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Home My WebLink AboutBuilding Permit #528 - 1600 OSGOOD STREET 2/1/2007 TOWN OF NORTH ANDOVER NoR APPLICATION FOR PLAN EXAMINATION ofrll ,.�•o .•s ^Y # + Permit NO: Pl/V] r Date Received Date Issued: Qc►Wus�� g� IMPORTANT: A h ant must complete all items on this page r4i+ - LOCATION i��6 Co Print PROPERTY OWNER v h- rint MAP NO.: PARCEL: ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential ❑New Building ❑One family ❑ Addition ❑Two or more family ❑ Industrial Alteration No.of units: ❑ Repair, replacement ❑Assessory Bldg ❑Commercial ❑ Demolition ❑ Moving relocation 0 Other ❑ Others: ❑ Foundation only �SC(RTION OF WORD TO REFPRMED 11 hjl G44 ]lIdentificationease Type or Print Clearly) OWNER: Name: o''�l� �iG 1A 4 Phone: Address: CONTRACTOR Name: +�4 Phone: r Address: 7aL ��,vtyi Supervisor's Construction License: Exp. Date: ^= Home Improvement License: Exp. Date: ARCHITECT/ENGINEER "ecL- Name: Phone: , 4 6` -77 Z-`7:i7z 7 Address: �)r—'Z &",Q 1A Reg.No. �I-VI FEE SCHEDULE:BOLDING PEPHT. SI2.00 PER$1000.00 OF THE TOTAL EST/MATED COST BASED ON x125.00 PER SFF, Total Project Cost :$ "/T FEE:t) ^ Check No.: (C2, Receipt No.: Q 1 Page I of 4 TYPE OF SEWERAGE DISPOSAL Swimming Pools Tanning/Massage/Body Art E] g El Public Sewer ❑ ." Tobacco Sales ❑ Food Packaging/SIles C>0 Well ❑ ❑ Permanent Dumpster on Site Private(septic tank,etc. ElElectric Meter location to project NOTE: Persons contracting with unregistered contractors do not have access to theu antyJund Signature of Agent/Owner Signature of contracto Plans Submitted Plans Waived El Certified Plot Plan El Plans THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF-U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS FIRE DEPARTMENT -Temp Dumpster on site yes no Fire Department signature/date r• COMMENTS Zoning Board of Appeals:Variance,Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments lwQ z #- C) Water& Sewetkonnection/Si¢nature&Date Drivewav Permit Building Setback ft. Front Yard Side Yard Rear Yard Re uiredProvided Re uired Provides Required Provided - 4 Dimension Number of Stories: Total square feet of floor area,based on Exterior dimensions. Total land area, sq. ft.: NOTES and DATA— For department use Page 3 of 4 Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM05 Created JMC.Jan.2006 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 Addition Or Decks ❑ Building Permit Application ❑ 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) 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 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 i r Doc:INSPECTIONAL SERVICES DEPARTMENTMFORMOS i i Page 4 of 4 Location Q� !QCs f No. � Date NORTh TOWN OF NORTH ANDOVER f � �? • OL � 9 Certificate of Occupancy $ �'�S'••°•Eta Building/Frame Permit Fee $ sACMus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # � Y 19965 Buildinghnsped.r NORTH Town of Andover dover Mass.4? COCMIC KEWICK TRATED P` BOARD OF HEALTH Food/Kitchen Septic System PERMIT T D 041" / BUILDING INSPECTOR THISCERTIFIES THAT.. ........... .. .1.!!t.r..rm ............................................................................................. Foundation has permission to erect. .. buildings on 16.0 ... Sl�Ad.4r....... T.... 00 A ............. Rough to be occupied 8S..... <! -..1............. Aad.a.se'r......................................................................................... Chimney 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. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough a? >q— PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUR ST TS ELECTRICAL INSPECTOR Rough .......C.. ..... Service z .. ................ ..... ................... BUILDING INSPECTOR Final Occupancy Permit Required to Occ 4py 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 Until Inspected and approved by the Building Inspector. Burner DEPARTMENT Street No. SEE REVERSE SIDE Smoke Det. 01/23/2007 12:29 6037728313 DWIGHT CROW AGENCY PAGE 01 a-OZ0,?a CERTIFICATE OF LIABILITY INSURANCE OLID s DA*t� M wo u.-�IR Cr.>?M-1 Al-23/07 Dwight Crarov THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATIO cY' to ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 81 Bort1moTith �"'�' Ste C HOLDEN.