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Home My WebLink AboutBuilding Permit #1046-2016 - 1600 OSGOOD STREET 5/1/2018 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 'Permit N0: �U I�J Date Received Date Issued: IMPORTANT:A licant must complete all items on this page LOCATION . PROPERTY OWNER ` Print 100 Year.Old Structure yesfno. o MAP NO:� PARCEL ZONINGDISTRICT Historic District yesno i Machine Shop Village yes .TYPE OF IMPROVEMENT. PROPOSED USE Residential Non- Residential ❑ New Building 0 One family 0 Addition 0 Two or more family ❑ Industrial ❑Alteration No. of units: El Commercial - ❑ Repair, replacement ❑Assessory Bldg Others: ❑ Demolition ❑ Other /yI ❑ Septic 0 WellFloodplain . OWetlands 0 Watershed District p Water/Sewer DESCRIPTION OF WORK TO BE PERFO MED: cp Identifileatiola, Please Type or Print Clearly) OWNER: Name: t, - Phone: 1-?8 S o . Address: ( L< i--�*0 kts_- 0D.1 ►,�` �1 'CONTRACTOR Name: . X,` Phone: 25.- Address: 1 g _�_41 f Supervisor's Construction License: Up. Dater Home Improvementbcense: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT: 92.00 PER$1000.00 OF THE TOTAL ESTIMATED COSTON$125.00 PER S.F. Total Project Cost: $ FEE: $_71 Check No.: Receipt No.:—_j 6 2P-n NOTE: Persons contractin with unregtered contractors do not have access to the guaranlyfun`l Si nature of A ent/ "Nne fi _g g __. ula Slg nature of contractor t Plans Submitted a L, Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ nNORTH BUILDING PERMIT1;z � 0-0 06'*6 6 TOWN OF NORTH ANDOVER 103 APPLICATION FOR PLAN EXAMINATION * y (,` 5 O �20 i17 n Permit No#: Date Received A°R.{TEC 11 �SSACHl1S�4 Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT:_ Historic District yes no Machine Shop Village yes. no . TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family El Addition El Two or more family [I Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septi ❑Well ❑ Flo do plain ❑Wetlands ❑LI 1Nater8hed Distrrct i Water/Sever - - a 4 R r i DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name: Phone: Email: 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 BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaty fund igDatu R_ _. Plans SuUmitted ❑ 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 m U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS QEALTH Reviewed ori Signa re CO ENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments !Nater& Sewer Connection/Signature&Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street } F.RE ----MENTTternp Dempster onsite e no' Loeateie� me a IVlai`n Street '� � ^a A na FirnsignueLdate �CIVIMENTtS aW wi: a.A,_."7.. R•+.•�4%«1."Ym..-1R+t-Lam.4- .....•.i..®„a.�.,...,.....•,_.,,,� 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 N® MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA-- (For department use) IOW �d e_ c1S5� ❑ Notified for pickup Call Email t Date Time Contact Name Doc-Building Permit Revised 2014 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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks 4. Building Permit Application 4. Certified Surveyed Plot Plan Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract 14 Section/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 OTE: 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 n 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 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: 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:Building Permit Revised 2014 }-r Department of Public Safety License#: MA-01 I License to Operate Amusement Devices Expiration Date:6/15/2016 Larry Cushing Enterprises,LTDCertified