HomeMy WebLinkAboutBuilding Permit #922-2016 - 1600 OSGOOD STREET 2/29/2016 BUILDING PERMIT S fLt.H, '
� 6 �
1 � O@. G '_
'
04�
�y, TOWN OF NORTH ANDOVER o
�2 qb p
APPLICATION FOR PLAN EXAMINATION
���� Date Received �1RA�Hwreo "`�5
Permit No#: �SsgoHos�� I
Date Issued: i
IMPORTANT:Applicant must complete all items on this page
LOCATION
PROPERTY OWNER ! ® �-
Print 100 Y u eture yes no
MAP PARCEL: �� ZONING DISTRICT: Historic District yes no
Machine Shop Village ye no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑Addition El Two or more family El Industrial
6,Alt r tion No. of units: ❑ Commercial
i
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑ Septic 1Nelh ❑ Floodplain ❑Wetlands ❑ Watershed' District
D Water
/,Sewer.
DES C IPT ON OFXORK TO BE PERFORMED:
71
OL- a G
e- dentification- P ase T pe or Print Clearly C
.�
OWNER: Name: �� � - � � _ � � Phone: ' 7 e
Address: 1e,9c
Contractor Name:�2 a Phone:
Email:
Address: �
01 V11
Supervisor's Construction License: _Exp. Date: 410J-9-5t "
Ex `
Home Improvement License: p� Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No. ;
FEE SCHEDULE.BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F�
Total Project Cost: $ 'T _FEE: $ - '
Check No.: d0 Receipt No.: c= �
NOTE: Persons contractin I ist ed contr ctors do not have access to the guaran and
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL f
Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming P001s ❑
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
PLANNING & DEVELOPMENT Reviewed On �' g
Si nature_ vU
COMMENTS Ph1r �TlC�S 7 5th- USQ ? ay�� Less ��G.NSL, .
.CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes
r.,
Planning Board Decision: Comments
'Conservation Decision: Comments
.!Nater & Sewer Connection/Signature& Date Driveway Permit
DPW Town Engineer: Signature:
_ Located 384 Osgood Street
FIREDEPAR�1�MENT Tem Du s 4 ' *:i
F ,. ¢ ,� `. ,,}-.� P mp tenon ite�.ayesu.i ;;
Qocated at`124MainlStieet `" f •,�' 'ssrr "` ""
Y �t A 1
sF re �Dep�artment4s gnature/datef�`��
[,-' t� + t '' rG i 4,.� t �L •,. `4 . I sk7 F:.Ii ..-,.:x r n .— j. "'�":y >
w
. . ..
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: lies No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA— (For department use)
® Notified for pickup Call Email
Date Time Contact Name
Doc.Building Permit Revised 2014
Building Department
FRoofing,
e required forms to be filled out for the appropriate permit to be obtained.
terior Rehabilitation Permits
it Application `
Workers Comp Affidavit I
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
dum ster permits require sign off from Fire Department prior to issuance of Bldg Permit
P
OTE: All p '
Addition Or Decks
i
Building Permit Application
Certified Surveyed Plot Plan j
Workers Comp Affidavit
Photo Copy of H.I.C. And C.S.L. Licenses
Copy Of Contract Work With Sprinkler Plan And
tion/Elevation
Plan Of Proposed
�. Floor/Cross Sec
Hydraulic Calculations (If Applicable)
I
Ilcable �
Mass check Energy Compliance Report (If App i
Engineering Affidavits for Engineered products
prior to issuance of Bldg Permit
OTE: All dumpster permits require sign off from Fire Depart
M
New Construction (Single and Two Family) 1
Building Permit Application
Certified Proposed Plot Plan
4, Photo of H.I.C. And C.S.L. Licenses
" 4� Workers Comp Affidavit
4 Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable) j
Copy of Contract E
2012 IECC Energy code
Engineering Affidavits for Engineered products
OTE. All dum ster 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 2014
Location
No. � Date
• - TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ "�
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ P t
Check# J4f J
Building Inspector
Enter construction cost for fee cal - North Andover Fee Calculation
Construction Cost
$ 54,545.00 m
$ - $ 654.54
Plumbing Fee $ 81.82
Gas Fee 100 comm. $ 100.00
Electrical Fee $ 81.82
Total fees collected $ 918.18
1600 Osgood Street
922-2016 on 2/29/16
Ophir Optics remodel
NORT1i
Town of ndover
h ver, Ma
o � ss,
[OCMI:A"61 l WICK y1
7,4s o
U BOARD OF HEALTH
Food/Kitchen
PERM- IT T D Septic System
THIS CERTIFIES THAT BUILDING INSPECTOR
. ..... ...... .. .. ..........
... Foundation
has permission to erect .......................... buildings on ...P1. 0o.eme .. . ..... �
Rough
to be occupied as .......... AA.^................................................. Chimney
provided that the person accepting this permit shall in ev 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
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRU TI Rough
C V
S
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.