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR PO Box i77 Stratham MU 03885-0177 LIALTER THE COVERAGE AFFORDED BY THE POLICIES SELO%l Phone: 603-772-.2868 FaXI 603-772-8313 INSURERS AFFORDfNC3 COVERAGE IMURED NAIL m mISI.IREx n CNA/MQAC Gle"on Arch1tects 152 Portsmouth Ave. stratbam NR 03885 moo: COVERAGE$ INSURER E: THE POLICIES OF M15URANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAIMED ABOVE FOR THE PIDUCY PERMD INDICATEQ,NOTWITHSTANDING ANY REQUfthENT,TERMOR CONDITION OF ANY CONTRACT OR OTMFR 00MMNT WITH RESPECT TO WHICH TM CFRTTFMRGTE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AMMEO BY THE POLICIES DESCMMD MEREMV IS SUIWECT TO ALL THE TERMS,EXCLt=M AND CONDITIpNT OF SUCH POlfC1ES.AGGREC3AT"@ LIhAITS SHOWN MAY HAVE BEEN REDUCED By PAID CLAMS. LTR TYPE OF IN,aURANGE POLICY NUMBER •. GE/ERAI.tf MMY � DATE LIMITS C,BMMERcuul GENERAL LIABILITYEACH DCCURRE3JCE y OLAIMS MACE EI OCCUR PROAS_S mvwumnee) $ MED om(Any eno peI„n) S dAL a ADV aw,uRY s GLwL AGGREGATE umrr AppLw PER: GENERAL AGGREGATE S POUGY ipm LDC PRODUCIT,-CCMPIpp AGG S -- AVTOMDBILBLIABI " AW Aero CO SINGLE uwr s ALL OWKED AUTOS . SCHEDULED AUTOS BODILY MIRY $ HIRED AUTOS (p-Pima" NOW-OWNED AUTOS (Parti Y f SPR 'DAMAG> S GARAGE LIABp.IT'y ANY AUT D AUTO ONLY-F-A ACCIDENT S CTTIIER THAN EA ACC S EXCIMSNMBRE LLA LIAORM A41ro ONLY: AGO a 7 OCCUR n CLAW MADE MACH OCCURRENCE S AGGREGATE .S OEDUCTIBLF f RETENTION s $ WORKM 00mpM BATMM AND S A EMPLOYERV LMIBQITI' TORY LIMIT& ER _ ANY A aaRve 01/23/0'7 01/23/08 E.L.EACH ACCOENT s 100,000 ": EC°S InL °PRrnIL Hsealow EL,R ASE-EA $1001000 OTHER ELrA3E_p01ICYLnVIrr $500 000 DI�CRIF MON OF OPERAT14NS/LOCATiDN,q f VB4ICI.BS!EICgAl81pNS ADE7®OY ErOORgEtITgrT/SPECIAL FRR04A5IpNS 2ERTIFICATE HOLDER CANCELLATION WATTF01 04OULD ANY OF THE ABOVE Des(MMD POt.KM BE CANCELL M OW—ORE THI:,EjIp) gASE 7 ,MwIssuwo Mt MER WML ENCP VM TO MAM. 10 DAYSWRITTEN NOTTCE TO TELE CBMFICATE HDLDM NAMED TO THE LSUT T.BFAILURE TO 00 SQ SHALL Watts Regulator #*Pose=No OBLMATTON OR LLABILRY OFANY 1600 Osgood Suet KIND uFav THE INSURER,TT3 AGdlrs OR I1. And0v0M MA. 01247 R>nREserrA 01/23/2007 12:29 6037728313 DWIGHT CROW AGENCY PAGE 02 IMPORTANT If the certificate holder is an ADDITIONAL,INSURED.the policy(les) must be endorsed.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements). If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy, certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of insurance on the reverse side of this form does not constitute a contract between the issuing insurers),authorized representative or producer,and the certificate holder, nor does it affirmatively or negatively amend,extend or after the coverage afforded by the policies listed thereon. `rwn-S rann„testi i Contract of tenant work at Watts Regulator 1600 Osgood Street, North Andover, Ma December 18, 2006 Scope of work: Remove and relocate storage files Remove and replace office wall Carpet three offices shown on plan Paint three offices shown on plan. All material and labor will be supplied for this work. The work is estimated to take 4 to 6 weeks to complete. Other areas: Architect to provide plans for the above mentioned work and to obtain permit. Construction work will be$19,500 Architects fee will be $5000. t% —7irchitecYcontractor att Regulator Dave Gleason Ty Muscat 603 772-7370 978 689-6036 Fax no. 603 772-6044 The Commonwealth of Massachusetts Department of Industrial Accidents W Office of Investigations w d 600 Washington Street �tW Boston,MA 02111 M www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly / Name(Business/Organization/Individual): 4!RGry CYC Address: I�5Z a �A. k A"?,-e.- City/State/Zip: City/State/Zip: '* vrPhone#: 6,45"�• 77Z, 77 Are you an employer?Check the appropriate bog: Type of project(required):. 1.,® I am a employer with 1 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ® Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp.insurance comp.insurance.$ required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself No workers' co right of exemption per MGL y [ �• 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no 13.❑ Other employees. [No workers' comp.insurance required.] *Any applicant that checks box#1 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. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: 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 of perjury that the information provided above is true and correct. Signature: 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 u�til 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-contiactor(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/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 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. #617-727-4900 ext.406 or 1-877-MASSAFE Fax#617-727-7749 Revised 11-22-06 www.mass.gov/dia