Maintenance Mechanic Lawrence H.Cushing II (978)658-3928 Laurence H.Cushing,III Cushing Amusements 196 WILDWOOD STREET WILMINGTON MA 01887 Marion V.Cushing U.S.I.D. # Device U.S.I.D. A Device U.S.J.D. # Device 10002 Go Gator 14353 DizzyDragon 10043 Taxi Jet 13343 Ferris wheel 10004 Round Up 13473 Casino 10006Sizzler 13751 Gravitron 10007 ,Merr3•-GoRound 1002355 wacky Arch Bounce 1002356 Fire Doe Belly Bounce 10009 Super Slide 10010 Rio Grande Train 10153 Zipper 10154 Bungee Jump 10513 Gladiator Funhouse- Scooby Shack 10566 Tea Cup 10567 Tempest 10302 Hampton Combo 10342 High Lite Musical Swing Commissioner of Public---------S Lssitet!Date Page I of I btai I c Up 71D V / J I I 03/31/2016 06:42 FAX 7273671407 THE_INSURANCE_130. 002/003 AC RO 0 CERTIFICATE OF LIABILITY INSURANCE �`03f3/nu1°gam' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND. EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S). AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If ills certificate holder is an ADDITIONAL INSURED,the policy(iss)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endofsemanL A statement on this certificate does not confer rights to the cortlfieate holder in lieu of such endorsemen a PRODUCER NAME: T Allied Specialty Insurance PHONE pAx No: JIUQ No- 10451 Gulf Blvd MAILS$ Treasure island, FL 33706 INSU AFrO=NGCOVERAOE NAIC5 INSURER A, T.H.E.insurance Company INSURED INSURERS: Larry Cushing Enterprises,LTD INssrleRC: DBA: Cushing Amusements INSURER 0: 196 Wk1wood Street INSURER E Wilmington. MA 01687 I RER F: COVERAGES CERTIFICATE NumBER: REVISION NUMBER: THIS 13 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REOUIREMENT.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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. P T R TYPE Of INSURANCE POLICY NUMBER AVOL VOR MOMIu00�FFF O Y EXP LIMITS GEN CULL.1ABILTIV EACHOCCURRENCE a 1,000.000 ZrGENI. MERCIAL GENERAL LIABILITY MI ES A °o s 100,000 CLAIMS-MADE �OCCUR MED EXP(Any one rear) a A CPP0101685-05 0611512015 06/15/2016 pER5ONAL 6 AOv MJURY s 1,000,000 OENERALAGGREdATE S 5,000,000 GGREGATE LIMIT APPLIGS PER: PRODUCTS-COMPIOPAGG i 1,000.000 ICY PRO- LOC $ AUTOMOaILE UASILW INS slN 750,000 ANY AUTO e00rLY INJURY(Per perw) 6 A ALL OWNEDX SCHEDULED CPP0101485-05 06/15/2015 06115!2016 BODILY INJURY(Per 390dw4) S AUTOS AU WNED PROPERTY DAM6A S X HIREDAUT06 X AUTOS UMBRELLAUAaX OCCUR EACHOCCURR NCE 6 1.0001000 X EXCESS UAa CUMMS-MADE ELP0010338-05 06/15/2015 0611512016 AGGREGATE 6 1'000'000 DED RETENTIONi6 TH WORKERS COMPENSATION X nF 6LI W CE AND EMPLOYERS'LIABILITYY/N 1,000,000 ANY PROPRIETORIPARTNERIEXECUTIVE T S A OFFICERIMEM SER EXCLUDED? NIA WCP0004495-012 OW27/2015 05127/2018 E.L EACH ACCIDEN (Mendatory In NN) E.L.DISEASE-EA EMPLOYEE6 1,000,000 lea ,deap"%ondv 1,000,000 DCRIPTION OF ERATIONSbelow EL DISEASE-POLICY LIMIT e EXCESS LIABILITY $4,000,000 EACH OCCURRENCE ELP0012188.00 4/16/2016 04/27/2016 A $4,000,000 AGGREGATE vTSCR PTION OF OPERATIONS I LOCATIONS I VEHICLES(Asch ACORD 101,Addltlond Remuln SenedvN,It nwnw open N MQU"e) EVENT DATE: 4/16/16 THROUGH 4/27/16 TO INCLUDE SET UP AND TEAR DOWN ADDITIONAL INSURED: JOSEPH N HERMANN YOUTH CENTER,INC.; NORTH ANDOVER YOUTH SERVICES;OZZY PROPERTIES.INC.,WITH RESPECTS TO THE GENERAL LIA9ILITY OPERATIONS OF NAMED INSURED ONLY. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Joseph N.Hermann Youth Center,Inc. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 33 Johnson Street Nord Andover. MA 01645 ACCORDANCE WITH THE POLICY PROVISIONS. Ozzy Properties,Inr:. 1600 Osgood Street AOTMO ENTAnvE North Andover,MA 01845 ACORD 25(2010105) 019819-201 CORD CORPORATION. All rights reserved. The ACORD name and logo are registered merles of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: General Businesses ADulicant Information Please Print Lembly Business/Organization Name: o f Address: 6 �D City/State/Zip: (� �-J k,D/ddi�hone#: J�lo5�. ;�j 9�� Are you an employer?Check t&Ippropriate box: Business Type(required): 1.[ 1 am a employer with employees(full and/ 5. ❑ Retail 2.❑ or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment I am a sole proprietor or partnership and have no ❑Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers'comp. insurance required] 8. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturingno employees.[No workers comp.insurance required]**4•❑ We are a non-profit organization,staffed by volunteers, I 1 Health Care with no employees. [No workers'comp.insurance req.] 12.�Other � zt *Any applicant that checks box#I must also fill out the section below showing organigani zation should check box#1. their workers'compensation policy information - organization corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an I am an employer that is providing iv kers'compensation insurance for my employees. Below is die policy information. Insurance Company Name:- ?4--:kS Or, p2 C if eo Insurer's Address: 1&14<5-1 a(a d Dar L r Ci /State/Zi h' P: --72-P A,S q R1j .,Ls 1,m/GL Policy#or Self-ins. Lic.4-JA/ Expiration Date: 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 an penalties of perjury that the information provided above is true and correct. Siomature: Q �j Date: ��'/ '/ / 0/,(� Phone#: CI 7 k to Q� .�Q-), Official use only. Do not write in this area,to be completed by city or town official. City or Town: PermWLicense# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass._ov/dia WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY i INFORMATION PAGE RENEWAL AGREEMENT Insurer: PRODUCER: Agent# 110451 Gulfulf Boulevard 1 T.H.E. Company Allied Specialty Insurance Inc. Boule Treasure IBlaad, FL 33706 10451 Gulf Boulevard Treasure Island, FL 33706 (Carrier Code: 40951) Carrier Policy #: WCP0004495-012 Carrier Prior Policy #: WC144495 1. The Insured: Larry Cushing Enterprises, Ltd. Mailing Address: 196 Wildwood Street Wilmington, MA 01887 Fein: 042714871 Other workplaces not shown above, Pile #: 90000000024SOIS SEE SSE OF OPERATIONS Type of Business: Corporation Risk ID 913226156 2. The policy period is from 12:01 a.m. on 5127/2015 to 12;01 a.m. on _ 5/27/2016 at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compeneation Law of the states listed here: CT MA ME NH RI S. Employers Liability Insurance: part Two of the policy applies Co work in each state listed in Item 3_A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 1,000.000 each accident Bodily Injury by Disease $ 1,004,000 PolBodily Injury b Disease each a Iloye y $ 1,000,000 each employee C. Other States Insurance: All states except: CA, ND, OR, WA, WV, and Wy P. This policy includes these endorsements and schedules: SEE SCHEDULE OF MDORSEMBNTS 4. The premium for this policy will be determined by our Man uaia of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Code Premium Basis Rate per No. To Estimated tal Estimated $100 of AnnualAnnual Remuneration Remuneration Premium SEE E SCHEDULEF 0 OPERATION'S Total Estimated Annual Premium $ 51196.00 Minimum Premium $ 870.00 Expense constant 338.00 Deposit Premium .00 WC 00 00 01 B Countersigned by f .i Joanne M.Rossi Administrative Assistant -000 ql OZZYPROPERTIES Osgood Landing 1600 Osgood Street North Andover,MA 01845 Phone:978.681.5004 Ext.11y Www.ozzyproperties.com jrossi@o Zax'978.681.5109 YProperties.com