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HomeMy WebLinkAboutBuilding Permit #336 - 1600 OSGOOD STREET 10/26/2009 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: _ ll IMPORTANT:Applicant must complete all items on this page LOCATION 16,0e 61,5 PROPERTY OWNER I kcO�> C--)6 c Azint 6&,7-u�tan Print MAP NO: PARCEL: ZONING DISTRICT:=Historic District yes rnMachine 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 el013/C le 5 Septic Well Floodplain Wetlands Watershed District Water/Sewer DE CRIPTION OF WORK TO BE PERFORMED: r 1' Y i- xo Identification Please Type or Print Clearly) OWNER: Name:12AV I O EW6Z1 Ei-, i�wl s Nf�Zi �f2_ Phone:/�.13` 9L/a -8a70 Address: 131 A R i ©V 4A • 6 ;�L CONTRACTOR Name: t4Oh574 Cft art/A Phone: / 4 ' f c - Z?(� , Address: 7 Rl�qA� /�/7 7/ Rol t 4,jed cl 0 ,3a (r Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER , U M - g Phone: Address:5 ? fiykaY-4 5-1-, 5,kL�m 0JCf70 -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: $� � FEE: $ �5 �- Check No.: Receipt No.: NOTE: Persons contractin i nregistered contractors do not have access to th guara ty fund gnature of Agent/Own �- Signature of contractor e 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 PP 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 V40RTH own of ;.t` _ 4 L Andover O A K E = dover, Mass., • COC HIC HE WICK y�. �d ORATED `s BOARD OF HEALTH Food/Kitchen Septic System � BUILDING INSPECTOR THIS CERTIFIES THAT 3#*dPERMIT T D ► ...�.�... ......... oundation has permission to erect •.............. buildings onA6 0................. .. . .. . ..................................... Rough AAA Chimney to be occupied as.......�r. 1.�!.... ..........�.......... ..... ........ .. 411WW. �.......•......................... v r vi o ded that the arson acce tin this permit shall in eve r� a conf r h p p p g p ry pct o o t e 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 CONSTRN STARTS Rough :.............;,,,.................................................. Service '��``BUILDING INSPECTOR 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. ACORD CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DD/YYYY) 0813112009 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Cowan Insurance Agency,Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 359 Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. ,verhill MA 01830 INSURERS AFFORDING COVERAGE NAIC# INSURED East Coast Cubicle Corp INSURER A: Employers Mutual Casualty Company 224 Blake Hill Road INSURER B. National Union Fire Ins INSURER C: Northwood NH 03261 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 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, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED A X COMMERCIAL GENERAL LIABILITY 3D62170 08131/2009 08131/2010 $100,000 CLAIMS MADE a OCCUR MED EXP An one person) $5,000 PERSONAL 8 ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s2,000,000 X POLICY 7 PRO LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT A ANY AUTO 3E62170 813112009 813112010 (Ea accident) $1,000,000 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) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSNMBRELLA LIABILITY EACH OCCURRENCE $1,000,000 A X I OCCUR F—I CLAIMS MADE 3J62170 0813111009 0813112010 AGGREGATE $1,000 000 AXDEDUCTIBLE $ RETENTION $10,000 $ WORKERS COMPENSATION AND X Tn WC STATU- OTH- B EMPLOYERS'LIABILITY WC5341013 0910112009 0910112010 E.L.EACH ACCIDENT $1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? NO 000 000 E.L.DISEASE-EA EMPLOYEE $ , If yes,describe under 000 000 SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $1, OTHER DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Attention Raquel (978)689-4128 Moveable office parfition installations. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION E-Squared Office Panel&Furniture DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN 360 Merrimack Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Door 9B IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Lawrence,MA 01841 REERESE �TIQ TH D ESENTATIVE :j ACORD 25(2001108) ©ACORD CORPORATION 1988 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, A1A-02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Naive (Business/Organization/Individual): a-fz± C Si" t) hl-cl Z_� _ -,,I, d Address: 4,-Z cz City/State/Zip: © LOA W o ok N.14 Phone#: Z Z7 C Are you an employer? Check the appropriate bog: Type of project(required): 1.❑ I am a employer with 4. ❑ 1 am a general contractor and I 6. Q 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.1 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. Q Demolition working for in any capacity. orkers' comp. insurance. 9. Q Building addition [No workers' comp. insurance 5. 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.Q Roof repairs insurance required.] t employees. [No workers' comp.insurance required.] 13.®Other-010 b�. �. *.:;.y an that checks box 9l must also Cil 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. lContractors 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 isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. f �>,,1 l Insurance Company Name: �YS �Uci` �cxSver/i �� C �� /"n// Q'/ 01 Policy#or Self-ins.Lic.#: 3 /D/ ® 17 d Expiration Date: Job Site Address: c00 0 0S c( ©© �� City/State/Zip: �� ,ndo( I V \G<< 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 herebycertify der t e pains and en hies f perjury that the information provided above is true and correct Sip,nature: ate: Phone#: Dj�/GE Aga e3 — 9goZ— G>°-70 L2 � l 7 �" �6, O 7a 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 2 chapter 1 p 5 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-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 permittlicense 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 Iike 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 Commonweal of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Poston, MA 02111 Tel.# 617-7274900 ext 4.06 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-72.7-7749 w—ww.mass.gov/dia East Coast Cubicle, Corp. Attention: Eva Hamory Quote 224 Blakes Hill Rd Northwood,NH 03261 Date Quote# Phone# 603-942-8270 Fax# 603-942-8294 8/28/2009 140 Name/Address Location Diversified Mentor Networks Description Quantity List %List Net Total Quote to:Knock down,move,and install: (10)Four person stations 16x16 (12)One person stations 8x8 (13)One person stations 5x7 (7)Private offices All projects to be steelcase product montage.All work to be done during regular business hours.All files,seating,and tables to be quoted separately. Total 13,500.00 13,500.00 It's been a pleasure working with you! Subtotal $13,500.00 Sales Tax (5.0%) $0.00 Signature Total Quote $13,500.00