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HomeMy WebLinkAboutBuilding Permit #178-13 - 1600 OSGOOD STREET 5/1/2018 TOWN OF NORTH ANDOVER / APPLICATION FOR PLAN EXAMINATION Permit NO: ` Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION Prat . PROPERTY OWNER lQg2 lD ' rint I 00,YebrrJ6ff Sfru6tTrW yes no MAP NO: t' 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 El Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO B PERFORMED: azz / __ -` Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: oe CONTRACTOR Name: Phone: � sr Address: Supervisor's Construction License: Exp. Date: LHome Improvement License: Exp. Date: 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: $ �/J FEE: $ Check No.: Receipt Receipt No.: NOTE: Persons contractin with unregistered contractors do not have access to the guaranty fund 5ignattare rof Agent/Own Signature of contractor . / Plans Submitted ❑ PI Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Type of Sewerage Disposal - Public Sewer Septic Tank Type of Water Supply - Town Water Well THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF Historic District: Approved Rejected _ Subdivision: Approved Rejected Water Shed: Approved Rejected Health: Approved Rejected _ Conservation: Approved Rejected Comment COMMERCIAL SIGN OFFS _ DPW: Approved Rejected Engineering:Driveway Approved Rejected Comment _ Fire Department:Review Approved Rejected 124 Main Street Comment — Planning Department Approved Rejected Comment Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/signature& Date 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 i Dimension I 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 I DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— For de artment use I ❑ Notified for pickup - Date E Doc:.Building Permit Revised 2012 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 Li Building Permit Application o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract o Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract a Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) Li 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 Li Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o 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 o 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 Doe: Doc.Building Permit Revised 2012 Location 1600 No. / Date 3/ 2. • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ " Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# 25674 Bui in Inspector NORTIy Town of 2 �.. E :. ., Andover _ t J_ No. - T ° h ver, Mass, ��1 /,2 ' coc NIc„twlcK �'i• p°RA TE D S U BOARD OF HEALTH PERMI* T T LD Food/Kitchen Septic System S S �� BUILDING INSPECTOR THIS CERTIFIES THAT A.42!2. ....... ,� .�. . ...... buildings on / 6D �SFoundation has permission to erect .................... ..................�C?P..4�_r.....:.......................... Rough to be occupied as ........f ........,���: ��................................. Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STS11�� /J Rough 'T� G�✓��`.� Service ........................ ...................................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. Smoke Det. SEE REVERSE SIDE L—'A/23/2012 14:05 9786833147 „rr��at gar uu �' F CERTIFICATE OF LIABILITY INSURANCE °�'�`�"�z � THIS CERTIFICATE IS ISSUER AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERT'IRCATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, THIS GERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHONZED RE:PRESENTAfi,'E OR PRODUCER,AND THE CERTIFICATE HOLDER, 1 P AMT; It 1 c+nftate h der is an A00111MAL INSUREU,"Ihe po"e w)mat Wi enorae . ItSUMCIATION ,Bug the lama and conditions of the policy,certain policies rmy requim an endorsement A stellsment on thisoertifirate does not confer rights tD the certiacate holder in lieu of such endorslmen PNOUCE RWGT M.P. Rolrtst IzxreuraaC Agc PAMat 1060 Osgood Strut A a North Andovor, MA 01945 INBURERtsIA o N6 e0 GE