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Home My WebLink AboutBuilding Permit #395 - 1120 OSGOOD STREET 11/18/2009 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued:zen Ik —01 IMPORTANT: Applicant must complete all items on this page LOCATION , Print PROPERTY OWNER I Print { MAP NO: 3 t - PARCEL:ZONING DISTRICT: Historic District yes !'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, replacemen ' Assessory Bldg Others: Demolition Other Septic Well floodplain Wetlands Watershed District Water/Sewer DESCRIPTIQN OF WORK TO BE PERFORMED: ' r - - c, 2/�c�.� ��1 Bbl 6unr, Identific 'on Please Type or Print Clearly) � ��;�3 OWNER: Name: - Phon �j Address:—I—/a) CONTRACTOR Name: Phone: Address: Supervisor's Construction License: a. L7 Exp. Date:—2,6 Home Improvement License: 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. Total Project Cost: $ Z/"-Sm FEE: Check No.:__ ��a'7 Receipt No.: NOTE: Persons contracting with unregist ed contractors do not have access to the guaranty fund Signature of Agent/Own 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 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 ❑ 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 No. _ ` Date `^ d� HpRTp TOWN OF NORTH ANDOVER 3�p�`(`•o I•,hO O 0 R 9 + s _ Certificate of Occupancy $ / ,ssACHU Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # �� Building Inspector T40RT#q ToVM of Andover iA 0 No. 3 . ...... 0= dover, Mass. . 0 COCHICHEWICK O"?ATED BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System • 11: BUILDING INSPECTOR THISCERTIFIES THAT........... ...... ....... .. ... .......................................................................................................... Foundation has permission to erect... . ............................... buildings on ... Im............. .TO) ....... Rough I #*j —unnewaft Chimney to be occupied as........... ....(0 ............................................. . ............... ....................................... ......... ....... 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 down PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONST S S Rough 01"6 S TS Service BUILDING INSPECTOR Final N - Occupancy Permit Required to Ocmpy 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. ,�•. �lassuchusetts- Delin�rtmcnt of Public Side" 1 BoalA of Builili� SR`,ervis'oLicense and nd<<rds ConstructionP License: CS 52309 Restricted to: 1G THOMAS4M HURLEY 4. 5 SALEM STREET ` N READING, MA 01864 Expiration: 1/14/2011 TrI#: 10776 ( u IIIIIII5sll lllt'1' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, A1A 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organizafion/Individual): as Address: Sl- City/State/Zip: / �, �Ll N (9 Phone#:_7S-1 696 - 7 6 4(9- Are (9- Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4.-B 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. 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for 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.❑ Electrical repairs or additions 3.❑ 1 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' 13.0 Other lYl comp. insurance required.] *;,.y applicant that checks box 91 mw—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 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: ' zr-r',, Policy#or Self-ins. Lic.