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Home My WebLink AboutBuilding Permit #839-15 - 1600 OSGOOD STREET 4/22/2015 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION -0.f� • S D e Received Permit NO. ,/ at _ Date Issued: 417,t, I' IMPORTANT: Applicant must complete all items on this page LOCATION. PROPERTY OWNERn-?,-7L_U INT)-4. Print 100"Year Old structure yesnno MAP NO: PARCEL:)1 ZONING DISTRICT: Historic District yes Machine Shop Village yes .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 Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands �� ❑ Watershed District ❑Water/Sewer w-t'1;� .� Lnv�,L DE_$CRIPTIOV OF WOkk TO BE PERFORMED: UI?214 go 4-0/1 1 rve, 7 1z ( '& S 1(tO Identificatn Please Typl dr Print Clearly) OWNER: Name: 1� Phone: - Address: 1'ko LAS, 1 CONTRACTOR Name: 24cz2lC��i-i Phone: ,r —43 - 3 Address: Supervisor's Construction License:. Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: a Address: Reg. No. , FEE SCHEDULE:BULDING PERMIT:$12 00 PER$1000.00 OF THE TOTAL ESTIMATED COST BAS ON$125.00 PER S.F. , Total Project Cost: $ P" FEE: Check No.: 'L Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent�Owner' -_ Sig-ature of contractor. Plans Submitted FE Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Plans Submitted ❑ -.Plans Waived ❑ '.Certified Plot Plan ❑ Stamped Plans ❑ STYPE OF_:SEWERAGEDISPOSAL Public Sewer ❑ Tanning/MassageBodyArt El. Swimming Pools ❑ Well ❑ Tobacco.Sales _❑ Food Packaging/Sales ❑ Pri.vate.(septic tank,etc:_ Permanent P'Mpster ori=Site ❑ -THE,FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM REJECTED: DATE:APPROVED PLANNING & DEVELOPMENT` ❑ ❑ COMMENTS ;CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed onSi nature J ` COMMENT Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes . Planning Board Decision: Comments b Conservation Decision: :Comments ,Water & Sewer ConnectionlS_ignature& Date Driveway Permit DPW To` x-! Engineer: Signature: Located 384 Osgood Street FIRE-DEPARTIVI:r;hf Temp Dump;stbr on site yes_:_. no Located at 124;Mairt Street- . - -Fire Departme►it•signatare/date f.F. COMMENTS Dimansion 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 DANGERZONE LITERATURE: Yes No- MGL-Chapter 166.Section 21A-F and G min.$100=$1000 fine 61 NOTES and DATA— For department use ® Notified for pickup - Date Doc.Building Permit Revised 2010 i Building Department :--The fol;�w ng is°'a=list of,the required,forms to be filled out for.:the appropriate.permit to be obtained. Roofil�g, Siding, Interior Rehabilitation Permits a Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C`.S.L :Licehses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dum sten. ermits require sign off from Fire De artment 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 ❑ 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 aprr�al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submAted with the building application Doc: Doc.BuiHing Permit Revised 2012 . Location �s'1'7CCs-v vC No. "1' Date • - TOWN OF NORTH ANDOVER • Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ K Check# Z Z- O `• Building Inspector %AORThi own of �.. � Andover 0 ,.r. - C h ." ver, ass 261S T O� LAN! A- COCNIC Nl WICK S V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ............. ......................................................... BUILDING INSPECTOR Foundation has permission to erect . ........................ buildings on 1100....cx .............. ........... Rough to be occupied as ........ .�Llt�.^... 1 ....C,. ......................................... chi provided that the person accepting this permit shall in every respect conform to the terms of the application inal 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 CONSTRUCTIO STARTS Rough . ............... Service al 2Z_/s� BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy.Buildin Rough Display in a Conspicuous Place o-n 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. i Department of Public Safety License#: MA-011 License to. Operate Amusement Devices Expiration Date: 6/15/2015 Certified Maintenance Mechanic Larry Cushing Enterprises,LTD Lawrence H.Cushing,III Lawrence H.Cushing II Cushing Amusements 196 Wildwood Street Marton V Cushing Wilmington MA 01887 (978)- T! 978)T! IS I_I? 1#1. r _. U.S.I.D..- # Devicetrr 10802 Hampton Combo 07066 Truck Stop 10842-.-. High-Lite Sw rig 10002 Go Gator Musical 10003 Taxi Jet '10853 :, Dizzy.Dragon, 10004 Round Up `13345 F&risVheel 10006 Sizzler 13473 Casino 13751_ Wisdom Gravitron 10007 Merry-Go-Round ` 10009 Super Slide 02855 Wacky Aroh Bounce 10010 Rio Grande Train ' I002856' '•:1 ire:Dog Belly:Bounce 10153 Zipper 10154 Bungee Jump 10513 Gladiator Funhouse- Scooby Shack 10566 Tea Cup 10567 Tempest 10602 Roll-O-Plane Conunissioner of Public Safety I sued DaVe Page I of 1 0 UP 0 73 604 I i iVLiVi i IBFO�ARIOB PAGR RbObRiiAL AMUMWT # l Issu=er: i Allied Specialty Insurance I=. T.H.F. Insurance C G'Gny , 10451 Gulf Boulevard 10451 Gulf Boulevard Treasure Island. FL 33706 Treasure Island. FL 33706 (Carrier Code: 40851) 1Carrier Policy #: VC1.44495. Cssr4m Prior Poly #: WCM213 r i 1. The Insured: Lmry tushing bbatarprises. Ltd. bailing Address: 196 Yildwod Street iTilsrington, bIA 01887; Fedn: 042714871 File #: 900000000245014 Otbes e� not sbmn abovss { F Type of Business: tion m Sam= OF 0 Risk ID: 913226186 2. 