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HomeMy WebLinkAboutBuilding Permit #447 - 1077 OSGOOD STREET 11/30/2011 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued- 0 EWPORTANT:Applicant must complete all items on this page LOCATION 95 re +Pr ' PROPERTY OWNER Unit# MAP NO: PARCEL: ZONING DISTRICT: Historic District ye no l V /1 //,fJ f ® - 2A_.11 Machine Shop Village y s no 100 year-old structure y 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 D peptic`: t®Well`" �Floodpla ©Wetlands ❑ Watershed_Distriet' ®Wafer%S were XSCRJPTIONOff WORD T BE PERFO �" dI P I (Identifica ' u Pl71s e a or Print Clearly) OWNER: Name: Phone: 7 Address: CONTRACTOR Name: i"CCLHLIacl'd Phone: �p 7 Address: Supervisor's Construction License: Exp. Date: f G/ Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$92.00 A $g000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost. $ �� FEE: $ Check No. Receipt No.:_ ?Z��J`� NOTE: Persons contracting with unregistered contractors do not have access he guar and Signature_•of�A -- ----- ,Si nafure.of�contra. for tir rt �.H r Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑. Tanning/Massage/Body Art ❑ SwimmingPools ❑ 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 Siqnature 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 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 ❑ Flo or/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 2008mi r — Location No. Date „ORTol TOWN OF NORTH ANDOVER 10 . 9 Certificate of Occupancy $ 09-j I sBuilding/Frame Permit Fee $ 'Is Foundation Permit Fee $ �. Other Permit Fee $ TOTAL $ Check # 2 4 b 51 Building Inspector TAORTH Town of Andover o' , �` dover, MassLAKE . • t 'Q COC MIC ME WICK 1' ' ' `1 DRAT E D P? l V BOARD OF HEALTH PERMIT Food/Kitchen Septic System THIS CERTIFIES THAT.............Aqv.o BUILDING INSPECTOR ........................................... ... """""""" Foundation has permission to erect......................... ............. buildings on ...... a a ......10. .....................................:....... Rough to be occupied as............ .. o.. . .../.. .6� ...9Zry­ies'pect ............................. ..... .. . .... .. Chimneyprovided that the person ccept g this permits allin co orm to the terms of the application on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Final Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTIIT S ELECTRICAL INSPECTOR [Rough ...................... .......................................................................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove FFinal h No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. FIRE-DEPARTMENT Burner Street No. IL SEE REVERSE SIDE Smoke Det. i 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 Name (Business/Organization/Individual): Address: City/State/Zip: P: hone#: v 7 Are you an employer?Check tht appropriate box: Type of project(required): 1. [ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. t 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.El Electrical repairs or additions 3. ❑ I am a.homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' comp. insurance required.] 13.0 Other *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. f Homeowners who submit this affidavit indicating they are doing all work and then 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site Information. Insurance Company Name: 7Y-) ?✓ C�, Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: 22 City/State/Zip: Attach a copy of the workers' co pensation 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 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 heme, nder th and penalties of perjury that the information provided above is t ue and correct. Si nate Date: / ell Phone#: Official use only. Do not write in this area,to be completed by city or town official. 