Loading...
HomeMy WebLinkAboutBuilding Permit #522 - 273 OSGOOD STREET 2/22/2010TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: �I Date Received Date Issued LOCATIO ��— IMPORTANT: ilicant must complete all items on this rnnt MAP NO: 50'-- PARCEL: / ZONING DISTRICT: Historic District Machine Shop' yes m TYPE OF IMPROVEMENT PROPOSED USE Residential N n- Resid_entia New Building One f raafly-1 Addition Two or more family Industrial Alteration No. of units: Commercial Re air replacement Assessory Bldg Others: Demolition Other ep is Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION /� WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: CONTRACTOR Supervisor's Construction License: C 7 40 /(20, Exp. Date: Ei i Home Improvement License: T Exp, Dater ARCHITECT/ENGINEER Phone: Address: Reg. No. r FEE SCHEDULE: BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $1900 PER S.F. Total Project Cost: $ FEE: $ Z Check No.: J Receipt No.: 21— NOTE: Persons contracting with unregistered contractors do not have access to the uaran fund �Jgnature of Agent/Owner Signature ofcontract- 1 r 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 COMMENTS HEALTH n COMMENTS x Reviewed on Signature Reviewed on Signature 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 F=IRE DEPARTMENT - Temp Dumpster on site yes �no Located at 924 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories: Total land area, sq. ft.: Total square feet of floor area, based on Exterior dimensions. 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 ❑ 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 ❑ 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 Location _�l7 s !l '7 No. Date MORTol TOWN OF NORTH ANDOVER 1 OL y Certificate of Occupancy $ Building/Frame�X Z = loll Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 3 2 d d- 22 ur 13 22ui3 Building Inspector The Commonwealth of Massachusetts Department of Industrial Accidents Office of investigations 600 Washington Street . U1 Boston, MA 02111 www mass gorldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers DD11Cant Infarmati-- Name (Business/Organization/Individual):_-��'Y/ Address: City/State/Zip: /WJ l ��/Phone #: Type of project (required): 6• ElNew construction 7. E]Remodeling 8• emohtion 9. Building addition 10 -0 Electrical repairs or additions 11 - ❑ Plumbing repairs or additions 12.0 Roof repairs 13. ❑ Other omeowners who submit this affidavit indicating they are doing all work and then hire outside contractors�,� ntractors must submion Fillcy t 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. I am 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. #: ,_ & L Q�� ©� 9 Ex�l �y piration Date: Job Site Address: ��y f ]o�r� e f� City/State/Zip: DIl 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 a pains and information provided above is true and correct Date /1 L 1lD Official use only. Do not write in this area, to be completed -by city or town official City or Town: Permitl[.iepneo f! issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: AreXwan employer? Check theappropriatebox: i I am a employer with =° 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ I am a sole proprietor or have hired the sub -contractors listed partner- on the attached sheet ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] 3. ❑ 1 am a homeowner doing officers have exercised their all work right of exemption per MGL myself. [No workers' comp. C. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] "`.4ny applicant that checks box #i must also fill out the section below shoeainc -eir weti mss' c^ tH i^ Type of project (required): 6• ElNew construction 7. E]Remodeling 8• emohtion 9. Building addition 10 -0 Electrical repairs or additions 11 - ❑ Plumbing repairs or additions 12.0 Roof repairs 13. ❑ Other omeowners who submit this affidavit indicating they are doing all work and then hire outside contractors�,� ntractors must submion Fillcy t 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. I am 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. #: ,_ & L Q�� ©� 9 Ex�l �y piration Date: Job Site Address: ��y f ]o�r� e f� City/State/Zip: DIl 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 a pains and information provided above is true and correct Date /1 L 1lD Official use only. Do not write in this area, to be completed -by city or town official City or Town: Permitl[.iepneo f! issuing Authority (circle one): L 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." 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 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 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), 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 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' 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 permittlicense 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 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 Washmgton Street Boston, MA 02111 Tel. # 617-727-4900 ext 4406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-72.7-7749 www.mass_gov/dia E O F=4 n 0 N N �A u o O w a v cn OH w � .or. � p w � O A4 � ^C U � G w a a � p w � G w' a � W � p w (U . cn w p H a d p ra G w" H w w w m cin O W . c o •as c I� h o O V •m C CD S oC y D c YW p }j ,� J V W •_... m H �y t�"I �0 Q' E C V�hh L G _A s m L � L _m _� H H W O E O m CL CD y m O cc = c � � � c o � CA _ C m fCIS.1 N O C Z m L C H O. m.O x m n=o N CO w H m D LLJLAJ Z C43 .y • L 41 C Z W •E asooy o L. V m O ®� C COD m� 0:5 Co ►- S CL m z 0 w a O U a r7 A ;0 �i N U 0 O v v pC CD E a: L O Z CD O h � C CD CM COD CO) I C W CDQ M� ca CDcc W L O O CL~ O � � 0 0 mo a CL cm< c CO2 =C cc c v J •O �tZ OCD C Z Q CD CL C.) vs c C c _cc CL CO2 D Gi V w O O F=4 P w A c o z � z :cam o z � z : o � a w z U x o a z •n H z w w A G.c o w a cn W O G, zx cz w rx U q w Rr � O nG �v q w w W p r.2 US C to p G W w v r. '' o cn o o ch � N E a CD CD O �- k' H Q :gym p +r Ca O o � 3 c CD c , _m c C.O h c �O h mo y O m �O C rJ:=ya ev Z C'� O CLCD C = co id~ H H LijCOD O +0.. W O 4::s ti S •y '_ J W C .y • V •E V ® Gi rm CO) a m go ; CL ®°� _ (p O` H �O F� Z r0. CS •_,. m E IE MA h O U3 c O cm O co c m cri0 c_ �c N O t 0 Z O 0 F. CD E CD L 0 V Z CD C. O H � C IC cm C CO) Q m m 0 CD CL co CD G O L 0 d a o�Q S C2 ccc V CL O tea) C Z CD CL U NA 0 C — C C c CLCO2 is 0 YI W 19 W W W 0 o C13 c :cam : o � C H O c •n G.c W O Q C3 CD � N E a CD CD O �- k' H Q :gym p +r Ca O o � 3 c CD c , _m c C.O h c �O h mo y O m �O C rJ:=ya ev Z C'� O CLCD C = co id~ H H LijCOD O +0.. W O 4::s ti S •y '_ J W C .y • V •E V ® Gi rm CO) a m go ; CL ®°� _ (p O` H �O F� Z r0. CS •_,. m E IE MA h O U3 c O cm O co c m cri0 c_ �c N O t 0 Z O 0 F. CD E CD L 0 V Z CD C. O H � C IC cm C CO) Q m m 0 CD CL co CD G O L 0 d a o�Q S C2 ccc V CL O tea) C Z CD CL U NA 0 C — C C c CLCO2 is 0 YI W 19 W W W 0 Insured: FOULDS, BRYAN & FOULDS, CYNTHIA Home: (978) 974-9207 Property: 274 chestnut Cell: (603) 545-1363 andover, MA 01845 Home: 274 chestnut andover, MA 01845 Claim Rep.: GONZALES, JENNIFER / Claim Number: 013733148-01 Coverage Dwelling Date of Loss: 1/30/2010 Date Inspected: Policy Number: FN2218162261119 1 Type of Loss: Freeze Deductible Policy Limit $500.00 $300,000.00 Price List: MAEM5B JAN 10 Restoration/Service/Remodel Estimate: FOULDS _BRYAN_&_ FOU2 Date Received: 1/31/2010 Date Entered: 2/1/2010 10:18 AM 1-14' 5"I l M L/R FOULDS_BRYAN_&_FOU2 Main Level 424.00 SF Walls. 