et r#recks boat t COMP. M' Susancc requirecL] I3.11.pm� t homeowners wbo a Rho m outtf=seotimi below airowier _ submit this RW&vk Wiceting they aro g t�rworked ooh Poti� information 4C*Maactors that check this box roust g an wm*end then hila outside conmciars,nu an add..ioasl sheer wbm' sho . tt a new affidavit . K' f name oFtha cnt-� vrt mdioatios may �� a�SioYer iisarf rsnsavui¢c2g:►nar�..-.:''�r;�er`s�� tn* Io.ura�rrefornry.e��,e� &esQw.b,'��.eY�lie�and joc site . . . nsuranee Company,Name' Policy#or Seif-ins. Lie. #: .lob Site ExPitaiion Date: Addrass•. Attach a copyof the workers' co CutylStat�/gup Failure to se mPe tion Poky d�laratioa r(showin r ewe coverage as Pad b the policy number and e i g required under Section 25A xp rafioa stale fineo up to$1,5D0 00 and/or one- car. f SGL C. 152 can Iead to the imposition of mini of up to 5250.00 a Y unprisonme»-0 well Ms civil penalties in the form of a incl P"mitim of a Investi . ��the vioia�hor- Bc advised that a copy of this statement S717P WORK ORDER a fine gallons of the DIA for insurance coverage verification. may be forwarded to the Office of I do,"Certify under the 'oma andpenalfi�°fPeFl+�y that the infnrmctionrn ' . Si P bided above is brae and eonrd Phone#: 09 Date: OffAcud!u4?only. Do not write in.&rx �4 m be rx►mptet�d by L,ar town.of,,W City or Town: Issuing Authority,(circle one): Permif/L.icease# 1. Board of Health 2. gnlui Q De 6 Other �+ par'finent 3.City/rwwn CIerk 4.Electrical Inspector S. Plumbing Inspecor. Contact Persorr: Phone#!: Information a nd Instructions Massachusetts General Laws.chapter IS2 requires all emp;oyers to provide Worked' compensation for their employees. Pursuant to this statute, EM m playee is defined as"..:every person in the service of another under any contract afhirt, express or implied,oral or written." I` An=player is defined as"an individual parmnership,essodatim, corpmBtian or other legal entity,or any two ormore of the'fiamping engaged in a joint enterprise,and ineludi"g the legal representeivs of a deceasad employer,brthe receiver ortnrater-of an individual,partnership,associaticiin or other legal•eartity,employing employees. 'However the owner-of a dwelling house having not more than three apartanents and who resides therein, or the occupant of the dwollmg house of another who employs persons to do malLntmance,construction orn-pair wrirk an such dweitinghornse or on the grounds or building appurtrnaat thereto shat]not of such employment be dwrned to be an employer." MGL chapter 152,§25C(6)also states that"every state o.w-local 6eengng agency shag withhow the ismanwor renewal of a license or permit to operate a business or *a construct in inthe commonwealth for any apPlicaat who has not produced•arxeptable evidence o�eompa cc with the insmramce coverage required." Additionaliy, MOL chapter 1 S2, §25C(7)states"Neither'tic commonwealth nor any of iia polif cgl subdivisions shall enter into mny co=d for the pm f0i,.snce of public waste. until-acceptable evidence of compiis nce with the ins=c e- requn=nards.of this d.mpter have bean presestted Wthe amyrtraafing authority." Applicants Please fill out the workers'.campensation.affidavit completely,by checking the boxes that apply to your situation and,if necessary, supply sub-�tor(s)rmne(s),addrsss(es):arnd phone number(s)along with their cartificate(s)of insurance. Limitcd'Liabiiity Companies (LLC)or Limited 1:mblity.Partnerships(LLP)with no employees other than the members orpartners,are not requh ed1to carry.work='cC)-,Tnpanmdian insman= Fan LLC or'LLP do=have ompioyees,a policy is required. Be advise=d that this affidavit may be submitted to the Department of industrial Accidents for cou5r oration of m ma=coverage. Also be sure to sign and date the affidavit, The affidavit should be returned to the city or town that the applicatiem far the permit or license is being requested,not'the Doparima t of Industrial Accidents. Should you have any questions repa-ding the law or if you aro required to obtain a wa*=s' oompensation policy,pkase-call the Department at the-nur.nber.listed below. Self-insured companies should enter thmir selt:innsu.^nnce'lieearnse number an thes appropriate i= G ' City or Town Ofursais Please be sure that the affidavit is complete and printed legibly. The Dgwmnent hes 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 sum to fill in the permittlicense number which will be used as a reference n=ber. In addition,an appiicant that must submit multiple Pmn*/Iicanse appiicsdOm in any given year,need only submit one affidavit indicating current policy'informsfion(if ne y)and.under"Job Site Addr-ess"the appiicant should white"all locations in (city or town)"A copy of'fhe affidavit that has been officially stamped or marked by the city or tavern may be provided to the applicant as proof that a'valid afrndavit is on Me fur funtmz permit or licenses. A new affidavit must be filled out each year. Where a home owner or citizen ii;obtaining alie;,-ns- 'or permit not related to any business or commercial vwtare (Les a dog license or permit to bum leaves etc.)said per16r3 is NOT.requi and to complete this a zf idaviL The Office of invesn"gstions 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. Tim Dopmtmm is address,telephone and fax number: The Commonwealth of Massachuse m Departinaat of IMaustrial Accidents o>tace of LavtStieatf ons " 600 Washington Street Bos� 1.4 02111 TeL 4 617-72-74900 i=406 or 1477-Mv SAFE Revised 5-26-05 Fax 4 61 7-727-774 www.masr gov/dia