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#: 11/30/2011 10:36 AM FROM: MTM Insurance Microsoft TO: 978-688-9592 PAGE: 002 OF 002 � 1 ACORD® CERTIFICATE OF LIABILITY INSURANCE DATE 111/30/30/2001111 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(les) 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 NA CONTAE:CT Victoria Lowes, CISR MTM Insurance Associates PHONE (978)6H1-5700 FAX AIC, 1C No: (978)681-5777 575 Chickering Rd E-MAILADDRESS.vickyl@mtminsure.com INSURERS AFFORDING COVERAGE NAIC# North Andover MA 01845 INSURERA:Preferred Mutual Ins Co 15024 INSURED INSURER B:Ca merce & IndustrV Ins Company 15172 Barcelos Construction Corporation INSURER C: 42 Tewskbury Rd INSURER D: INSURER E: Hampstead NH 03841 INSURERF: COVERAGES CERTIFICATE NUMBER:11-12 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 MAYHAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR LTR TYPE OF INSURANCElum 20a POLICY NUMBER POLICY EFF MMIDDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $ 100,000 A CLAIMS-MADE a OCCUR CPP0160581934 /16/2011 /16/2012 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 rAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PRO- JECT I LOC $ AUTOMOBILE LIABILITY EOM�BIINdEDtSINGLE LIMIT 1,000,000 A ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED PCA0100708575 /11/2011 /11/2012 AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident Underinsured motorist $ 1,000,000 X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 AEXCESS LAB HCLAIMS-MADE. AGGREGATE $ 1,000,000 DED I X I RETENTION$ 10,000 UC0160583494 /16/2011 /16/2012 $ B WORKERS COMPENSATIONVvC STAT U- OTH- ANDEMPLOYERS'LIABILITY Y/N TORY IMIT ER ANY PRO PRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) 003250311 /21/2011 /21/2012 E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Certificate holder as listed below CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood St. N Andover, MA 01845 AUTHORIZED REPRESENTATIVE // �y� L Mancinelli, CIC/LIN (��ti21U/// 1611'a ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025(201005).01 The ACORD name and logo are registered marks of ACORD 11a.s,.sit chu.�c[t� _ B I)c r oar• 1 .u- d of Buildin.: Rc,.[�1en[ Const .ulation�; �vction Su rncl Standar lice Penrrspr Lic ("; rase; C3 73265 erase DANIEL J BARC 42 7-EWKSB11RyELOS HAMPSRD TEAD, NH 03841 E r X r Piration: 8125/2012 rr#: 3495 a Construction Contract This contract is between Barcelos Construction Corporation and Angus Realty Corporation to supply all materials and labor to replace roofing materials above the vestibule at Butcher Boy Market, 1077 Osgood Street, North Andover, Massachusetts. Contract price for this project is $3000.00. by: Acce tedp Angus Realty Corp. Alan r Barcelos Constructio rp. aniel Barcelos, President b� Date. . . . . TOWN OF NO TH DOVER PERMIT F LUMBING ,SSACNU`+� This certifies that . . . . . . . . . . . ? . . . . ./ . . . . . . . . . . . . . . . . . . . . . . has permission to perform . . . . e.k.� .`. . ( .`. . . . . ,y � G f fi� tto C � . . plumbing in the buildings of . ✓d7 5? �_� r ` .. . . . . . . . . . . . . . N rth Andover, Mass. Fee.�")�. . .Lic. No...?°. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . '_/ G LUMBING INSPECTOR I Check * C f i t MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town: t�'I'h �CUW , MA. Date:_�>-2 Permit# Building Location: 0sh2c- 1 9-k Owners Name: OT)�VS l Type of Occupancy: Commercial[O Educational❑ Industrial❑ Institutional❑ Residential❑ New:❑ Alteration:❑ Renovation:9 Replacement:❑ Plans Submitted: Yes❑ No❑ FIXTURES DEDICATED z SYSTEMS O '^ W Y U > z LA 2 to Cil p D a Z Ln ;5Y C (A ¢ Q v~Wi z Q = LU R O V) Uji- m v=i W G � h > x Ln l7 a x = J Q 3 J Q In Q W 0z cc 0 o W z W Z LL oef O W a e x = a p 3 x z a '� 3 a Y z v=i ~ LLJ W LU U a m m o c ° = x > > ° = o a a a a u a oWe a g g rr � 3 3 3 o a c7 3 SUB BSMT. r BASEMENT 1ST FLOOR 2"D FLOOR ' 3RD FLOOR 4T"FLOOR ST"FLOOR 6T"FLOOR 7T"FLOOR 8T"FLOOR Check One