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Home My WebLink AboutBuilding Permit #227 - 2 JOHNSON STREET 9/16/2011 i TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: IMPORTANT-Applicant must complete all items on this page LOCATION- S 0 k 4 50!r, p�- Print PROPERTY OWNER Capl (-eie (�/- Print MAP NO: ! tp ~ PARCEL: ZONING DISTRICT: Historic District es no Machine Shop Village yes no � TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition P-rWo or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑Other (0 Septic' ®#Welk ®Fl_oodplam. (®�IWetlands� WRaterslied' Dis"tncf% DESCRIPTION OF WPRK TO BE PERFORMED: lw fea ,fs_ 46ga 7,e,',,, 4-44#eay S'i P 4 n , dentification Please Type or Print Clearly) OWNER: Name: eewY R2 ee-4 Geos f' Phone: o�'3a8- i663 0 Address: /7 ��: lam• I��ore�e; 11ls� mlF�{S� CONTRACTOR Name: -Igrox r,' 61,4&00 , 4Q lCe- Phone: 6937--4;1C Address: (0 9 40'a �*14,f /�0 lid W—.,e� W1 A- O��5 Supervisor's Construction License: e.5 XC30ai. Exp. Date: 141,11,4,01z- Home 41,1 f a o/z. 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: $_ y Check No.: OSV<— Receipt No._02 C-t NOTE: Persons contracting with unregistered contractors do not have a ess to the g anty f d Signature:of Agent%Owner Signature of,contrac Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE F SEWERAGE DISPOSAL Public Sewer Tanning/MassageBody Art ❑ Swumnmg Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. -E]. Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS t s . HEALTH Reviewed on Signature COMMENTS•' Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature$ 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 '4« 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 e( 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 ❑ 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 VOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit -n all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals hat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording oust be submitted with the building application Doc: Doc.Building permit Revised 2008mi � J r Location �i No. 14 — Date ' w NOTOWN OF NORTH ANDOVER O'�•. :•1ti0 ? �. • O F R Certificate of Occupancy $ :.. CHU <� Building/Frame Permit Fee $ _ry Foundation Permit Fee $ Other Permit Fee $ _ TOTAL $ i Check # � zo 24591 Building Inspector f The Commonwealth of Massachusetts Department of Industrial.Accidents Office of Investigations 600 Washington Street UJF Boston,MA 021X1 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/FIectricians/Plumbers Applicant Information Please Print Le ibl Name(Business/Organization/Individual): 6 0tkle ef�1� Address: Eo e D 2 City/StatelZip: J� W ._. , f'{� �. Phone#: Are you an employer?Check the appropriate bov. Type of project(required): •1.❑ I am a employer with 4. I am a general contractor and 1 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.1 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers"comp.insurance 5. ❑ 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 11.0 Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roofrepairs insurance required.] 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 their workers'comp,policy information. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: W« 9'0 Expiration Date: /.s /Z-- Job Site Address: .9 ,TiD 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 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$250.00 a day against the violator. Be advised that a copy ofthis statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do 11ereby certify un the ains and en o _ er'u th y at the inform P P .fP J rYation provided above is true and correct. Sip-nature: G— Date: ,# Phone#: �'!