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HomeMy WebLinkAboutBuilding Permit #301 - 1140 OSGOOD STREET 10/17/2006 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION o`No DT 6 qti 0 Permit NO: , d/ Date Receivedio ggococ.ac.u...c P�^` Date Issued: © �7 �4SSAc►+us���� IMPORTANT: Applicant must complete all items on this page LOCATION 10�i 1100 S GiO o® rint PROPERTY OWNER C//.24/ P-7e Print MAP NO.: 35' PARCEL: 04> D ZONING DISTRICT: /365, TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential ❑New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: Repair, replacement ❑ Assessory Bldg 'Commercial ❑ Demolition ❑ Moving(relocation) ❑ Other ❑ Others: ❑ Foundation only DES C ION OF WORK OBE PREFORMED Identification Please Type or Print Clearly) OWNER: Name: Phone: ���'`l&el- 36.7 y Address: CONTRACTOR Name: C.A!�e- 4LV. �0�. Phone: tq-& x/7,3 iQf'97 Address: 7C--gp AAe-e �T x�i;f V. Supervisor's Construction License: Oy� f?4 Exp. Date: /® 7.,::� 42 Home Improvement License:/ _ Exp. Date: ARCHITECT/ENGINEER _ Name: Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost :$ 2��UCS ° FEE:$ ' Check No.: ;;7�,�` Receipt No.: Page 1 of 4 TYPE OF SEWERAGE DISPOSAL Swimming Pools ❑ Tanning/Massage/Body Art E] Public Sewer Tobacco Sales ❑ Food Packaging/Sales ❑ Well ❑ Permanent Dumpster on Site ❑ Private(septic tank,etc. ❑ Electric Meter location to project NOTE: Persons contracting wit ` nre is r ntractors do not have access to the guar ' ty f ` Signature of Agent/Owner Signature of contractor` Plans Submitted ❑ Plans Wai ed ❑ Certified Plot Plan ❑ Stamped ans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF- U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMEND% DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS . FIRE DEPARTMENT - Temp Dumpster on site yes no Fire Department signature/date COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments I Water& Sewer Connection/Signature& Date Driveway Permit i Building Setback(ft.) Front Yard Side Yard Rear Yard Required Provided Required Provides Required Provided Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: NOTES and DATA— For department use) i Page 3 of 4 Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM05 Created JMC.Jan.2006 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 Addition Or Decks ❑ Building Permit Application ❑ 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) 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 In all cases if a variance ors special permit was required the Town Clerks office must stamp the decision from the P P 9 P 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM05 Page 4 of 4 Location do No. Date NORTq TOWN OF NORTH ANDOVER Of••. o ,�'�y0 � 9 + I at ; , Certificate of Occupancy $ s4CHUS Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # ,s `9694 / Building Inspector NORTH Town of Andover 0 It 0 No. 3ol 0 LAKE over, Mass., COCHIC ME WICK � RATED P*' Is WARD OF HEALTH Food/Kitchen PERMJ Septic System T D BUILDING INSPECTOR THIS CERTIFIES THAT.............. bA-%AW#%r ...................... ........... . . ...... Foundation has permission to erect........... ............................ buildings on ...y... .......... ........... .. ..... ...... ........ . ............ Rough 0 to be occupied as............... .. . .......46%. . .....F"..*4......r41111111W. Chimney provided that the person acre Is rmit shall id every respeqonform to ftterms of the application on fl Final this office, and to the provisions of the Codes and By-Laws relating to the Ins t' Construction of Buildings In the Town of North Andover. wowttv PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUC;T17 STARTS Rough ... ......0 0.00=� Service Final Occupancy Permit Required to Ocmpy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough 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. ACORD. CERTIFICATE OF LIABILITY INSURANCE °A9/19%o6' PRODUCER THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION A & K Fowler Insurance Agency ONLYAND CONFERS NO RIGHTS UPON T HECERTIFICATE 200 Park Street HOLDER THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. North Reading, MA 01864 I INSURERS AFFORDING COVERAGE NAIL# INSURED INSURER A: Western World Insu_ra_nce_Compa _ Lear Dev. Corp. INSURER B: Hanover Insurance Com an — _ _ 200 Park St. INSURER c:AIM Mutual Insurance Com an North Reading, MA 01864 --- ------- - ----- - --- ---- _P INSURER D: INSURER E: COVERAGES 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 CONTRACTOR 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR�ADD'L POUCYEFFEC TIVE POLICYEXPIRATON LTR INSRI) TYPE FIN URANCE POLICY NUMBER ATE MM/DD/YY DATE MM/DDW LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1 000,000 AMAGETaRENTEOT— --- A X COMMERCIAL GENERAL LIABILITY NPP1053397 9/5/06 9/5/07 PREMISES Eaoccurence $ 50,000 CLAMS MADE DxOCCUR MED EXP(Any one person) 1 $ 1 000 PERSONAL&ADV INJURY $ 1,000,000 GENERALAGGREGATE $ 2 OOOJ Q00 GENT AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOPAGG $ 1,000,000 POLICY PRO LOC PRO- JECT AUTOMOBILE LIABILITY R ANYAUTO AMN714974702 1/8/06 1/8/0,] COMBINED SINGLE LIMIT(Ea accident) $ 1,000,000 M) ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) $ X HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) i GAR AGE LIABILITY AUTO ONLY-EA ACCIDENT S ANYAUTO OTHER THAN EAACC $ AUTO ONLY: AGG $ �EXCESS/UMBRELLALIABILITY EACH OCCURRENCE $ OCCUR CLAIMSMADE AGGREGATE $ I RDEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION ANDI Vv STS TORI H Y LIMITS ER C EMPLOYERS'LIABILITY AWC7021159012006 5/16/06 5/16/07 E.L.EACH ACCIDENT $ 1,000,000 ANY PROFR IETOR/PAR TN ER/EK EC UTNE OFFICER/MEMBER EXCLUDED? E.L DISEASE-EA EMPLOYEE $ 1,000,000 If)es,d ascri be aider SPE CIALPROVIS1CNSbebw E.L.DISEASE-POLICY LIMIT $ 1,000,000 OTHER 0 E.'SCRIPTIO N OF OPERATIONS/LOCATIONS/VEH IC LES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Insurance verification CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIESBE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS W RITTEN Lear Dev. Corp. NOTIC ETD THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TOO OSO SHALL 200 Park St. I MPOSENO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR North Reading, Ma 01864 REPRESENT TIVES. AUTHORL7,6 REPR EN ATIVE ACORD 25(2001/08) ©ACORD CORPORATION 1988 The Commonwealth of Massachusetts • Department of Industrial Accidents Office of Investigations j a 600 Washington Street Boston, MA 02111 sx www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le•?ibly Name(Business/Organization/Individual): Le.-At, Deyc l m 4 C./,Orlo, Address: ZOp �< cS City/State/Zip: /UDI g4"C/; Phone#: " ?8- 3% - 6 o t5 Are you an employer?Check the appropriate box: Type of project(required): L❑ I am a employer with 4. ❑ I am a general contractor and 1 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. + �• 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.❑ 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.❑ Other *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 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: A ,VA'/ t yrewt G� Policy#or Self-ins.Lic.#: 14r_y 7Drr G- 16 9 0� �00(o_ Expiration Date: o 7 Job Site Address: IN" 0Sn9o& `'„ • Ibfit%. F"10V*_A�- City/State/Zip: ! .J-JQf', f A,.,;, 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 gainst the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the IA for i ur c cov ge verification. I do hereby cer lyy maunder e n an nalties of perjury that the information provided above is true and correct Signature: Date: /v Z (l W i v Phone#: �� p' W ? o Z2 J-y 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 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 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 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. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia