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Home My WebLink AboutBuilding Permit #572 - 1267 OSGOOD STREET 3/26/2010 BUILDING PERMIT NORTft q st��o ,6 ti TOWN OF NORTH ANDOVER 03 ` p APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received * ��SSACHUS Date Issued:—I: lJ IMPORTANT:Applicant must complete all items on this page LOCATION c�c S� �d /Y C�s no PROPERTY OWNER &L r* t r ,, � Print MAP 210 3y—PARCEL: ZONING DISTRICT: Historic District yes �t Machine Shop Village yes n TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration tl No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DE CRIPTION OF WORK TO BE PREFORMED: r� ie ro Identification Please Type or Print Clearly) OWNER: Name: L-4i Phone: Address: ZAe 7 /q ` CONTRACTOR Name: VGA, &j tebnfne Phone: I� -(v -Jrl, '% j Address: 4?' ohc n T �v� f f� Qlo5-3 Supervisor s Construction License: f /lJ Exp. Date: Home Improvement License: >j��l� Exp. Date: -,;2e. -/0 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: $ (01 :60 FEE: $ Check No.: Receipt No.:-2_2 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund signature of 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 i 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 2010 i Building Department The following is a list of the required forms to be filled out for theappropriate ermit to be obtained. p 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) o 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:Building Permit Revised 2008 i NORTH 0 O*f 4Andover O No. , L AKE =Y dover, Mass., C- ': OC HI.HE WICK AORATED S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System IN III. l/ BUILDING INSPECTOR THIS CERTIFIES THAT [..fl#.."... . f.kv ...................... �i�. ........................... """""""" "' Foundation has permission to erect....................................... ildings on ...� .��.........��.oaw'.. g • Rou h tobe occupied as........ ....... ........r.......... ............. +.�.. ............................................................................. chimney provided that the pers acce ting this permit shall in every resp 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 UNLESS CONSTRU N STARTS Rough . .. ..... .................. `......................... Service BUILDING OR 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. FOURNIER Family Roofers & Painters JAMES DEBRECEW-t MAPLE ST. EXTERIOR PAINTING - CARPENTRY- ROOFING FHUEN, MA 01844 FREE ESTIMATES .. 978-683-5127 S� J Ivey Q; 4 13c"rr� k ss 7 � vC 1:67/c7 i R1!nL<,r re.5-� rte® u TOTAL 10 ON ACCEPTANCE ozq v 3 W ` WHEN STARTED ` HALF COMPLETE BALANCE WHEN COMPLETE ✓ �l/ ALL CHECKS TO ALBERT FOURNIER OR JAMES DE13RECENI v 1.t .;z > ai 411 �''if �:T —r- .3..k":�rx �"' ��... .sr � m'�3�'t��.�--r-�{"t-"rr'a:+,t� f� '.�. _ {aT.w,x.-,�;.w:.,.sx'twr�''�++'�z '�'tn• - i I I PRODUCER TH18 CERTIFICATE 18188UF�D ASA MATTER OF INFORMATION ONLY AND CONFERS NO:RI HTS UPON THE CERTIFICATE Degnan Insurance Agency HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 96 Salem St ALTER THE COVERAGE AF IORDED BY THE POLICIES BELOW Lawrance.MA 1"3. COMPAN AFFORDINO INSURANCE INSURED COMPANY A GRANITEISTATE INSURANCE COMPANY James Debrecani I i 2.TanagarWay j Londanderry,NH 03063-0000 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE N: O ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOT WITHSTANDING ANY REQUIREMENT;TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAYIPERTAIN,THE INSURANCE AFFORDED THE POLICIES DESCRIBED HERRN 18 SUBJECT TO ALL THE TERMS,O CLUSIONB AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,OR rfm i 00 OF N>s+RAMa Pauore o e>¢EtA A DEM?LOYERB'LY�eILiSY j i PROPRE:70R1 i UNM PMTNeRe/eIQCUTNE OFFrJ=ANE; NCL o Exp❑ 7434607 5/11/2009 5/11/20101 "T+�TONYLIMrre oo Applm to MA Opwvjmq Oar. ACCIDENT S 100 lm IaMiE POLICY LIM S 600,E OPERA S 100.00 RE THE WORKERS COMPENSATION POLICY DOES NOTPROVIDE COVERAGE FOR JAMB DEBRECEN. CERTIFICATE HOLDER CANCELLATION NORTH ANDOVER.BLDG DEPT SHOULD ANYOPTHEABOVEDesCRIe®POLICII1sECJwcEILEDeeFORSTHs ATTN: BRIAN LEATHE WFATKIN DATA THeREOF.THE Ifs<mNO COMPANY WILL ENDEAVOR TO MAIL 1Q 1 WO OSGOOD ST DAYS WRRTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT NORTH ANDOVER, MA 01645 FAILURE TO MAIL SUCH NOTri smALL up 6360 OILMATION OR L WiLRY OF ANY KIND UPON THE COMPANY.rrS MINTS Oi REPREWNTATNef. AUTHORIZED REPRESENTArVE I f i The Commonwealth of Massachusetts Department o f industrial Accidents Office ofLnvesti,ations 600 Washington Street U, Boston, MA 02111 www mass-gorldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers APPlicant Information �-- Please Print Lealibi JName (Business/Organization/IndiOdual): to Address: �✓1 City/State/Zip: L-o11 d< Phone#: p 7 - / Armee you an employer?Check the appropriate bore a employer with 4. ❑ I am a general contractor and I Tie of project(required): . employees(full and/or part-time) * have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet $ 7. ❑Remodeling ship and have no employees These sub-contractors have working for me in any capacity. workers' comp.insurance. g' ❑Demolition [No workers' comp. insurance 5. ❑ We are a corporation and its 9 ❑Building addition required.] officers have exercised their 10•❑Electrical r 3.E] I am a homeowner doingall k right worof ex repairs or additions exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' . c.comp. 152,§1(4 and we have ve no insurance required.] t em to employees. 12-[�oof repairs P Y [No workers y comp.insurance required.] 13.❑ Other A-n3'a=pheant that cheers box:-1 must also 01 out the section below w eg:... Homeowners who submit this affidavit' -r w'orice s'compens�� row _ mdrda n a they are sheet h work and then hire outside contractors must submit anew 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 information. my employees Below is the policy and job site Insurance Company Name: +T Policy#or Self-ins.Lie. 1 e716 0 7 Expiration Date: Job Site Address: 6 o O Attach a copy of the workers'compensation policy declaration page(showing th/epolicy�number/v Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to thimposition 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 forwarded to the Office of Investigations of the DIA for insurance coverage verification I do hereby c fy under th s and penalties of pePFury thrct the information provided above is true and correct Sienature: 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): L Board of Health 2.Building Department 3. City/Town C1erk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: i Information ani d 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 apartvients 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,§35C(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 coxnpliance 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 unrtil 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 snare to sign and date the affidavit. The affidavit should be retained to the city or to-m that the applicatron for the pernttor licence is being requested,not the.Depara:ent 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 bum leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would like to than you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call- The allThe Department's address,telephone and:fax number. The Commonweal& of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washmgton Street Boston,MA 0.21.11. Tel. ##617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax 4 617-72.7-7749 vww.mass.gov/dia 7Location /Or 6e No. Z-- Date �ORTh TOWN OF NORTH ANDOVER O: • • Ow f 9 • ; ; Certificate of Occupancy $ r Building/Frame Permit Fee $ �,�C NUSE Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # L v v 22u / 6 Building Inspector