Initial Construction Control Document
To be submitted with the building permit application by a
d Registered Design Professional
for work per the 8th edition of the
aM °t Massachusetts State Building Code, 780 CMR, Section 107
Project Title: 4&J� Date:
Property Address:
Project: Check one or both as applica le: ❑ New construction %%CAxisting Construction
Project description:
I A Registration Number: Expiration date: , am a
registered d ign professional, and I have prepared or directly supervised the preparation of all design plans,
computations and specifications concerning:
Architectural [ ] Structural [ ] Mechanical
] Fire Protection [ ] Electrical [ ] Other
for the above named project and that to the best of my knowledge,information,and belief such plans,computations and
specifications meet the applicable provisions of the Massachusetts State Building Code, (780 CMR), and accepted
engineering practices for the proposed project. I understand and agree that I(or my designee) shall perform the necessary
professional services and be present on the construction site on a regular and periodic basis to:
1. Review,for conformance to this code and the design concept, shop drawings, samples and other submittals by the
contractor in accordance with the requirements of the construction documents.
2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable.
3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and
quality of the work and to determine if the work is being performed in a manner consistent with the approved
construction documents and this code.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107.
When required by the building official,I shall submit field/progress reports(see item 3.)together with pertinent
comments,in a form acceptable to the building official.
sa
Upon completion of the work, I shall submit to th a `Final Construction Control Document'.
Enter in the space to the right a"wet"or
electronic signature and seal: a No.
SALEM,
Phone number: V, mail: ,
Bui i ic' 1 Use Only
Building Official Name: Permit No.: Date:
Version 06 11 2013
The Commonwealth of Massachusetts
Department of IntlustriglAccitlents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass govIdia
Workers' Compensation Insurance Affidavit:Builders/Contractors/EIectricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/fndividual): wZ
v
Address:
City/State/Zip: Phone#:
b � ,
Are yon-an employer?Check the appropriate box: Type of project(required):
1.n I am a employer with / �. 4. ❑ I am a general contractor and I
.—L--Z 6. ❑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.? 7. E]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.❑ I am a homeowner doing all work right of exemption per MGL I LE]Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roofrepairs
insurance required.)t employees.[No workers'
comp.insurance required.] 13.❑Other
*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 aie doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors 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 is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:-
Policy#or Self-ins.Lie.#: I)A C,2 *T l -7 ;r Expiration Date: j
Job Site Address:_ l (0 0 Loc r i7 ,� 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 requiredunder 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 DTA for insurance coverage verification.
I do hereby certify under the pains andpenalties ofperjury Aat the information provided above is true and correct. -
Signature: t. --- `rte_.-- -"� 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.PIumbing 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 ofhire,
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 maybe 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 retumed 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-andprinted legibly: TheDepaitmeiifhas 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. Anew affidavit must be filled out each
year.Where a homeowner 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 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 Massarl?u.:sPtts
Mpartment of fadmtdal Accidents
Office of I4Yestigation's
600 Washington Stroa
Boston,SIA,02111
Tel,#617-72.7-4900 ext 406 oz 1-877,MA.SSAFE
Revised 5-26-05 Fax#617"727;7749
wwwanass.vov/dia
CERTIFICATE OF LIABILITY INSURANCE
_ 32/24 `15
THS CERTIFICATE JS J831JED AS A/MATTER OF INFORMATION ONLY AND S 140 RIGHTS WON TW CER'TJSCATF- HOL.DEJ;t TBS
CERTIFICATE 'DOES NOT AFPII'MA4TIVEL7 OR NEGATNEL`l AMEW, EXTEND OR ALTER THE COVOME AFFORDED BY THE P+MMES
BELOW- THIS CERTIFICATE Of MS1JR M CE DOES NOT CONST U11i: A CONTRACT SETNYEEN THE IiSSUNG IIV URERf%, At THO
REPRESENTATIVE OR PRICER,AND WE CEFMMATE HOLDER.
IMPORTANT., 3 the eertl cite holder Is an ADDI110NAL IN5URE J'.the pobi;Weelt must be endorsed. If 5UBROGAnON IS WA- D,submit Iia
the teens wW cmftdiiliom ofthe policy,certitin po5toes Fm.Y require an endorm**raL A id2ienretd CB t?is oertilicate Idea a a'I4A eonktr fi hb;fu the
curRificaft holdcr'in lieu of such erdim-=ncn4s). WNTACT
H.P- P.ab42=ts 1rLauraf;a4_ AgrencyM34W.
1&Er1x
1060 Or-good Street s9: _
North; Andgwrar, fid. 01845 rRSURERSI AFFOROM,C010 'RAGE KAIC A
rrsuRm A t Msixt2hants Mutua.g.
INFORM mwRE s:Guard Insura1noe
DOWGILERT CONSTRUCtION CO'_ , INC IM9uletimc:Marahantr Mutual Cd k _—
616 38SEX STREET INSURERD:Emovidernce mutual - --
LAWMNCEr MA 01841 INSUIZUR t!