#: �� ISC�ofj Expiration Date: Job Site Address: City/State/Zip: l �{ Attach a copy of the workerscompensation policy declaration page(showing the policy number and exp ation 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 ce under the pains and penalties of perjury that the information provided above is true and correct. Signafore: Date: 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#: 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 bean 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 appIicant 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-contractors)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 permit 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 permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple perinit/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 bum 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, M.A..021.11. Tel. # 617-7274900 ext 4.06 or 1-877-MASSAFE Fax# 617-72.7-7749 Revised 5-26-OS vwww.mass.govfdia R.S.CONSTRUCTION Invoice 56 UPHAM ST MALDEN MA 02148 Date Invoice# 781-696-7649 Il Bill To Ship To P.O. Number Terms Rep Ship Via F.O.B. Project Net 30 1� W) Quantity Item Code Description Price Each Amount 1 Y S ?'> r �q11 Z,4 boy hw!o ) 1 ye a Phone# E-mail Total l �� , 11/18/2009 12:30 6176660037 At4AZONIA INSURANCE PAGE 01/01 ACCAT CERTIFICATE OF LIABILITY INSURANCE -MIDWrTYY) _ 1:L/18/09 PROELtem TRIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION AM ZCKia Tnsu=aucs AgIgEacy Inc. ONLY AND CONFERS NO RIC-;HTS UPON "HE CERriFiCATE 56 S xe HOLDER. THIS CERTIFICATE DOES NOT AMr--ND, EX-END OR ALTER THE COVERAGE AFFORDED BY TIDE_.30L,ICIES BELOW. SCMEIrV1110, MA 0.1413 INSURERS AFFORDING COVERAGE ` 'MUIERA: AIN Mutual I>Ixiaia mute Co Ra COM UCTION INSUMRa 157 KR EN ST INSUMR C. lM8095t I& 02176 INSUTERM 1_ 1 N3iJtZE1 t E COVERAGES .. — THE POLIGFS;f3rir,,at�'r'II+R3CEU EDBELt71h1HK%EBEENISS EDTOTHEiWLITE'NAMEDAa Fai-,HEPa.=PERiG'DINDiCATE1 NCTWIThSTm411)Ip43 AAO REO J1REWNNT TEW OR CONDITI{7hI OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TC>WHICH THIS C;ERTIFICATI: MAY BE I3SUED OR MAY PELT AIN,THE(AUIRANCE AFFORM SY THE POLICIES DESCRBED HEREIN IS SUBJECT TO ALL TH5 TERMS,EXCLUSIONS AND C bNDITION;a OF SUCH PPL`^.IM.ACTGM'GATI E L#&M SHO`r94 MAY W` E SE:e4 REDUCEDD BY PAI 1)CLA?A, . 1wp9mfu POLICY NufAsm PSTLd4'C EFFE P =Mt4 LIi Im —— Q;I MAL,UAtdff FJ�N ClGCURRENCE DAWISGIE TO 4ZE Cfll4t{ERMAL GENERAL LIMILI Y CIES Me=urmnol $ CLAWS MADE E-I OCCUR MEb �GS�Yone peraort) S PERSONAL8ADVIMJURY $ GEN31ALAGGRFGATE $ 0 WLAGGREGATELMT APPLIES PIER PRODUCTS-00MOP A6:l S POUCY LOC _ AI>TOMOBILE LTAO NTY 00M384ED SINGLE UM iT ANYAUTO (Es 8=161) S ALLOW ELIAUTO$ BODILY MdURY � MHEDULEGAUTO$ perpa im) HIRED AUTOS BODILYfNdURY � NON-0WMD AUTOS IPQr,Oydowj PROPERTYDAMAGE pyera�sltent) G(RAGE LIASILI M AUTO ONLY-EA ACCIDENI ANYALOO OTHEF THAN EAA(,, E ALITDONLY_ AE;; 5 E:CESSILIKEIRELLAL1ABJUTY EACH OCCURRENCE b OCCUR _CLMS MADE AGGI&CATE S IDEDUCTIBLE 5 RETENTION WDRKQ I&COMPENSATION 1h�e STATU. QT i- AND MA fLOYRIM UANLffY A ANYPRI1PRFMFNPAF'TTIEMXEM-1 Y� 702253,3022009 7/24/09 7/24/10 ELEACMACCICENT $ !;00,000 Of-RCEI MEWER EXCiLDED? fNinedmixgInNM I 1315 SF•EA EW ;jE !io0 o00 ff d�sCd69u�rHar rs 'EA IE-POLOI.Iiut r s iOO GOO INSCRIFMcm DF OPERATION$I UN AMONS I VENCLES i EXCLUSIONS ADDED BY E NDORSEMEW I SPECIAL PROVISIONs RAXXUND 3 SANTANA, OWMM IS EXEMPTIM FROX WOE COMFBNSATION POLICY CIERTIFICATE HOLDER CANCELLATION SMULD ANY OFT FIE ABOVE CEBMOMPOUCIES BE CANCEL LE:!6EFORE TF E EXPIRATION GATE t»tEOf,SHE i85LL NG INSURER MYIL L PSIDl4VOR TO MAL 30 O AYS WMTtEN 2Y OF >a mTR AVER NOTICK TO rrM CERTIFICATE HOLDER NAIITEI!TO 714E LEFT,63j-FAMURE TO DO SO SH&" FAXs 979-689-419S IMPi:A N8 O N OR IITY OF Ater JINa UPON THE INs_ F-P.Tf II AGENTS QR 1120 OSGOOD ST REp NORTR . MA AUT" REPRESE ACORD 2: (200-"1) OW2009 ACORD GORPORATIOlkAll rlghis reserved. The AC ORD name and fogo are rag i eir+e Yk4 OfAcoRD