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HomeMy WebLinkAboutBuilding Permit #697-11 - 1600 OSGOOD STREET 4/14/2011 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: I Date Received Date Issued: ORTANT:Applicant must complete all items on this page LOCATION /600 0S c,oad &fk i� �6T Print PROPERTY OWNER �.' 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 X Others: ❑ Demolition ❑ Other Ccti/03:0 S.,ephu 0Well Floodpl`ami ❑.Wetl'ands i Watershed(I)istrct .0 Water/Sewer DESCRIPTION OF WORK TO BE PERFORME�D: &T 1600 OS oo j La.9doo; /� ,eo 2 7!: 1,24 I%fo p l e ;c- S4 Fl y W,-J/ :�S,y�cc!0-7 ,or.'� 2 zo/r (Identification Please Type or PrintClearly) OWNER: Name: yn �. �1Y7•� eir-YS7� Phone:(?/Py0T)s 135a Address: An, &KC 160 Se4.4 /oak CONTRACTOR Name: Phone: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST ASED ON$125.00 PER S.F. Total Project Cost: $3cvop-- FEE: $ �� i'Ve,Iv?1 i P,el %Jt' , Check No.: Gt l 4 Receipt No.: aqo �k-�� NOTE: Persons c ntracting 1vith unregistered contractors do not have access to the guaranty fund Signatur O r ignature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ i TYPE OF SEWERAGE DISPOSAL 4 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 E CONSERVATION Reviewed on Signature COMMENTS 4 EALTH �� 'T, Reviewed on Signature COMMENTS Zoning Boe�,d of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes s Planning Board Decision: Comments Conservation Decision: Comments Water & Severer 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 t Ll Notified for pickup - Date Doc:.Building Permit Revised 2008mi 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 o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o 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 o Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit E3 Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o Engineering Affidavits for Engineered products (VOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) 3 ❑ 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) o Copy of Contract Li Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products TOTE: All dumpster permits require sign off from Fire Department riot to issuance of Bid'" .Permit p p a i all cases if a variance or special permit was required the Town clerks office must stamp the decision from the Board of Appeals iat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording lust be ro submitted with the building application Doc.Doc.Building Permit Revised 2008mi T - ORTf-1 0VM of 0 over E .No. V7 -;wl C, A K E o �` dover, Mass., A- COCHICHEWICK AORATED SS ` BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System • BUILDING INSPECTOR THIS CERTIFIES THAT......... ......« ..... ... (.,Gl.ut.1.. ..... ..........t,.1.,L�....... ....I..�. . ..................................... Foundation s .. . has permission to erect........................................ buildings on .� &.... .. ... .......... ...........:............................. Rough to be occupied as.............. l�-i✓1.�.. .....-. .. L..s `..-..... 1A. .. �T..c�aJ.......................... Chimney ' provided that the person accepting this permit shall in ev ry respect conform to the t6rms 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 lid PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI T TS �v Rough :.............. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the 1 Premises — Do Not Remove Final No Lathing or Dry Wall To BeDone FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner. Street No. SEE REVERSE SIDE smoke Det. i ��3ti. �RCzn �✓� �+t . The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 'Y www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information /-� Please Pr><nt Legibly Name(Business/organization/Individual): T�. ©ws Q - h Address: �►• �p 6 0 City/State/Zip: Seq�,b/pp , 0,3 7 phone . Ar you an employer?Check the appropriate box: _ [2. • am a employer with 4. Type of project(required): ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction ❑ I am a sole proprietor or partner- listed on the attached sheget. �. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp,insurance. coin .insurance 5. 9• ❑Building addition [No workers ' p ❑ 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 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no required.]t 12.❑Roof repairs insurance re ) employees.mployees. [No workers' comp.insurance required.] 13A Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I 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 and their workers'comp.po]icy 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: 1,95711;r S ,e C, �� as cc , Policy#or Self-ins.Lic.#: We C, X033 63. � / Expiration Date: G c Jt0b Site Address: I' 4 00 0.S 00J 4a, .� INJCity/State/Zip: �1 ,4� lf�zarl 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. Idoherelycerti u er the pains an penalties ofP er!'ury thatthe information provided above is true and correct. Si nature: hDate: Phone#: 9/ 3Sa 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 M 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-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 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 cityor town may be y 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 t g p o 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 anquestions, please do not hesitate to give us a call, y The Department's address,telephone and fax number: The COMMonwealth of Massachusetts Department of Industrial Accidents Of#iee of Investigations 600 Washington Street Boston,MA,02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#61.7,727-7749 www.mass,gov/dia F—DAT A�® CERTIFICATE OF LIABILITY INSURANCE 5/5/2 ) 010 PRODUCER Allied Specialty Insurance, Inc. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 10451 Gulf Boulevard HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Treasure Island, FL 33706-4814 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 1-800-237-3355 INSURERS AFFORDING COVERAGE NAIC# INSURED Dean and Flynn, Inc INSURERA: T.H.E. Insurance Company DBA Fiesta Shows Inc INSURER B: P.O. BOX 460 INSURER C: Seabrook, NH 03874 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 ADDT POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATIONLTR lb= TYPE OF INSURANCE DATE(MMIDDfYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE` $ -DAMAGEO RENTED COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS MADE 1-1OCCURMED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PROJEC LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ t ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO EA ACC $ OTHER THAN AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N WC103303 5/26/2010 5/26/2011 ANY 0 I ITS 1 A OFFICER/MEMBER EXCLUDED?PROPRIETORIPARTNER/EXECUTIVE❑ E.L.EACH ACCIDENT $500,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $500.00n OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL, 0 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS A ENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTAT �� J ACORD 25(2009/01) ©198 -2009 RPOF served. The ACORD name and logo are registered marks of ACORD Department of Public Safety License to Operate Amusement Devices ,. Eugene J. Dean, Jr. License 4: MA-001-10 (603)474-5424 Issued Date: 3/14/2011 Dean&Flynn Inc., ` .,�°'� ` , Expiration Date: 2/15/2012 Fiesta Shows ' — ---- Certified Maintenance Mechanic 15 Pine St.,PO Box 460 Eugene Dean Sr. Seabrook NH 03874A U.S.I.D. # Device UI D ={#--D veve ice .$ $ - U.S.I.D. # Device 10465 Boomer's Circus(NM) 10482---Slide(NM) =% "" 1001901 Jungle Island t; # > 10466 Merry Go Round '��` 10486 Umb�rella`DuneCi 1001971 Jungle Island A Frame . "� A _4 �^ Bouncer 10467 Slide(NM) -i 0488,.--;Dizzy,Dragon € i4r to ) tom' 1001973 Dalmation A Frame 489 ayBu S3 Bouncer Tooterville -- Act- 10469' Earthquake 1'0490 Umbrella-Combo. q 1001974 Funny Farm A Frame 10470 Orient Express I OS89a�4'�'Stars ip 206b Bouncer � �- „„ 1001975 End Zone Obstacle Course 10471 tBounce(Winnie-NM) 10655 'Eucky l;izzy'Funl3ous'e 1001976 3 in 1 Kid Combo 10473 Convoy Cinema 2000 10656 Grand Chance Carousel I001977 Wacky World 10474 Rockin'Tug 10817 Re-Mix 1I I002406 Atlantis 10477 Merry-Go-Round 10819 Traffic Jam 10478 Raiders(NM) 13347 Mardi Gras(NM) 10479 Crazy Bus .1000121 Bounce-CA 10480 Convoy 1001900 Candy Factory Monday,March 14,2011 ommissioner of Public Safety Page 2 of 2 0 r Department of Public Safety License to Operate Amusement Devices ,.,i,T Eugene J.Dean,Jr. License#: MA-001 -10 603 474-5424 Issued Date: 3/14/2011 Dean&Flynn Inc., Expiration Date: 2/15/2012 Fiesta Shows ` -''�'1. Certified Maintenance Mechanic 15 Pine St.,PO Box 460 Eugene Dean Sr. Seabrook NH 03874 U.S.I.D. # Device 1 r'U.S I D` 4 Device ,. U.S.I.D. # Device If., --, . 02738 Falling Star `ti+ I022T ', ackN"Worm P"' t -^ 10447 Thunderbolt r w 05266 Pharoah's Fury1031 1_ "`Music Fest 10448 Scooter F � - ; 09974 Slide(NM) 10390 Nittany Ferns Wlieel , 10449 Gondola Wheel 09975 Scooter(AMS) 1,0394 `�Ha d`Ma sioon Dark f- .'C 10452 Alpine Funhouse(NM) 0997& Tilt-A-Whirl 4'7 10453 Dark Ride-Castle of Evil WON Cobra- 09979 Nittany Ferris Wheel ` ' *. 10454 Artie Blast 10439 Zipper, - 09980 Turtles j 10455 Sea Dragon 10440 Twister._ 10016 Swinger 10441 Surfer(Tip Top) 10458 Haunted House(NM) _ 10017 Tornado 10442 Zipper 10460 Flying Bobs 10018 Round Up 10461 Dragon Wagon 10443 Cyclone Round Up 10081 Mini Enterprise 10444 Cliff Hanger 10462 Berry Go Round 10167 Freakout 10463 Mini.let Panda 10445 Sea Dragon 10204 Eurobungee 1046 10446 Tilt-A-",h 4 Mini.let Elephant irl Monday,March 14,2011 ommissioner of Public Safety Page 1 of 2 Y