INSURan r:•
COVERAGES _ CERTIFICATE NUMBER_ - REVISION NUMBER.,
THIS 15 TG CakTT`! I IJA I I HF NCA i M i F :40-I CYAI I LAVE BEEN Iii ED TO Tl E W;URL-D I A-11E3 ABOVE FOR THE POLICY PERM
INNrAIT0. NoT'.111TDWAN[M ANY REQ L.ITZE&E- T.TEEM OR WlxlDITX)N"LT- ANY COITM CT aJR01'-F-H 17{7f uf&- 11 M*H RKSFI-d',I 10 V►W+I fHG
CERTIFICATE ICY iR I-R-jI,JFII(xt MAY Fi-Hr.AW. IHI- INfiTIHANCl- A14ORDED BY Ti E POLIOCS WSMISM HEREIN 15 SLiBJECT TO ALL THE T1 WS,
t7 GLtjb7EM AND}"f:r IDMS OF-SUCH PGALIC:IFB.L tA11TS SHOM MAY I LA"dE BE, 1 RMLiCEO Q1'r?AX)CL VIS
LSK lAC[31lSL #{ r`CuCI xumeERI�Ai11'Oil7tiTY1 # 10171
TYPE 4F IkSMIIIET I,I,igle+kva i , a p"23/i� 3 23(15,;sel l s!i:auar.wza ' t 1,000,00
D � uAas:� I ,BOP008676�9 � �
c aiiawGf TG REN7E-11
X COL NERCOLGr6TR111t:MIITY I Irltfr r$.tu�r_tw-. is
+-ILAL -MADE Xs 00:11MpIE3EK=?Arw,:mprsm; S 5,1000
MEFIALr-01ECATE s 2,0004000
IL,4*IA;::;ill(;A'.1 I MTAPPISSPER IPF2[lt}t 11:1:: 1'IM+.TII+Hr;t; s 2'.0011,01311.
D AUTGNOBLELIA9IUrf CAP0051510GOlf'a
312.3 15 "1 �f'iE' vcn t+t�I CLst4'f
ssa:�+ii S 1,00 "000
f+ti�ih,'Ji MIYt Y IV.IMY1111w'w=-m S
rs 1 C"WA C krS•1 lyafo I11 FJm a rmmyY —Xtk*-<, >i
ikrG" Km
.�I nr;ti Is(t JPEF�iY awl y
Idtx n.ALlr '•r2L
1
F1 7S Ursssrfu,ur.uus t�(l ul'e T CQa513€150Q 3122IL!i 31'23/f Lg;II(x:I nail hK:1 s' - 1,000,000
EACESSLLAB .Lhl'15 E4MCaE, AC.Q.RE A E '! 1,000.000
OCD--- r�r er Iu l 11x1 s 1
a e h� N ti:A I1G- i
,iwnartcuEr�A +1 D47C55I�T i0,i6fi 14dt,7fii
AMD EMPL{3YEiWLt"ulrrY � t1t wrLwtsCY.
YfN
MW'PS:r'FP.V*3pFF(!rIN F67 rG'r711hR AI'tl iMi::?'18 NI �: �. �}0lJ 000
OFfiCF.k4�iNMri Ea4:r UEED7 W i A� I_ ��
ft[ri��r in NMI �I EL DaE/sa= Eh 6'4�'LGY:.j 7f .I.Q0fJ,cDCt
R}w.•A�r_tfiuxi�� N ( I EL Dd•ME-RXI',YLMr-I S 1,000 000
I115172G`IAJ'1 V Of�F�.TI TIv'Ltii4vs
1
FtYGMP°19C]N 4h!CFI'ttfASi.?N$r LC"'W'45 i YEIGMEro iapa.�+A. L}JM,&UtLonA1.Wmdm Mch*;1m,d ffE"■imam 6 reW 1W)
CERTIFICATE ..DER CANCELLATION _ +
SHOULD AMY OF THT AOD'E DE SCRIBED POLICIES BE CANCELLED BEFORE
TIE EXPIIUTIOW DATE THEREOF, ND'FICE WILL BE DELIVERED IN
DZZY PROPERTIES INC,1600 05GOO ACCORDAdICEWITH THE PCILICY PROM DNS. �
ST LLC .i?CiMEE OrTIGE PARK LLC
OT ND-RE STATION LLC 17tMDEE h41THOP �I1E�SFll3A+,T.E
RE,DS�QINC LLC HERITACE PLACE L t
I -- '4�:A HA #�i A 5 � N2i.�C[�SI, P_ ROBERTS
ro ISBB-2110 ACORD C40RPORA1I0N. All rrfgtm reserved'.
ACORD 25(tui DM) The AGORD/malls and logvam rcglsteredmarks of ACORD
T�I1CItr: Fera: (603) 458-1090 t.+tail:
, Massachusetts Department of Public Safety
j = Board of Building Regulations and Standards
License: CS-048040
Construction Supervisor -"
TADEUSZ DOW61ERT
175 BRADY AVE
SALEM NH 03079
4
CA--CtExpiration:
Commissioner
10/29/2017