'Pias V-MAA7 P—•s+DA s� f:� >seoY AIL-�- as to =.-Ol a_n. oe 5/27/2015 at the insared`s sailing address: 3. A. BorkWs Coepeasation Isrsace: Part Ogre of the policy applies to the WOA=m C oration Ler of tiie states listed bergs MA MS IN RI B. gWployecs LiabiliIW Iassram:e: Pact Tea of policy spp3-1es to tioadt 3a each stata listed in Item 3.A. The Beit o of OUT JJAWity =dw Past TOO are: Bodily Thjury by Accident $ _._1-M-O 40* WAdddfft Bodily Wur9 h9 Dimmm $ bW � Bodily Tojury by $ C. Otbes States Imwrance: All states eNW tVAD. OH, VA. W. add Vr D. This poli g9 includes tbese e�dorsesaats a> d s MM Sammm OF TS ? 4. The praline for tbris policy gill be determined by car Manuals of hales. Batas and Rating Plms=. Ali repired below is O&JOat to verij._adon seed by sadit. Mode PreBiaaa Rate PerUtimted �. 'Lon of Aral Amoral �� Raomeratlott Yresaivn SBS OUNDWA OH OPS 1 Total Inbiated Ammeal Premilm $ 5.700.00 lbiniumm Preeiva $ 900.00 8spense cmwtant $ 338.00 r VC 00 00 01 A ,a :- "Yk The Commonwealth of Massachusetts . ` = Department of Industrial Accidents Office of Investigations j - 600 Washington Street A Boston MA 02111 YX www.mass govAUa Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly N31rie(Business/Organization/lndividual) 04 Address: 64 �� -LA ' J City/State/Zip: v Phone#: Are you an employer?Check appropriate boa: Type of project(required): 1.6&I am a employer with ❑ I am a general contractor and I 6. ❑New construction employees(fWl and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling ship and have no employees Thi sub-contractors have g, ❑Demolition and have workers' working for me in any capacity. employees9. E] Building addition (No workers' comp.insurance comp.insurance.i required.] 5. [] We are a corporation and its 10.❑Electrical repairs or additions 3.El 1 am a homeowner doing all work officers have exercised their I Ln Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12.C]Roof re irs insurance required.]t c. 152,§1(4),and we have no 1 Oth employees. [No workers' 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 IContractors that check this bar 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 emploYee& Below is the policy and job site information. �-- �� z Insurance Company Name: Policy# or Self-ins.Lic #: /�l y�y yS� Expiration Date- 7 d,01 3 Job Site Address: d �1" iS T- City/State/ZiV >`i V Attach a copy of the workers'co pensation 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 db hereby certify under the'prains d penalties of Perjury that the information provided above is true and correct Si ature: 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 b.Other Phone#• Contact Person: ALLIED SPECIALTY INSURANCE, INC. 10451 GULF BOULEVARD TREASURE ISLAND, FL. 33706 Toll Free 1-860-237-3355 National 1-800-282-6776 Florida Certificate Number: 38 CERTIFICATE OF INSURANCE This certificate neither affirmatively nor negativelyamends, extends or alters the coverage afforded by the policy( ies) described hereon and is issued as a matter of information and confers no right upon the holder. The polic (ies) identified below by a policy number is in force on the date of certificate issuance. Insurance is afforded onl with respect to those th coverages for which a .specific limit of liability has been entered and is subec to all terms of e policy having reference thereto. Nothing herein con'�ained shall modify any provision of said policy. In the event of cancellation of the policy the company issuing said policy will make all reasonable effort to send Notice of Cancellation to the certificate holder at the address shown herein, but the Com any assumes no responsibilities for any mistake or failure to give such notice. Any insurance made a part of the policy includes as a person insured with respect to an occurrence taking place at a Carnivals site, 1 the fair or exhibition association, sponsoring organization or committee 2 rthe owner or lessee there of (31 a municipality granting the Named Insured pemission to operate a(n) Carniva s, but only as respects bodily injury or property damage caused by or contributed to by the negligence of the Named Insured while acting in the course and scope of their employment. NAME& ADDRESS OF INSURED: ADDITIONAL INSURED: Larry Cushing Enterprises, LTD dba Cushing Amusements Joseph N.Hermann. Youth Center Inc. ,North it ingtonoM Street Andover Youth Services & Town of North Wilmington MA 01887 Andover & Ozzy Properties Inc. as respects to the general liability pertaining to the NAME ADDRESS OF CERTIFICATE HOLDER: operations of the named insured only. Joseph N.Hermann Youth Center Inc. 33 Johnson st.N.Andover Ma 01845 Ozzy Properties Inc. - DATES= to 1600 Osgood st.N.Andover Ma 01845 PRIMARY COVERAGE EXOVEgAG -27-2015 CE9 Company: T.H.E. Insurance T.H.E.. Insurance Company Company , Policy Number: CPP0101485-04 ELP0010338-04 LIABILITY LIMITS BI/PD AGG: $5, 000; 000 $1, 0001000 OCC: . $1, 000, 000 $1, 000, 000 Excess of Excess of Food Products: $1, 000_ 1000000, 000 --� '. Policy period: ' From: 6/15/14 . 6/15/14 0/00/00 To: 6/15/15 6/15/15 0/00/00 * - COMBINED SINGLE LIMIT Coverage shown herein applies only to those items scheduled the policy. on or endorsed to A ril 24, 2014