HomeMy WebLinkAboutBuilding Permit #534 - 1077 OSGOOD STREET 3/4/2010 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: `3 Date Received
Date Issued: -� 41 7o
IMPORTANT: Applicant must complete all items on this page
LOCATION 6
�
PROPERTY OWNER Print int
Print
MAP NO: 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:
a
entification Please Type or Print Clearly)
OWNER: Name: J l_ Phone: —
Address: \\ S
CONTRACTOR Name: ft�� 041hone:
Address:
Supervisor's Construction Licee: Exp. Date:
Home 'Improvement License: Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
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: $ ��® �C—Oy FEE: $_
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signatureof Agent/Owner _ Signature of contractor
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. 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 Signature
OMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
j
I
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
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 .�-- 9, ► ten r-
Photo Copy Of H.I.C. And/Or C.S.L. Licenses
-jP Copy of Contract
r 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
No. -6-,3 — Date
MaRTN TOWN OF NORTH ANDOVER
3? � SOL
0 9
Certificate of Occupancy $
Building/
Frame Permit Fee $
SSA�NUSE
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # 3�c
2 2 L, 0
/ Building Inspector"
V'
r
NORTH
Town of Andover
No. �3
T14 �_ -sem
dover, Mass.,
0 LAKE
If, co
ORATED C:)
S BOARD OF HEALTH
Food/Kitchen
P E IT T Septic System
�4 BUILDING INSPECTOR
THIS CERTIFIES THAT..... i ...........`.!..i........ ... .... ....................................... . .. D. . . . . . . .. .
. Foundation
has permission to erect........... .............. buildings on ................. ......... ................................. Rough
Chimney
to be occupied as.. ......... .... .....�.. ...................
provided that the person ac ting ithis permit shall in every respect conform to the terms of the application an file in Final
-0*0 pti�i
this office, and to the porovi ons 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 N 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTTRRU q TT Rough
Service
.................. .... ......................................................................................
BUILDING INSPECTOR Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Rough
Display in-a Conspicuous Place an 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.
Modern Wood Products,Inc Invoice
35 Batchelder Road
Date Invoice#
Boxford, MA 01921-2121
10/26/2009 588
N
J
Bill To Ship To
Perfecto's CAFE Perfecto's CAFE
Phil Jay Phil Jay
515 Lowell St 515 Lowell St
Peabody,Ma 01960 Peabody,MA 01960
P.O. Number Terms Rep Ship Via F.O.B. Project
10/26/2009
Quantity Item Code Description Price Each Amount
1 Cabinetry Set of cabinets for Perfecto's Cafe,From measurements taken at 21,000.00 21,000.00T
site.All laminate interiors,black toe kicks and MDF
water-resistent panels.
All laminate boxes to be made with W/A Windswept.
Bagel'area 48"wide with sides extending to top 84"High,Soffit
above for light.
48"sliding doorbase cabinet section 33"high.
13'of evenly devided base cabinets with sliding doors to
accomadate two sinks
v'
1T�f�Linless-steel countertop with two inch front edge with
two sinks 15x15 lv'j
,fridge cover 36hx 36 d x30 w with green top..
80"Cash drawer cabinet 36"deep x 34"h with drawers in
center open sections per side
51"fridge cover with top and sides and back with three tier
shelf unit on back.
Lr t 54"trash cabinet by exit door with cutout in green top.
152"wide by 52"high refrigerator panel cover with toe kick
built in and side leg on left,right side to wall with shelves on
upper back side.
Two laminated counter tops for window 101"X 13"with 2"
front edge.
c ,lj= One panel connecting cash cabinet with refrigerator panel.
THANK YOU FOR ALLOWING US TO QUOTE THIS JOB.
-Total
i
Page 1
Modern Woad Products,Inc Invoice
35 Batchelder Road
Date Invoice#
Boxford, MA 01921-2121
10/26/2009 588
Bill To Ship To
Perfecto's CAFE Perfecto's CAFE
Phil Jay Phil Jay
515 Lowell St 515 Lowell St
Peabody,Ma 01960 Peabody,MA 01960
P.O. Number Terms Rep Ship Via F.O.B. Project
10/26/2009
Quantity Item Code Description Price Each Amount
1 Installation Removal of existing empty cabinetry at 1115 Osgood St, 7,000.00 7,000.00
N.Andover,MA. Installation of new cabinetry-three men
Please provide dumpster at site.
Sales Tax 6.25% 1,312.50
THANK YOU FOR ALLOWING US TO QUOTE THIS JOB.
'Total $29;3.1, 50
Pagc 2
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02/23/2010 TUE 11:34 FAX 001"001
DATE(MMIDONYYY)
ACC?R& CERTIFICATE OF LIABILITY INSURANCE
14., 3123/2010
PRODJCER �— P78-8b7-3304 THIS CERTIFICATE IS I3SUED AS A MATTER OF INFORINIATION
UC-ONE-.IGHIIISGN INSURANCE q' c',LY I ONLY AND CCNFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOER NOT AMEND, EXTEND OR
7GRDn EEr i AL'fik ;-tiE CCV€RAGE AFF'C+RDCL BY THE POLICIES BELOW.
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TOPISFIELD, 'VSA. 01983 I�INSURERS AFFORDING COVERAGE —�NAIC#
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ANY REOUIRERIF I'r,TERM OR CO\i:'- ".:T OF OTHER DO:�LJMENIT%khTH RESPECT TO VIH!CH THIS CER'Iirr_: I'AY BE ISSUED OR
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CERTIFICATE HOLDER _ _ _ _ _ _ _ _ ':!ANCELLATION _
— - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES EE CANCELLED BEFORE THE EXPIRATION
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T1e A,1._hD r;11E c.nu it lc.;r 31V I E C lli'e•al I IT,,,,rk.of AC^.F7
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office ofInvestigations
Uf ..600 Washington Street
Boston, MA 02111
www.mas&gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information PIease Print Legibly
Name(Business/Organization/Individual): LjdbL
GT
Address: d
City/State/Zip: Phone#: 5 (f
7111
employer?Check the appropriate box:
em to ye, with 4. [7Tpe of project(required):
P Y ❑ I am a general contractor and I
yees(full and/or part-time).* have hired the sub-contractors 0 New construction
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.
[No workers comp. insurance 5. 9 ❑Big addition
' p ❑ We are a corporation and its
required.] officers have exercised their 10.❑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.❑ f reps'
insurance required] t employees. [No workers'
comp.insurance required.] 13. Other �/
M),apphwnt that checks box 4I must--Is)a'out the section below shoe:WaPolicy infor_
Homeowners who submit this affidavit indicating they are doing all work and thenrhire utside contractors mast.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:
Policy#or Self-ins.Lic.#:
Expiration Date:
Sob 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 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 certify under the pains ndpenalties ofperjury that the information provided above is true and correct.
:-g
ature:
/ Date.:
Phone#: C
EEContactPerson:
only. Do not write in this area, to be completed by city or town official
a: Permit/License#
hority(circle one):
Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector
son: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee 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 shall 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-contractor(s)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 permait 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 appropriate 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 permittlicense 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. # 617-72.7-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax#617-727-7749
www.mass.gov/dia