599.31 SF Walls & Ceiling 19.48 SY Flooring 53.00 LF Ceil. Perimeter Ceiling Height: 8' 175.31 SF Ceiling 175.31 SF Floor 53.00 LF Floor Perimeter DESCRIPTION QUANTITY UNIT COST RCV DEPREC. ACV 14. Remove Tear off plaster on wood 185.31 SF 1.32 244.61 (0.00) 244.61 lath ACV 16. Remove Engineered wood 175.31 SF 1.90 333.09 (0.00) 333.09 flooring - Standard grade 59.97 42. Dust control barrier per square 63.00 SF 0.52 32.76 (0.00) 32.76 foot Totals: L/R 610.46 0.00 610.46 i�---- i 15,911- i D/R 434.67 SF Walls 616.40 SF Walls & Ceiling 20.19 SY Flooring 54.33 LF Ceil. Perimeter Ceiling Height: 8' 181.73 SF Ceiling 181.73 SF Floor 54.33 LF Floor Perimeter DESCRIPTION QUANTITY UNIT COST RCV DEPREC. ACV 20. Remove Tear off plaster on wood 45.43 SF 1.32 59.97 (0.00) 59.97 lath Totals: D/R 59.97 0.00 59.97 Total: Main Level 670.43 0.00 670.43 2ND Floor FOULDS_BRYAN_&_FOU2 2/22/2010 Page:2 L/R 618.67 SF Walls 946.88 SF Walls & Ceiling 36.47 SY Flooring 77.33 LF Ceil. Perimeter Ceiling Height: 8' 328.22 SF Ceiling 328.22 SF Floor 77.33 LF Floor Perimeter DESCRIPTION QUANTITY UNIT COST RCV DEPREC. ACV 23. Remove Tear off plaster on wood 256.16 SF 1.32 338.13 (0.00) 338.13 lath 976.31 24. Remove Engineered wood 328.22 SF 1.90 623.62 (0.00) 623.62 flooring - Standard grade 976.31 43. Dust control barrier per square 28.00 SF 0.52 14.56 (0.00) 14.56 foot 1,646.74 Totals: L/R 976.31 0.00 976.31 Total: 2ND Floor 976.31 0.00 976.31 Line Item Totals: FOULDS_BRYAN_&_FOU2 1,646.74 0.00 1,646.74 Grand Total Areas: 1,477.33 SF Walls 685.26 SF Floor 0.00 SF Long Wall 685.26 Floor Area 1,334.67 Exterior Wall Area 0.00 Surface Area 0.00 Total Ridge Length FOULDS BRYAN & FOU2 685.26 SF Ceiling 76.14 SY Flooring 0.00 SF Short Wall 743.95 Total Area 166.83 Exterior Perimeter of Walls 0.00 Number of Squares 0.00 Total Hip Length 2,162.59 SF Walls and Ceiling 184.67 LF Floor Perimeter 184.67 LF Ceil. Perimeter 1,477.33 Interior Wall Area 0.00 Total Perimeter Length 2/22/2010 Page:3 Line Item Total Material Sales Tax Replacement Cost Value Less Deductible Net Claim FOULDS_BRYAN_&_FOU2 Summary for Dwelling @ 6.250% x 5.46 1,646.74 0.34 $1,647.08 (500.00) $1,147.08 2/22/2010 Page:4 Recap by Room Estimate: FOULDS BRYAN & FOU2 Area: Main Level L/R 610.46 37.07% D/R 59.97 3.64% Area Subtotal: Main Level 670.43 40.71% Area: 2ND Floor L/R 976.31 59.29% Area Subtotal: 2ND Floor Subtotal of Areas Total 976.31 59.29% 1,646.74 100.00% 1,646.74 100.00% FOULDS_BRYAN_&_FOU2 2/22/2010 Page:5 LO 0 N N C 0 r_ O Q 0 Uo O N C,4 ;0 CO> M to04 r CL r z It 00 F-- o Q W Q a=N� M LU U Om Lu O V W wOf0� Y U a, A O Z z m C L L m ¢ = d U CS U R a In e � d H v e w N c O Ci R V y c c R F- � O C) C E Cc! :Q w m o �} U N o N CK ¢ N U N o O o O=�wr m K a O U) a=_Zui o O 3 J U Lcot e„ O G Y (D 00 U) 3� c uLi w o w L 0' C) d W z It 00 F-- o Q W Q a=N� M LU U Om Lu O V W wOf0� Y U a, A O Z z R' C iL V+ L m ¢ = R fl' c ¢ 74 h H � d H e R O z It 00 F-- o Q W Q a=N� M LU U Om Lu O V W wOf0� Y U a, A O eye 0 4 _N N a O u h H � d H e � F- O O o =L) R F- � d W y NNIn k... M Lnui E '4N 1ar� ttt tlt' t•, C -C. ci E O o O=�wr m K a O U) a=_Zui o O 3 J U e„ n w g y Y (D 00 U) a