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Home My WebLink AboutBuilding Permit #324 - 1600 OSGOOD STREET 11/12/2008 j BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION b Permit NO: Date Received °ogwTp'pP` f ��SSACHUS�� Date Issued: 2 �� IMPORTANT: Applicant must complete all items on this page LOCATION D !. rint .PROPERTY OWNER ;!2 tl Print MAP NO 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 ' Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE REFORMED: r V 2•' O lJ 4 rG !.v L� Identification lease Type or Print Clearly OWNER: Name: m D Phone: A !' Address: Co U m f CONTRACTOR Name:% V/ t r Phone: Address. Supervisor's Construction License: Gf�r�y Exp. Date: Home Improvement License: .. .. Exp. Date: J ARCHITECT/ENGINEER — Phone: 9"Z? ea' � 7 40( Address: J Aaa . ��" �j�/'� ,(�/�,.�_Reg. No. FEE SCHEDULE:BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. o✓ Total Project Cost: $_ 3o2O O`i FEE: $ Check No.: 7c '�72, Receipt No.: NOTE: Persons contractin unregistered contractors do not have access to the guaranty fund gnature of Agent/Own _Signature ofcontractor �- 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 I CONSERVATION Reviewed on Signature COMMENTS , HEALTH Reviewed on Si nature 7//--.,,�� i COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes n Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature &Date Driveway Permit DPW Town Engineer: Signature: g g Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date 2r "a COMMENTS �J 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 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 I ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit o 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 i CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 324(1.1/12/08) Date: 3anug 9, 2009 THIS CERTIFIES THAT THE BUILDING LOCATED ON 1600 Osgood St—0ZU Properties MAY BE OCCUPIED AS Cafeteria Renovation IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Ozzy Properties 1600 Osgood St North Andover MA 01845 Building Inspector %1®RTH Town of Andover . b' * C' A odover, Mass. - o =' � COCHICHEWICK y�. f f s RATED PPG K 4 Cl BOARD OF HEALTH Food/ itc � d. ; PERMIT T DSepttc System (�� BUILDING.INSPECTOR THIS CERTIFIESTHAT....... lJ.....�-5. ...d. ` /........... / ...... .. ..L... A ...............�.: Foundation has permission to erect........................................ buildings on .........../G..0.a.......Q.s . .. ....................................... Rough to be occupied as.............................G"t. o..>� :�?� ........ ... <"r^. :' ..:.................................................. Chim~-'\ey-,' Provided that the person accepting this permit shall in every respect 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. �G��c ��' c' ivy PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPMS IN 6 MONTHS ELECTRICAL INSPECTOR_ UNLESS CONSTRUCTION S TS Rough --� Service ........................... .............................. . ................................................. BUILDING INSPECTOR tnal 1 Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place o�n the Premises — Do Not Remove Final No Lathing or D■ Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. TOWN OF NORTH ANDOVER Construction Control Affidavit Project Number: #0807089 Project Title: Luci's Place Cafeteria Tenant Fit-Up Project Location: 1600 Osgood St, Building 30, Cafeteria on 2nd Floor @ SE corner Name of Building: Building 30 Nature of Project: Tenant Fit-Up Plan for Luci's Place In accordance with Section 116.0 Registered Architectural and Professional Engineering Services-Construction Control of the Massachusetts State Building Code, I, Gregory P. Smith Registration No. 8688 being a Registered Professional Engineer/Architect, HEREBY CERTIFY that I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning: Entire Project Architectural XXXX Structural Mechanical Fire Protection Electrical Other(specify) FOR THE ABOVE-NAMED PROJECT AND THAT SUCH PLANS, COMPUTATIONS AND SPECIFICATIONS MEET THE APPLICABLE PROVISIONS OF THE 780 CMR MASSACHUSETTS STATE BUILDING CODE. ALL ACCEPTABLE ENGINEERING PRACTICES AND APPLICABLE LAWS AND ORDINANCES FOR THE PROPOSED USE AND OCCUPANCY. I FURTHER CERTIFY THAT I SHALL PERFORM THE NECESSARY PROFESSIONAL SERVICES AND BE PRESENT ON THE CONSTRUCTION SITE ON A REGULAR AND PERIODIC BASIS TO DETERMINE THAT THE WORK IS PROCEEDING IN ACCORDANCE WITH THE DOCUMENTS APPROVED FOR THE BUILDING PERMIT AND SHALL BE RESPONSIBLE FOR THE FOLLOWING AS SPECIFIED IN SECTION 116.2.2 1. Review, for conformance to the design concept, shop drawings, samples and other submittals which are submitted by the contractor in accordance with the requirements of the construction documents. 2. Review and approval of the quality control procedures for all code-required controlled materials. 3. Be present at intervals appropriate to the state of construction to become, generally familiar with the progress and quality of the work and to determine, in general, if the work is being performed in a manner consistent with the construction documents. UNDER SECTION 116.4, I SHALL PERIODICALLY SUBMIT A PROGRESS REPORT, TOGETHER WITH PERTINENT COMMENTS, TO THE ANDOVER BUILDING INSPECTOR UPON COMPLETION OF THE WORK, I SHALL SUBMIT A FINAL REPORT AS TO THE SATISFACTORY MP } CO READINESS OF THE PROJECT FOR OCCUPANCY. - DRtjh�� k' flY P. Signature and Stamp (no facsimile) RMTH WD MA. =sf SUBSCED AND SWORN TO BEFORE ME THIS DAY OF o 2008 1�%V�A r600ro-Ik MY COMMISSION EXPIRES NOTARY PUBLIC LINDA VANDEVOORDE Notary Public-New Ha mpshke My Commission Expires March 10,2009 10/28/2008 13:35 FAX 19786833147 M.P.ROBERTS INSURANCE z001 ACORD.