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Home My WebLink AboutBuilding Permit #674 - 1320 OSGOOD STREET 5/4/2010 L BUILDING PERMITof "°oT" TOWN OF NORTH ANDOVER ^6'° o APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received 0 ,'y wTco '( Date Issued: _ C �Ssgc►+us�� IMPORTANT: Applicant must complete all items on this page LOCATION O LSCS-Crej' PROPERTY OWNER r `` jC �j 'nn;' .^_ Print I `MAP 210`3 PARCEL:, 0 ZONING DISTRICT: Historic District yes ,Machine Shop Village yes 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 PREFORMED: Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: } CONTRACTOR Name: Phone: Address: 210 ; Supervisor's Construction License: Exp.. Date::. Home Improvement License: Exp. Date:-- ARCH ITECT/ENG I NEER ate.ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 60 FEE. $ Check No.:_ //� Receipt No.: G NOTE: Persons contractin with u gistered contractors do not have access to theguaranty fund ignature of A ent/Owner ___ g_ _ M _, 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 I 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 924 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 2010 i 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:Building Permit Revised 2008 The Commonwealth of Massachusetts Department o f Industrial Accidents Office Oflnvestieations 600 K'ashinb ton Street Boston, 1,I4 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print L.ealibly Name (Business/Organization/Individual): 1 (,A- Address: �'j 20 OF,6 co o City/State/Zip: _ T'_Phone#: Con g) n\ S Are you an employer?Check the appropriate box; L❑ I am a employer with 4, ❑ 1 am a v Type of project(7edeneral contractor and Iemployees(full and/orpart-time).* have hired the sub-contractors6 ❑New constr2.❑ I am a sole proprietor or partner- listed on the attached sheet ❑Remodelinship 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 adreiluired] officers have exercised their 10•❑Electrical r3• am a h omeowner d ' doing all work right o gh f exemption per MGL 11.❑Plumbing repairs or myself. (No workers'comp. c. 152,§14 eP additions ce required-]t )�and we have no 12 Roof r inst?rsn q ] employees_ [No workers' ❑ repairs Pomp.insuz'ance required.] 13.[] Other `AnY Valicant that checks boy,.#1 must also ED out the se,12 a below shop:r.. _ Homeowners who submit this affidavit indicating the,are doing work=ing'comp__,,4_ V"_poo-1--y r,cc�tIon. +Contractors that check this box must attached an additional sheet showing thework 'hire outside contractors must submit a new affidavit indicating such. name of the sub-contractors and their workers'co I am an employer that is providing workers'compensation insurance or m e policy information. information. f Y mptoyees. Below is the policy and job site Insurance Company Name- Policy#or Self-ins.Lic.#: Expiration Date: ------------ Job Site Address: Attach a copy of the workers'compensation policy declaration ave(showing City/State/Zip: Failure to secure coverage as required under Section 25A of MGL . 152canlead to the impositionnumber bof nz al matron date). fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the fom7 of a STOP WORK ORDER nand a of of up to$250.00 a day against the violator. Be advised that a copy of�statement may be forty Investigations of the DIA forY forwarded insurance to the O coverage verification. ice of g trop. I do hereby certify under the pains andpenalties of p Signature: erjury thrtt the information.provided above is true and correct Phone#: Official use only. Do not write in this area, to be completed by cit),or town offciaL City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing 6. Other a Inspector Contact Person: Phone#: Information an 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 t She 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 apartDXents 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 r--aIIstruct buildings in the commonwealth for any applicant who has not produced acceptable evidence of coxn►pliance 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),addresses)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'comp enation 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 stare to sign and date the affidavit. The affidavit should be.-etu-ried to the city or town that the application for the pen�tit or license is being request:d,not the.Depart: emnt.of Industrial Accidents. Should you have any questions regardirxg the law or if you are required to obtain a workers' compensation policy,please call the Department at-the.numbe:r 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 ffidavitThe Office of Investigations would like to drank 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 Investic;atiFons 600 Washington Street Boston,MA 02111 Tel. # 617-72.7-4900 ext 406 or 1-977-MASSAFE Revised 5-26-05 Fax #617-727-7749 urvruJ.mass..gov/din. ' lown of Andover XAORT#1 10 LAKE = dover, Mass., � COCMICKEWICK �1. ORATED pP�\ �C:) 1�10S BOARD OF HEALTH E N pkFood/Kitchen Septic System THIS CERTIFIES THAT.............. BUILDING INSPECTOR .�....... ........... .............. ........ ............................... Foundation has permission to erect.................. .. ................ buildin o l buildingn.. 0..... �. Rough to be occupied as.................... 1+ Chimney .... ......... ... . ®. ................. ............................................. provided that the person accep mg thi ermit shall in every respect conform the terms of the application on file in this office, and to the provisions of the Codes and By-Laws relating to the Insp tion, 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 CONSTRU START 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 Rough Final No Lathing or Dry (Nall To Be Done Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT' Burner Street No. SEE REVERSE SIDE :j - Smoke Det. Location d_ No. Date v r of MO�T��ti TOWN OF NORTH ANDOVER Certificate of Occupancy $ �sJ�cHusEt� Building/Frame Permit Fee $ Foundation Permit Fee $ 4 Other Permit Fee $ TOTAL $ Check # 2 L I -- 22 . 9 4 Building Inspector