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Home My WebLink AboutBuilding Permit #609 - 1600 OSGOOD STREET 4/16/2008 If BUILDING PERMIT pF�00 H 4, 6 °3` ," ' TOWN OF NORTH ANDOVER ° APPLICATION FOR PLAN EXAMINATION o Permit NO: Date Receivedra 9q"`"••-•• i/ Date.Issued: e(� gCHl1S IMPORTANT:Applicant must complete all items on this page LOCATION Print PROPERTY OWNER J �. 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 rAlteration No. of.units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer „ D SCRIPTION F WORK TO BE PREFORMED: ,r !'GAY ro 14 , r Identification lease Type or Print Clearly) OWNER: Name: 160 Q Phone: l q zr Y 5� i Address: 16 ,00 .I CONTRACTOR Name:` a C Phone: 9"2 - Address: ° t=` x .� , � f C g�-- `I Supervisor's Construction License: �9,01(0 Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: 6 Address: � �' ix �a f� .lE ,�� Reg. No. } o FEE SCHEDULE.BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED CO T ASED ON$125.00 PER S.F. Total Projectwe..., FEE: $ Check No.: Receipt No.: C� NOTE: Pers"o co acting with unregistered contractors do not have access to the gu anty fund Signature of Agent/Owner Signature of contractor ® = �" 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 k Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes t Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: ocated 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster pn 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 u 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 Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Com Affidavit Comp a It ❑ 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 DEPARTMENTMFORM07 Revised 2.2008 i w Oa• .v y� f M M '�..YSL.♦ • swaM CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER , Building Permit Number 609 Date: June 17. 2008 THIS CERTIFIES THAT THE BUILDING LOCATED ON 1600 Osgood St Bldg#20 Merrimac Valley Library Consortium MAY BE OCCUPIED AS Commercial Tenant Fit UP IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BtUDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Ozzv Prouerties 1600 Osgood Street North Andover MA 01845 Building Lis Vtor �� f NORTH '9 o : tAndover No. `d C, - o dover, Mass., O LA COCMICHEWICK �� d ADRATED pP�\ S BOARD OF HEALTH PERMI T D Food/Kitchen Septic System • BUILDING INSPECTOR THIS CERTIFIES THAT.......10 . ....... ..... ... ... ........................ ................. .................... ` Fou � � i has permission to erect........................................ buildings on ./ ..............�..............,c ... `� Rough t0 be Occupied as .. ....... .!/�` ...1. .., W. .H�`�... ...... 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 l PERMIT EXPIRES IN 6 MONTHS Final ELECTRICAL INSPECTOR UNLESS CONSTRUCTIQ%�iSTARTS ou o/ V ...... ............................ ................................................................. Service BUILDING INSPECTOR 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 d w Street No. OX SEE REVERSE SIRLJ Smoke Det. 11/14/2007 14:43 FAX 19786833147 X.F.ROBERTS INSURANCE Ig003/003 - - OATE(M>M>�YYI ACDEQ. CERTIFICATE OF LIABIMY 1NSURANCE Tmjs,cERnW.►n is�ssuEc As A MATTER OF uFoRMAMON PRODUCER ONLY AND CQNF�S NO RIl3Iti l UPON THE CERTIFICATE K.P. ROBERTS INS AGCY INC HOLDER• DO`CERTlplCATE DOES NOT ANENo. EXTEND OR 3060 Osgood Street ALT1Ht THE COMM R AFFORDED Elf THE PouCiEs BE�ow- North Andover, Dpi 01845 tNSURPRS AFFORDIN;lD VERAtaE NNc# (970)693-8073 _ - FJZND= 3032%m ms co INSURED DOWGIERT CONSTRUCTION CO. , INC. met w P n 8 DUNDEE PARK DGMEA Ct ANDOVER, MR 01810 am"0-_C iRD IN GROM MIlp1RER iz COVERAGES _ THE Pourna OF IMSIJRANCE LISTED BELDW HAVE BEEN=1160 7 ..THE wISURED NN W ABOVESPFC THE POLICY PEWO E A AY EED OR ANY REQMEMENT.TERRA OR CONCNTION OF ANY CONTRACT OR QRtER OOCl1MENT WfM T TO WHICH THI6 MAY PERTAIN.TME INSURANCE AFFORDED BY THE pOLICIES.UMMM.FIEREIN IS SUBJECT TO ALL THE TERMS.MLUSONS AND COINDMONS OF SUCH POLICIES.AGGREGATE t9Ypt$SHOWN MAY HAVE BEEN REMMSYMD CLAN& rort _ p0uC1►NUMBER umffs ka ma GE-- uaNuir, - m77 E�OCCURRENCE s 1,000,000 LupiffoLuc 9, 5 00 g COMMERCIALGENSLwHu�► PRIZE Ee L_A-10-6-000 -_- MEvuhra..v = CLAIMSMAOE ®OCCUR cPPoo64437 10/26/07 10/26/08 pmomm-&ADVr = 11000.00 GENERAL AGGREGATE s 2,000.0nb LIMIT Mn*,p FavaucTs.COMPIOPAGO a 1,00Q.000 m=y Loc I AUTON088J:LUIBSnY ANYAWO ALLOWNEDAUiO bio ao l RY i S1,NEOULED AUTO8 — YINJIAtY HREDAUrO= i IPaamdeiM) NON-OWNEDAUTOS PROPERW DAMAGE i GARAGELINIUTY - AUTOONLY-EAACCIDW i ANYAUiO EAACC 4 AUTOONIY AGG = EXOESSUMBRELLAUMMM I EACH OCCURRENCE S ❑tX/1=ABMADE AGtaATE S S OEDUMLE i RETWnON S Im = WORIM"COMPEN8ATIONAND A R t7R fMPL&& -- DONC703930 10/26/07 10/26/08 E.LEACMACCIDENT I 500,000 D o� eNeea emue 9t E.L.msEASE.EA EMPLOYEI s 500 000 E.L.DffASE_PO=LlMIT = 500 000 anfEa !I 1 oBSCR�rbNofovERA"fiOrgrLOCAT10N8�VEH�C�Beo�CwsbaBADDEOBYEENTtiPECu�PRov�sfoNB COVERING OPERA?IONS OF TBE We= MMM, AS IiSQMM FOR WORK FREPORNKD AT 1600, 1590,1610,1630 OR 1636 OSWOD STREET, NORTH ANDOVER, MA. ADDITIONAL INSUREDS AS RESPECTS THIS POLICY: 1600 OSGOOD STREET, LLC AND OZZY PROPERTIES, INC CERTIFICATE- CANCELLATION $HMO ANY OF THE ABOVE OESCRBEO FOUC93 BE CANCELLED BEFORE M EXMRAnON 1600 080000 STREET, LLC DATE TNEREOF.THE MUM INSURER WU ENDEAVOR TO MAL 10 DAY$WRITIIEN C/O OZZY PROPERTIES, INC NOS TO"M%RTMICATE HOLM NAMED TO TME LEFT.Sur FAILURE TO 00 SO MOU 1600 OSGOOD STREET IMPOSE NO OBLIGATION OR LVIB OY OF ANY KM UPON TME INSURER.rts AGENTS OR NORTH ANDOVER, ILA 01845 RMESLWATrVEs. titAUTIWRIZEO RET'REBENTA ACORDW(�0 M) fitA CORPORATION 1988 i i Bo��ot�tit8tlf�'ti' ttbtts�� i�� ' Construction Supervisor License License: CS 48040 ii Birtodate 10/29/1955 Expiration 10/2.9/2009 TO 5601 e Restriction ':00 TADEUSZ DOW616:LT 175 BRADY AVE SALEM,NH 03079 Commissioner i 11/14/2007 14:43 FAX 19786833147 M.P.ROBERTS INSURANCE 10003/003 OATEO&VOOW ACOB,Q,� CERTIFICATE OF LIABILITY INSURANCE YVY) 11 1a 007 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION N.p. R08ERTS INS AGCY INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AMEND. EXTEND OR 1060 Ongrood Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. North Andover, MA 01845 INSURERS AFFORDING COVERAGE NAIC# 978 -8073 INSURED DOWGIERT CONSTRUCTION CO. , INC. INSURER A: PROVIDENCE X TirUAL FIRE INS CO INSURER B: 8 DUNDEE PARK INSURER C: ANDOVER, MA 01810 INSURER 0: GUARD INSURANCE GROUP 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 CLAMNS, p EFFEC 0 IRATI w8RTYPE OF INISMUL POLICY NUMBER OAT D LIMITS MACH OCCURRENCE i 1.000.000 GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY PREMISES(Ea Gccuren s i 50 ,000 CLAIMSMAOE QX OCCUR MED EXP(ArryWig person) i 5,000 CPP0064437 10/26/07 10/26/08 PERSONALA AOV INJURY s 1,000,000 GENERAL AGGREGATE i 2.00O 0-Q& PtOLICY AGGREGATE LIMIT APPLIES PER: PRODUCTS.COMPIOP AGO b 1 00000 FljRa LOC AUTOMOBILELIAIIILITY COMBIINNED SINGLE LIMIT i ANYAUTO ALLOWNEDAUTOS BODILY INJURY — s SCREOULED AUTOS (Per person) HIRED AUTOS BODILYINJURY 6 NONAWNEDAUTO$ (PxsccrdeM) PROPERTY DAMAGE i (Petawidenl) GARAGE LIABILITY AUTO ONLY•EA ACCIDENT i 1-1 ANYAUTO OTHERTHAN EAACC $ AUTOONLY: AGG s EX ASSIUMBRELLA lIAB0.1TY EACH OCCURRENCE $ OCCUR ED OAi18MADE AGGREGATE i i DEDUCTIBLE $ RETENTION i WC Li WORKERSCOMPENSATWNAND ATU MRYLIMITS I X ER" EMPR T0WADOWC703930 10/26/07 10/26/08 E.LEACHACCIOENT s 5000:000 D ANY PR0PRTN ��iGSUMBANA CLUUM? cE.L.DISEASE.EA EMPLOYE S 50 Q Q D O Sd"emeunex ElDISEASE-POLICY LIMIT I S 500 000 IAL PROVISIONS below i OTHER DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT)SPECIAL PROVISIONS 1 COVERING OPERATIONS OF THE NAMED INSURED, AS REQUIRED FOR WORK PERFORLIED AT 1600, 1590,1610,1630 OR 1636 OSGOOD STREET, NORTH ANDOVER, MA. ADDITIONAL INSUREDS AS RESPECTS THIS POLICY: 1600 OSGOOD STREET, LLC AND OZZY i PROPERTIES, INC CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 1600 OSGOOD STREET, LLC DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3.0 DAYS WRITTEN C/O OZZY PROPERTIES, INC NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT FAILURE TO DO$0$HALL I 1600 OSGOOD STREET IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR NORTH ANDOVER, MA 01845 REPRESENTATIVES. AUTHORIZED REPREBENTATI f 6�� ACOR025(2001108) 0 ACCIRD CORPORATION ISO$ II TOWN OF NORTH ANDOVER Construction Control Affidavit Project Number: 0711147 (Architect's Job Number) Project Title: MERRIMACK VALLEY LIBRARY CONSORTIUM TENANT FIT-UP Project Location: 1600 Osgood Street—2nd Floor— Building 20 North Hallway Name of Building: Osgood Landing Building 20 Nature of Project: Tenant Fit-up In accordance with Section 116.0 Registered Architectural and Professional Engineering Services-Construction Control of the Massachusetts State Building Code, I, Gregory Smith Registration No. 8688 being a Registered PFe€essienal EflgineeF/Architect, HEREBY CERTIFY that I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning: Entire Project Architectural X)00000 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 j consistent with the construction documents. UNDER SECTION 116.4, I SHALL PERIODICALLY SUBMIT A PROGRESS REPORT, TOGETHER WITH PERTINENT COMMENTS, TO THE BUILDING INSPECTOR UPON COMPLETION OF THE WORK, I SHALL SUBMIT A FINAL REPORT AS TO THE SATISFACTORY COMPLETION AND READINESS OF THE PROJECT FOR OCCUPANCY. Signatur (no facsimile) A/{G'�f o $MTN [� yJ V D t SULSCRIiED � SWC N TO BEFORE ME THIS /�l SAY•F� 2O�i } MY COMMISSION EXPIRES NOTARY PUBLIC 1 The Commonwealth of Massachusetts Department of Industrial Accidents W Office of Investigations 600 Washington Street f, WrW Boston,MA 02111 M 5� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / Please Print Le ibl Name (Business/Organization/Individual): 1 Address: City/State/Zip: �,� �,��. Phone.#: `� ifs �� -50 Areyou an employer?Check the appropriate box: Type of project(required):,, 1.[�i am a employer with� e-O 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0-Remodeling ship and have no employees These subcontractors have g, f,]Demolition working for me in any capacity. employees and have workers' 9. E]Building addition [No workers' comp.insurance comp. insurance.$ required.] 5. E] We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.E]Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other 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. $Contractors 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: te W,= J Policy#or Self-ins.Lic.#: a 1")C-- Expiration Date: / Job Site Address: - City/State/Zip:Ze 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 and penalties of pgrjug that the information provided above is true and correct. Signature Date: ��/ /� S� 5 — 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." i An em to er is defined as an individual partnership,association corporation or other legal entity,or an two or more P Y, P P rP g h'� Y 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,operiWa 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 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. # 6.17-727-4900 ext.406 or 1-877-MASSAFE Revised 1122-06 Fax# 617-727-7749 www.mass.gov/dia NORTH .9 0 of over No. A o ' dover, Mass., COC HICHEMCK �d ADRATED 7`s BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System • BUILDING.INSPECTOR THIS CERTIFIES THAT....... ....�... .... ....�........... ....................................................................... Foundation has permission to erect................: ...................... buildings on ./ ...... .�' � ?tl .... . .� ........ U Rough R t /n� Chimney to be occupied as ..... ... . .........:.............. ./...........G... ...................Gl. 2 .. ........... provided that the person accepting this permit shall in every respect conform tothe to s of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspectio , 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 E)PIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU. TARRoughRough ...... ........................................................................................................ 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 SIREJ Smoke Det. Location egrDDG��/ No. Date �aRT� TOWN OF NORTH ANDOVER F D tT Certificate of Occupancy $ MU E<� Building/Frame Permit Fee $ Foundation Permit Fee $ , Other Permit Fee $ TOTAL $ Check # , Building Inspector