NAIL ►NUJ,AER At W0X ►_ants Mut u ]__,__—, NOURED Lw :QMrd •Tri ur _ c DOWGIERT CONSTRUCTICN CO. , INC ,NSU a 616 ESSEX STREET LAMINCE, MA 01841' i F; COVERAGES CERTIFICATE NUMBER, REVISION NUMBER: THIS IS TO CERTIFr THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED AQOVE FOR THE PMICY PERIOD IND CATED. NOTWITHSTANDING ANY AMUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR 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, EXCLUSICiNS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, audf IF MIN IN? .. TYPBOltINBURANCE ,ten AO MBER /D LINRTS ,ay MERALUABILITY CMP91B j S06 -1/23/12 3/23/13 EACH OCCURRENC $ 1,Q�Q r 000 COMMERCIAL G•£NEPAL LIAOUTY �� � n accuQeacc_ sQ,0 ,. CIAIMS.M OE R OCCUR MED EXP nyarp Person! 9QQ —, Pe}Y$01Nh4R A6V INJURY $ 1,Q00�00P- GENERAL A6GRfiGATE OQ0,Q� GEN'LAGGRMATEL.rdITAPPLI[SPER PROQUGTS•CDMPJR)FAGG & "1 Q 000 POLIGY PR COC � AUTOMOB149 LIABILITY g N ;EPMOLE LIMIT ANYAUTO BODILY INJURY(Per pgtypn) $ AUQS't SCHEDULED 8441LY INJURY(Pgr gCEidanti $ HIR T'EDAUTOS N�QdJtd AOEO ��Ws ereoe�' nt1 9 p� UINRILLAuapOCCURCUP9142034 3/23/12 3/23113 ,cN OCCURRENcE s ,1,OJ:KOO QR01101BLJA6 — CLAIM$-MADE A, _ GREGA s 1,000 000 r 11) REI•NT qN$ H ANDEMR6 OMPELIASI IT DO4�C122432 10/26/11 10/26/12' U. ANDHMPLOYER@ LIAEIILITY DE TO3Y.LIMlTI ANY ieMezcu7ECRJTIVE NMA �,i_sae_�L�1 �_. �OOQ.Q00 e �etlueu 19r L+.L,•0.19EA3E_-EAEMPLQY 1,000.000 &4� IPTiONt pPEPATON BI w E.LD gA8 •PDC iT ; OQQ oQ' I OEBORIPTION OPOPERA'rICV148I LOCATIDNB IVMCLEB{ACath ACORD 1011,AdAtImal R6001b 3ftdu*,Lrm"gVB0d kurogWrod) COVER'NO OPERA!rIONS OF TI4E NAMD INSURED AS 1.REQUXED roR WORK pERF'O D ,AT DUNDEE OFFICE PARK 1-6 DUNDEE PAPJK DRIVE ANDOVEEt, MA. DUNDEE OFFICE P.ARK'LLC .AM OZ,ZY PROPERTIES,INC, ARE LISTED AS AN ADDITI=L IN8unr) CERTIFICATE HOLDER CANCELLATION DUNDEE OV ICE PARK, LLC SHOULD ANY OF THE ABOVE DESCRIBED POIr 0 fle 9E CANCISLLED BIEFORK C/d OZi:Y PROPERTIES, INC. THIS EXPIRATION NCE THTOEppTHELIICYREOF, NOTICE WILL, BP D78LIVLRIED M 1600 ©;;GOOD STRZET NORTH IMOVER, MA 01845 AUT►IpR¢EO Ra PReaENTA 'P ACORD 25 201 OJOS 1988 1A ACORD GORPGRATiON. All rit8 Rsemd. { ? Th@ AC narrMr>antl logo registerradmsrks tsfACORB gh N'IRNiB: Pea: E-Mail: The Commonwealth of Massachusetts Department oflndustrialAccidents Ii Office of Investigations ' .i_ 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print'Le0bly Name(Business/Organization/Individual):- Address: Business/Organization/Individual):-Address: 1 � 8 City/State/Zip: ,. ���.z- - �'� Phone#: moi' 2.9 6-'R- 5--9) Are you an employer?Check the appropriate box: Type of project(required): 1.ET I am a employer with t '" 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or-part time).* have hired the sub-contractors 2.El aim a sole proprietor or partner- listed on the attached sheet.t �• ❑Remodeling ship and have no employees These sub-contractors have 8. F1Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition co [No workers comp.insurance 5• El We are a corporation and its 10.El Electrical repairs or additions required.] officers have exercised their 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' 13.❑Other comp.insurance required.] *Any applicant that checks box#I 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 add 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: 6--aIna d`�/l +/j�,C C 0 u. Policy#or Self-ins.Lic.#: ( C s - -.. 2 -7 Expiration Date: . Job Site Address: of o?i 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 andpenalties o._� erJ'urthat the information provided above is true and coxrec� Signature: Date: 2— Phone# Official use only. Do not write in this area,to be completed by city or town offaciaL 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#: I Massachusctts- Department of Puhlic Sat'et� Board of Building Regulations and Standards Construction Supervisor License License: CS 48040 sr TAbEUSZ DOWGIERT 17�,BRADY AVE R, SALEM, NH 03075 Expiration: 10/29/2013 f Curomissioner Tr#: 5561 i