- CERTIFICATE OF LIABIUTY INSURANCE DATE10/20/08 PRODUCER THS CEWIRCATE IS ISSUED AS A MATTER OF INFORMATION M.P. Roberts Insurance Agency ONLY AND CONFERS NO RIGI{TS UPON THE CERTIFICATE HOLDER THS CERTIFICATE DOES NOT AMEND. EXTEND OR 1060 Osgood Street ALTER TH:. COVERAGE AFFORDED BY THE POLICIES SELOK North Andover, MA 01845 INSURERS AFFORDING COVERAGE NAIC 0 INSURED INSURERA Providence Mutual DOWGIERT „WSTRUCTION CO. , INC INSURER B: Guard Insurance 616 ESSEX STREET INSURERC: LAWRENCE, MA 01641 INSURER D. INSURER E; COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEO ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CON017ION 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. IMSR ADULPOLICY NUMBER POLICY EFFECTIVE POLICY E7IPIRATIDN LIMITS TYPE OF INDUB&IMA-GENERALUABIUTY EACH 0CCURI7SNCE S 1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY IEPABS 5 100,000 CLAMSMADE U OCCUR MED EXP —P-- S 5,000 A .. CPP0064437 10/26/06 10/26/09 PERSONAL&ADVNJURY s 1_0 0 0 000 _ GEWRALAGGREUATE s 2-000,000 GEN'LAGGREGATEUMRAPPUESPEIt PRODUCTS-CCMPOPA03 S 2,000,000 POLICY PRO. LOC AUTOMOBILE LIABILITY COMBINED SN 0.E U M R ANY AUTO IEll emw9m) S ALL OWNED AUTOS BO OILY N JUR Y S SCHEDULED AUTOS (Rprpasm) HIRED AUTOS BOO LY N JUR Y NON4WNEOAUTOS (Pa,m,&%) S PRCPERTYOHMAGE S (Rlr ecclwl) GARAGE UABIUTY AUTO ONLY-EAACCDENT S ANYAUTO OTHER THAN EAACC S AUTOOhW: AGO- S EXCESSNMBRELLALIABILITY GACMOCr.UPRENCE -- S OCCUR CLAIMS MADE AGGA133AYE $ S DEDUCTIBLE RETENTION 5 S WORKERS COMPENSAYH)N AND WC STA - OTH• B EMPLOYERWLIABIUTY DOWC911544 10/26/06 10/26/09 EL BICHACCIDENT S 1 000 000 ANY PROPR IETORIPARTN ERIEXECUTNE OFFICERIMEMBEREXCLUCE07 E.L.OISEASE•EAEMPLOYEE S 1,000,000 WrPROVIStON6bk. EL DISEASE•POLICY LIMIT IS 1,000,000 OTHER ' OESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PROVISIONS I F-603-456-1090 CERTIRCATEHOLDB2 CANCELLATION SHOULD ANY OF THE ABOV2 DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION TOWN OF NORTH ANDOVER DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAL 10 DAYS WRITTEN 1600 OSGOOD STREET NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO$HALL NORTH ANODVER, MA 01845 IMPOSE NO OBLIGATION OR LIABILITY OF ANY IONO UPON THE INSURER,ITS AGENTS OR REPRESENYATIVES. 0q I MR i AUTHORIZED REPRESENTATIVE I - //14 rog�w�� ACORD 25(2001108) 0 ACORD COLORATION 1988 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations [ Vk 1 600 Washington Street ` Boston, MA 02111 1'15 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip:�� -e�. Phone#: 1-7 7g- 1<,P s_'729 -2 Are you an employer?Check the appropriate box: Type of project(required): 1. ' l am a employer with / yi 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6.1 ❑New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 1 7. ❑ 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.❑ 1 am a homeowner doing all work right of exemption per MGL l l.❑ 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' 131-1 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 aiidavii iiidicaiing they are;duiiig all work acid Then hire outside cuntraciors 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. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. A Insurance Company Name: ` C Policy#or Self--ins. Lic.#: O�G ' Expiration Date: G Job Site Address: l�o(� g %� 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. 1 do hereby certify under the pains andp� alti � - rjury that the information provided above is true and correct Simature: Date: 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): 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/lieense 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. # 617-7274900 ext 406 or 1-877-MASSAFE Revised 5-26=05, Fax# 617-727-7749 www.mass.gov/dia G p `sos!i DA Construction Supervisor License ` License: CS 48040 Birthdate: 10/29/1955 EXP iell ion: I 10/29/2009 Tr# 5601 r ' Restriction: 00 TADEUSZ DOWGIEERT I 175 BRADY AVE f SALEM,NH 03079 l f Commissioner �ORTM � 0 0Andover No. o dover, Mass., z0 LA a� COC MICMEWICK %S RATED 4 BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System / BUILDING INSPECTOR THIS CERTIFIES THAT......./..27.1 �5. ...d. ............� AA ... . . . 43.. . Foundation has permission to erect........................................ buildings on .........../...C.. ��.......Q.f�: . ..r�..................................... Rough G!•• q d1q-V G L Chimney to be occupied as........................... ^ '.............. ........ ... r^. "..r...:......................... ........................ provided that the person accepting this permit shall in every respect 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. C�Cc �� c %vim PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR. UNLESS CONSTRUCTION SPRTS Rough ................ ....................7............... `,--.o...................... 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. Location1�49 T>& A00,r 0 Isla'do Voltl- FIov11- No. ! Date . ' TOWN OF NORTH ANDOVER !/V Certificate of Occupancy Building/Frame Permit Fee $ 310 ...- Y Foundation Permit Fee $ Other Permit Fee $ ' koTOTAL Check# 25377 Building Inspector