HomeMy WebLinkAboutBuilding Permit #436 - 329 OSGOOD STREET 11/22/2011 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
VI
Permit NO: Date Received
Date issued: �22�
IMPORTANT:Applicant must com fete all items on this page
LOCATION,
Print
PROPERTY OWNER S Unit#
Print
MAP NO: PARCEL ZONING DISTRICT: Historic District yes no
Machine Shop Village ye no
100 year-old structure ye no
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
,� -r"'�.rF;s F's"' '�}'T.dr`+r.:*k't'4^a YF'_'-! s tri" _.�T-..+T.`4.i'� .-i"^- -�g;� -rt ^y.'. .zr ... ,y--,„ -r:•:+
'(j Sep"tic�t }(]Well. ❑Floodplam�er r®►Wetlands. � ',® aWatershedDisfrict '
�'I��w�3 I�SeVYBT �...+_° "•i� �.,...._.,-.f'`�`�r `�''°� „�,«_. 4� _ _r_A .i'.� [i _ .:�.� e�+d _ .... +s�r.ti;�i�.�?k
DESCRIPTION OF WORK TO BE PERFORMED:
Identification Please Ze/orrint Clearly)
OWNER: Name: Gas Phone:
Address: .-5 eoeo
CONTRACTOR Name: / ,- 4!�e Phone: ell3�Y���
Address: 'Q V/ �/ G
Supervisor's Construction License: 1J1981,i� Exp. Date:
Home Improvement License: I ff o'1 Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
- I
FEE SCHEDULE:BULDING PERMIT:$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
Tata! Project Cost: $ /4 - FEE: $ I ___
Check No.: U . • �"• Receipt�Na"�. �
NOTE: Person with un gis`te?,& Nhtr CtoY to the guarantyfund
�Sir�nature of aenf/Owner`_ ; _ nat_re o _contractor
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 Calculationslicable If Applicable)
pP )
❑ Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
MOTE: 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
Doe: Doc.Building Permit Revised 2008mi
i
• I
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ j
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/Massage/BodyArt ❑ 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
f
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:
ocated 384 Osgood Street
FIRE DEPARTMENT -Temp umpsteeronA-06 y-e-9 no �'��1�_
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, roast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$10041000 fine
NOTES and DATA— For department use
i
i
El Notified for pickup - Date
Doc:.Building Permit Revised 2011 June/mi
Location
No, l "' Date
O� NO RTh ,h TOWN OF NORTH ANDOVER
3
F s
9
}�o Certificate of Occupancy $
sCMUs t� Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
24838 Building Inspector
NORTH
ONM Of Andover ..
0 VO
No. _ - -
o , dover, Mass.,
Q - LAKE
COCKIC ME WICK V
A0RATEO FP�,`�5
BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT ! ' .>t.:....... .............................................................................
............ ....
Foundation
has permission to erect........................................ buildings on .3a a. Rough
. . ..
to be occupied as.............. ..... .../!`.11.r.k�onform
.........................
Chimney
provided that the person acce g this permit shall in every resp to the terms of the appl' 9i .
file in Final
this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration'an 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 T ;. Rough
:...¢.... ..........................
....... ...... .... Service
. ... ,..
BUILDING.-.
UILDING INSPECTOR
Final
Occupancy Permit Required t0 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.
Com.•\. r
The. -C6* mmonwealth of -Massachusetts
Department-of Fire Services
Office of the State Fire Marshal
P.0.BoN 1021 State'Road,.Stow',MA 01775
PERMIT Date:
North Andover -Permit No
Di :;/7;
r
•(Cityof Town) (If Applicable) g
In accordance.with the provisions of NL'G.I,.l 4 8 Ghaliter�(�asprovided in section 5 7 7 f',MR 34
This Pcrmitis anted to:. Stmt Date
Full name of person,Firm or Corporation
Permission to locate dumpster - for construction/renovation/demolition of building.
Comments: , dumpster. must be . 251 from structure if unable to place with required
Restrictions:clearance dumps-ter must be covered with plywood or tarp end of 'work -day
at
(Give locatio street d no: of descn�bc-iusuclimarin5
_ 'ttt�' -d dequatc idcntiFicatioiibf location)
FecPaids 50 .00 Fire Chief
This Pemut will expire- lot-71-11 SignaRu o o crrnit (Title)
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: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeLribly
Name(Business/Organization/Individual): G `j
Address: nz;� eg
City/State/Zip: f & Phone
Are you an employer?Check the appropriate box:
1�I am a employer with _ 4. El am a general contractor and I Type of project(required):
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sh%et. 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.❑ 1 am a homeowner doing all work right of exemption per MGL 1 1.❑Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs
insurance required.]t employees. [No workers'
comp.insurance required.] 13.❑Other
*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.
lContractors 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 formy employees. Below is the policy and job site
information.
Insurance Company Name: 41,
G �
i711 iZoo�,Ge_
Policy#or Self-ins.Lic.#:_azC QQ/ 0 2:L? Expiration Date: 2—
Job Site Address; C00 -Siff D� City/State/Zip: //0,
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 th 'ns . d penalties of perjury that the information provided above is true and correct.
Si nature:
Date:
Phone#:
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
LL6.Other
g Authority(circle one):
rd of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
ct 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 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 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 burn 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. 4 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax##617-727-7749
www.mass.gov/dia
i
T.