Only Certificate# n� Installing Company Name: CMe U" El Corporation Address:(96 5JA-4 N'• City/Town: L0Y7J 0y^JeY State: >� ❑Partnership Business Tel: ��J'�"[J�I-�¢©z7 Fax: (r-'03-Lj3L(-Y?,07 Firm/Company Name of Licensed Plumber: Q� �A/1 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes(z No El If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. II\\ A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: Title 9 Plumber Signature of Licensed/ er Cityrrown (Master License Number: l ��— APPROVED OFFICE USE ONLY [—]journeyman The Commonwealth of Massachusetts c w s Depalr'tmentoflndustrialAccidents jut tI � Office of Investigations 600 Washington Street f;`�a is Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le0bly Name(Business/Organization/Individual): cm P fluk, 10L, + ),LG Address: City/State/Zip: Lpnlgy-J f�K6'1 X73 'hone#: (pQ3-LB`-I—VaQU Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. El am a general contractor and I � have hired the sub-contractors 6. F1 New construction employees(full and/or part-time). 2.KI am a sole proprietor or partner- listed on the attached sheet. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition A working for me in any capacity. workers'comp.insurance. 9• ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions • 3.ElI am a homeowner doing all work right of exemption per MGL 11.�,Plumbing repairs or additions myself.[No workers'comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 1311 Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then 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 acid their workers'comp,policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: 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 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 fonn 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 certify under the pains and penalties ofpeijury that the information provided above is true and correct Signature: Date: Phone# 03 — '-13t-f— 00 Official use only. Do not write in this area,to be completed by city or town official. 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#: Date.3 .. .. ...... 40R7H a? �` TOWN OF NORTH :ADOV - PERMIT FOR GAS IN UjaTj ON ^I SACHU This certifies that . .... .rte. . . . . . . . . . . . . . . . . . has permission for gas installation . . . tr S .. . . . . . . . . in the buildings of' . . . . . . . . . . . . at .,1�'. ?. . . 11. .r r c . . . . . . ., North Andover, Mass. Fee.70. . . . . Lic. No.� .° .`. . . . . . . . .. :":�,r:t.. . . . . . GASINSPECTOR Check# 2 '� MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: lV or,i-V A40Je-jK_ _, MA. Date: -3 -2-- ) l Permit# y Building Location: /0-72 ax Qod S1 Owners Name: 61'l Q1 L66414 Type of Occupancy: Commercial 0. Educational ❑ Industrial ❑ Institutional ❑ Residential ❑ New: ❑ Alteration: Renovation: ❑ Replacement: ❑ Plans Submitted: Yes❑ No❑ FIXTURES ca ui W Lu z N U = a m = FO w v cn ~ Cn O W W z F- a z W W = a O F- W N w m 0 Q a H o 0 w x N > W z ~ W a W w w v m W o > W z 0 _jP P O z J 0 o y W � W W o z W >- N —� a a m W O z 0 ~ F- 0 0 (7 t9 W W > O a O W Z Z W a FF_ LL 4� O a a a F- > > > 0 SUB BSMT. BASEMENT 1 FLOOR 2 FLOOR --i'FLOOR 4 1 H FLOOR 5 FLOOR 6 FLOOR 7 FLOOR _8'FLOOR ` G Check One Only Certificate# Installing Company Name:__�'Y1� I' �-} El Corporation Address: 9(a �yd� �� City/Town: Londc)n�eLe! State: N ❑ Partnership Business Tel: (P 03-q3 Lj- $?000 Fax: (o 09-L13N-yto n'7 [,Firm/Company Name of Licensed Plumber/Gas Fitter: Q fNlr / INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes 0 No❑ If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy Rf Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box❑;I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Type of License: By R`Plumber Title Gas Fitter Signature of Licensed mber/ as Fitter Master City/Town ❑Journeyman License Number: APPROVED OFFICE USE ONLY ❑LP Installer