��"33 U Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other C ontact Person: Phone#: 08/09/2010 13:10 9786833147 PAGE 05/05 CERTIFICATE 4F LU413iLITY INSURANCE D;-M wm'Ym) 8 9 10 TM CERTIRCATE IS ISSUED AS A MATTER OF.VW<N=AT10N ONLYAND CONFERS NO MGKFS UPON THE CERTIFICATE HOLDR TM CERTIFICATE D= NOT AFFMAMELY OR Ni9GATWMY AME3O,i18I END OR ALTER THE COMWE AFFORDED BY TK POv(ro DEL.tWY. THIS CERTI[ACATE OF 1 SURANCE D08S NOT CMaffTM A COiMMACt BETWEEN THE DBLItNG iNSURER(S),AUTHOt RED REMESENTATIVE OR PRODUCER,AND 7HE CERnFICATE.NOLDE pri, IM PORTANT: If We cefUlik=te holder is an AOOnKX4AL NCAJR=111! w lsatrst be endAT{ IS WAiVm,suii�m tt's teams and coni atone of the pcpky,oertsk poticlea may regtdre arindorsarnalrt. A sU t amt on tMacaftiftcate does not Confer riglu b Me certificate holler in lieu of such PRIDCUCER ; 2i.P. Rabsrts It>au7rance Agency"=,: 978 683-8073 (978) .683-3147 1060 Osgood Street KazCh' CSovor MA 01845 ^�' y� 3 +' � 1¢}! 2916 Cl ae A Risk Placa ent Services Inc. K= LI3 `WC. `r w � R 10 MPA=ZCA DRIVTs tN9tlrt�c- tv�3'L"n AZts"'k3V`M I& 01845:1 ---------- COVERAGES CE3t17ETCATENU61TsER:` r,: R>_MON NUMBER: IHS IS TO CEI:"IF(i1-IAT THE POUCES OF iNS AW CE UMD BELOW HAVE BEEN ISSUED TO THE t ORM NAMM ABOVE FOR THE F(XICY PERM INDICATE. NQi°NTH$TANDNG ANY WO-1IREMENT,TERM OR CONDITION CF ANY CONTRACTOR OTHER DOCLNVEN'WITH RESPECT TO WHIGti THIS CERTIFICATE MAY t3E ISSUED OR MAY PEtTAPI,THE II "MM AFFOFDM BY THE POLICIES CI SCOMSED NGiEPI IS SUB.lECT TO ALL THE T tM, E)CLUSiU43 AND_CONDITIONS OF6VCH POLKIM LM M SHOVMi MAY FWVEet;[�N REDUCM BY PAIDCLAM3, TME Or INBURPNCEpTrrfl VOUCY� A EXP LtIRTB VM Im"MoNym rm . EACHlx 6EIERALLNIEIMJTY CLffWTlce S 11000 000 CCDAMkr.ETU RENTED t 50,000 14Lti�WERALLIABLITY :.,_. A CLAMS-RADE OCCUR 3DD9812 6/15/10 6/X5/X] urt o v7 ore eea, S 0 mRS wsAOVIrt m S ;L"000.000 Ge RAL AGGREGATE t 2 000�OQ @tLACC 0.TEL94TAPPUESPER PRODUCTS-COW10P AAG t .EcT POLICY LOQ S AIlWiK�LEITABQiTY J COI.ENEDSINGL LIIA E rr . •'`'�r,: t IIOOILY 04.Il1P.1'(Per•pe wN t +ILLOwI�O A(Rpg ' Hl�IAFAAUTOS DODLLY w4Aw(Por mcwenQ t PROPEM OPM(M HMO G Ver-ditm $ NOM-0IMIEOAtftUB � t imv8c - t U10RUAUAS OOcvR € EACH OCCUFRENCES ER�E3SLr48 CLAM954KOE RE7EI4f10N •>' t YIOR2"3A'RON l J 14gVAT, OTH MD!lRPLOrE3ffi'UABILl1Y Yin r ti•q , FR i3 AmPR0pRETMPi )2CUT a: �+CC50075810120 9 8/15/09 9/15/16 o xeazWao� Nl EL EACH ACODENt S 1,000,000 1 000 000 tDEt T7ONCFOPEPATI"bw. ' EL.DISEAl.;E-POUCYtaerr S 1 000 000 DESCwPreorle�oPe�utorasrLncxzpNzrY�q�We,d,AlooRAlol.11daeor.tRe lduer.,araa..peaeueequeeel GERuwwrE HOLDER i.CANCELLATION SHOULD ANY OF INE ADOVE DESCFaeD FOUCtE8 gE CAmcm ifi0 BEFORE { TIE Exr[PAYM D/UE TNEreoi% mu= vYILL ITE DEUVERED IN ACCOROANCEW(M THE POLICY PROVISIONS. AIni10i7aW SP1rrATrvE w T -on9 AGORA CORPORATION. All right reserved. ACME)2S(200MI TIR ACORD neuro and logo ":MgW*fed marks of ACORD 7 1 NORTH To of .. ..... ..... No. _ Jilt ` o , dover, Mass., �• �6. 1 - LAKE COCMICME WICK ADRATED BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System i �. BUILDING INSPECTOR THIS CERTIFIES THACT......................... ............... ..................... .............1...��... .............................................. Foundation has permission to erect.......... ::....................I..... buildings on ..............t.�.....MWV00% .....d....... ........... Rough to be occupied as....15; .................... .. .. ........ ..1. ..... .... .... ..... ..... provided that the arson acce tm this ermit shalTin eve ]res act conform fo the t ms of thea lication on file in P P P g P �1 P P� 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 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCRough 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 SIDE smoke Det. i �= Massachusetts.- Department of Public Safet Board of Building; Rc0lations and Standards Construction Supervisor License License: CS 75302 BENJAMIN C OSGOOD '► '.i 69 OLD VILLAGE LANE NO ANDOVER, MA 01845 Expiration: 12/4/2012 ('ummissiuner Tr#: 6267