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HomeMy WebLinkAboutBuilding Permit #196 - 1600 OSGOOD STREET 9/14/2009 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: I PORTANT: Applicant must complete all items on this page LOCATION ir Q g d rint PROPERTY OWNER Print Jq 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 J Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTIO OF WORK BE PERFORMED: _ e ` o d1A co Identification Please TypV or' rint C1earY�.G — s OWNER: Name: do 4 L Phone: Lf � Address: CONTRACTOR Name: Phone: Address: Supervisor's Construction License: 1 ,�f-a L/O _ Exp. Date: D Home improvement Licenser Exp. Date: ARCHITECT/ENGINEERo hone: T(j Address:-,5-74) g. No.e FEE SCHEDULE:BULDING P MIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. oy Total Project Cost: $ 3 7 of �V© FEE: $ 60 Check No.: 7f Receipt No.: NOTE: Persons contracti i unre istered contractors do not have access to the guaranty fun d Signature,of Agent/O Signatureof contractor,' Plans Submitted P aived Certified Plot Plan Stamped Plans i 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 Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments r ',,,Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster gn site yes no Located at 124 Main Street CJ Fire Department signatureldate 1 V-3 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 1� ❑ 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 ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses 4 ❑ 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: Doc.Building Permit Revised 2008 NORT►y Town of 4A,ndover 0TO No. LAKE dover, Mass., �`� o ^� COC MIC ME WICK V ,. �i9 ADRATED PPS` �� 1`s BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System. BUILDING INSPECTOR THIS CERTIFIES THAT /i(O 0 .. ............ Foundation 'on has permission to erect...:..................................:. buildings on ....,1.. .......... .. .D4. .......:... ,1/.2 Rough n imne to be occupied as.........:./ .l.... ...U�....................... ........ .. ..........� /.ro�....... ..E�r. y provided that the person accepting this permit shall in ev respect conform to a terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspectio -, A teration and C struction of Buildings In the Town of North Andover. ��� Z a 'Pell p na PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT, EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI STARTS Rough. ........ .......................... .... .......... ................................................. Service WING 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 Dobe FIRE DEPARTMENT' Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. 10/28/2008 13:35 FAX 19786833147 H.P.ROBERTS INSURANCE i0ool ,�CORt ,M CERTIFICATE OF LIABILITY INSURANCE DAT 10/2810 PRODUCER 7mS COMRCATE 15 ISSU®AS A MATTER OF.INFORMATION M_P. Roberta insurance Agency *&y AND COX#Mn NO RK*" UPON THE CERTIFICATE 1060 Osgood Street AATER T1FE CSOVARC OVAGEATE DDIES NOT AMEND. EXTEND OR AFFOMD BY THE POLICIES BELOW North Andover, MA 01845 INSWORS AFFORDING COVERAGE MAIC 0 INSURED MIRSRA.Provideace Mtual DOWGIERT C,WSTRUCTZON CO. , INC INSURERS Guard Insurance 616 ESSEX STREET INSURERC; LAWRENCE, MSL 01841 INSURER D. INBLMiSR E; COVBiAGPS THE POLICIES OF INSURANCE LIS ED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEO 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,E}OCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. w POLICY NUMBER POLICOY EFFECTIVE POLICY I>xPIRATION LIMITS GENERAL LIABILITY SACHOOCLRRFENCE S 1.000.000 DAMAE>ETORENTEO s oa 000 X COMMERC(ALGENERALUABIL1Tf Q8EB1 CIAMSMADE OCCUR MEDEXPLAmwepwsm) S 5,000 ACPP0064437 10/26/08 10/26/09 PERsOKmAADVNJLRY s 1,000.0 0 GENERAWORg;ATE S 2,000,000 GEN%A00RFOATELIMRAPPLIES PER PRODUCTS-CONPiOPA03 S 2,000 000 POLICY PEO• LAC AUTOMOBILE LIABILITY SNGLEUmT S ILL giCA�Mt) ANY AUTO ALL OVOIEDAUTOS BOaLYNJURY S SCHEDULED AUTOS (RX Pam) HIREDAUTOS WDILYNJURY S 11b,aQidet} NON-OWNED AUTOS PROPERTYDAMAGE S — (Rx ECCim+11 GAPRAGELIABRM AUTOOPLY-EAACCD@IT S ANYAUTO OTTER 7H AN EAACC S AUT00N.Y; AGG y OMESSNMBRELL USSILITY EftC IOCCURRENCE .. S OCCUR CLAIMS MADE AOGR63AYE S s _ DEDUCTIBLE S RETENTION S S WC STA OTN• WORKERS COMPENSAYION AND EMPLOYERS•LIABILITT B DOWC911544 10/26/08 10/26/09 ELGLCNACgOENT s 1,000,000 OFFiCGRIMeAGERFXCLNUDEoD? CuTNE EL,aQ5ASE•EAENPUNEE S 1,000,000 SPEt;rplff-to wbikw ELOIEEAM-POUCYLTAHT S 11000,000 OTHER I 0MCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDOR6FMENTISPECIAL PROVISIONS 1 F-603458-1090 CBMBOATEHOLOM CANCELLATION SHOULD ANYOF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION TOWN OF NORTH ANDOVER DATE THEREOF,THE ISSUING INSUr"W IL#,ENDEAVOR TO 14011,10 DAYS WRITTEN i 1600 OSGOOD STREET NOTICE TD THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 90 SHALL NORTH ANODVER, MA 018455' IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRE6ENTAMCL ALJTNOR>ZED REPRESENTATIVE ACORD 25(2001108) ®ACORn CORPORATION 1986 s i Y construction Supervisor License. li i License: CS 48040. Birthdate 10!2911.955 ' Expiration=_10/29120Q9 Tr# 5601 TADEUSZ DOWGiEERT iJ 175 BRADY AVE Commissioner SALEM,NH 03079 I The Commonwealth of Massachusetts Department of Industria!Accidents Office of Investigations 600 Firashington Street Boston, MA 02111 www.nxassgov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant,.Information Please Print Leaibl Name(Business/Orpniza6on/individual): Address: City/State/Zip: L n ;-� y��r � Phone Are yo an employer?Check the appropriate box: F7 �R of project(required): 1. am a employer with� 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors New construction . 2.❑ 1 am.a Sole proprietor or partner- listed on the attached sheet,i einodeling ship and have no employees These sub-contractors have . 8. ❑Demolition working for me.in any capacity. workers' comp.insurance. [No workers'comp. insurance 5. 9• ❑Building addition 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.❑ PIumbing repairs or additions myself. [No•workers'comp, c. 152, §I(4),and we have no 12.required.] ❑ Roof repairs insurance re<N ] .employees. [No workers' 13-El purer comp. insurance required..] *Any applicant that checks boz#l must also fill out the section below showing their workers'compensation policy information. t Homeownin 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 a7ached an additional sheat showng.the home of the sub-contractors and their workers'temp.policy information. an employer that is provading:workers' information. p �y !compensation Insurance for my employeeL Below is a e o ' and'ob site Insurance Company Name: l Policy#or Self-ins, Lic.#: ( Expiration Date: D Job Site Mdress---Z6 Address---Z6 4.0 0 S'Q p 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 e. 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 certa r the pains and penaiiies of penury that the information provided alcove ' true and correct Si tures I C Date: Phone Official use only. Do not write an 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 riding Department 3.City/Town own Cleric 4. Electrical Inspector S.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 t ustee 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),addresses)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 requiredto cavy 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' oampensation policy,please call the Department at the number listed' low. Self=insured companies should ent-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.offiicially 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 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 Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 TeL #617-727-4900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax#617-727-7744 www.mem.gov/dia Iq Sep 08 09 04: 24p NORTH ANDOVER 9786889542 p. 1 -. . OFFICE OF BUILDING INSPECTOR ' TOWN OF NORTH ANDOVER •���'�`' ' CONSTRUCT N CONTROL PROJECT NUMBER: PROJECT TITLE: PROJECT LOCATION: NAME OF BUILDING: U NATURE OF PROJECT: IN OR ANCE VVITH ARTICLE 116 OF THE MASSACHUSETTS STATE BUI11 PAIG CODIE. I, REGISTRATION NO. BEING A REGISTERED PROFESSIONAL ENGINEER/ARCHITECH HEREBY CERTIFY THAT I HAVE PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS, COMPUTATIONS AND SPECIFICATIONS.'CONCERNING: ENTIRE PROJECT 0 ARCHITECTURAL_ STRUCTURAL 0 MECHANICAL 0 FIRE PROTECTION 0 ELECTRICAL 0 OTHER(SPECIFY) -------------- FOR THE ABOVE NAMED PROJECT AND THAT,TO THE BEST OF MY KNOWLEGE,SUCH PLANS, COMPUTATIONS AND SPECIFICATIONS MEET THE APPLICABLE PROVISION OF THE MASSACHUSETTS STATE BUILDING CODE,ALL ACCEPTABLE ENGINEERING PRATICES. AND APPLICABLE LAWS AND ORDINANCES FOR THE PROPOSED USE AN D OCCUPANCY. I FURTHER CERTIFY THAT I SHALL PERFORM THE NECESSARY PROFESSIONAL SERVICES AND B EPRESENT ON THE CONSTRUCTION SITE ON A REGULAR AND PERIODIC BASIS TO DETERMINE THAT THE WORK IS PROCEEEDING IN ACCORDANCE WITH THE DOCUMENTS APPROVED FOR THE BUILDING PERMIT AND SHALL BE RESPONSIBLE FOR THE FOLLOWING AS SPECIFIED IN SECTION 116.0 I. Review, for conformance to the design co which are submitted the cont g concept shop drawings,samples and other submittals by contractor in accordance . documents. v►nth the requirements of the construction 2. Review and approval of the quality control procedures for all code-required controlled materials. 3. Be present at intervals appropriate to the Stage of construction to become,generally familiar with6the 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. PURSUANT TO SECTION 116.2 .2 1 SHALL SUBMIT WEEKLY, A PROGRESS REPORT TOGETHER WITH PERTINENT COMMENTS TO THE NORTH ANDOVER BUILDING INSPECTOR. UPON COMPLETION OF THE WORK, I SHALL.SUBMIT A FINAL REPORT AS TO THE SATISFACTORY COMPLETION AND READINESS OF THE PROJECTFO CUP CY. SUBSCRIBED AND SWORN TO BEFORE ME THIS G�h NATURE le ..— sDAY OF IV_aCo9 8.c NOT RYPUBLIC s MY COMMISSION EXPIRES 10 b ��} /600 os/yoe) �� / tea Location cy No. Date i NORT1y TOWN OF NORTH ANDOVER O AL �o Certificate of Occupancy $ /00 Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 2G4 Building Inspector a.