EIN#51-050-3313 .Haverhill. MA 978:374.9224
MA Re HIC#149221 .
jif
Reg. Lawrence MA 978.687.7339
our MA tic.UCS#78130 Hampton NH 603.929.9224
BBB. Single-PlyLicense#1711 oftn9 Hampstead NH 603.329.8200
1932 O. Toll Free 1.888.SOS.ROOF
1
265 Winter Street
Haverhill.MA 01830
6
ce ed Factory Trained -TFactory Certified
Name. Date:
Telephone: V-6 Al . phone: E-Mail:
Billing Address: F Address:
Scope of Workd Re-roof ❑Re-roof Approximate Roof Area:. zJ
:a
/Prepare for re-roofing by ensuring all safety measures in accordance with OSHA standard regulation�sd landscape is properly protected.
1temove existing layers of shingles down to roof deck and dispose of in a legal fashion.fro ';pq»site.
,�`Inspect wood deck,if we discover any rotted wood,replacement will will performed t* ``�- .��►► per LF for roof deck boards. If
substantial deck rot is discovered,re-sheathing of roof deck can.be performed at*$ :R -per SF.If individual sheets are found to be
rotted/or de-laminated,removal;dispos d1acerrient will be performed at*$ per sheet.If any trim boards are rotted,
replacement will be performed at*$ per LF for new pre=p.in pine:. Inspect siding at roof line and all flashing behind siding,if
we.discover any damaged flashing or siding at the roof line;replAcement will be performed at*$ If wood deck,siding,and
flashing is sound,we will -nail any loose wood to a ers w ck,and prepare for roofing.
_.
�stall 8"drip edge to all rakes and eaves.Color `
C�''Apply ice&water shield(UNDERLAYMENT)as per.manufacturers'.specifkations and/or
❑ 131�1Y� � deck:
R. e-flash all plumbing stack pipes,and any roof penetrations as re uired and dictatedby good roof practice to ensure water tightness.htness.
❑ If
upon inspection,we discover chimney lead to be-wornror deteriorated,replacement will be performed at*$
Install a new Year ❑ Traditional Architectural ❑.Designer.
Furnish and Install a new shingle over style ridge vent system �St
L[2/
I All debris generated by Lambert Roofing Co.,Inc.will be cleaned up and disposed of from the,job site in a legal fashion.Under no
circumstances willthe watertight.integrity.of.the building e compromised:
ec�al def , 1�j�,; r's '' ok
Ax
UPON COMPLETION AND PAYMENT IN FULL,ROOF SHALL HAVE A WORK 81P GUARANTEE P I OF
YEARS HONORED AND'ISSUED BY THE LAMBERT"ROOFING'CO AN YEARS HO O D SUED BY THE
-]�A A� TT TSA L'TT T77 T'D T T f'D.A TT�_aIeQ.
SHINGLE MANUFACTURER. ® ..��s�,��� � -- ��„ g
j *Denotes potential additional costs above the total estimated price.
I
TOTAL CONTRACT PRICE ND PAYMENT SCIIEE ,
The Contr tor�g es p f n the wo f h t)V�Vt nd/faz s I �v Q. stal sum of: $ (r .
I ! olla
Pa l be made according to the following work schedule:
$ deposit upon signing contract
$ b _or upon completion of
$ u4�tion of contract.
forbids demanding full-payment until contract is completed to both party's satisfaction)
Yolmay cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the
contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram or bydelivery,not later than midnight of the
i third business day following the signing of this agreement:See attached notice of cancellation:for for an explanation of this right.
r
O NOT SIGN THIS CONTRACT IF THERE ANY BLANK SPACES
Acceptance of the Contract Proposal
Home Owner(s)Sig tune Date: ! /
Contractor's Signature: Date:
w> ,limhPrtrnnfinar rnm --- ;a ,
AC& --
CERTIFICATE OF LIABILITY INSURANCE DATE(iVlryl€DOIYYYY)
11/01/2011
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO'RIGHTS UPON THE CERTIFICATE HOLDER, THK
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER'THE COVERAGE AFFORDED BY THE POLICIE:
BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZE[
REPRESENTATIVE OR PRODUCER,ANa THE CERTIFICATE HOLDER.
I:MPCTRTANT. if the certificate holder is an ADDmoNAL INSURED,the peiicy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject t(
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to th€
certificate holder in lieu of such endorsemerit(s
PRODUCER CON NAME ACT Jerrold. 1Kamera:s
ALLAN INSURANCE AGENCY INC. P
r (976) 745-5905 FAx --
C o;(g78} 745-5483
3 1/2 Jefferson Avenue 2134 Floor E-MAIL
ADD
E .Jerrol€t.4allaninaura:nce.com
P.O. BOX 511
INSURER S AFFORDING COVERAGE NAI[0
$AL2 MA 01970-0511
_. INSURER A:.S.eneC a S e C i 31 t IIl&
INSURER a$gafety Insurance"_Coiit ;gin. ...
TGLRC Inc. INSURERc:.Alterra ExcessSurplusSur 1us Ins.
dba Lambert Roofing Company iNsuRERD:Chartis Insurance Com an
.265 Winter Street INSURER E: `-
Ha+rerhs.31 MA 01830 INsuRERF:
COVERAGE,$ CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOL
INDICATED. NOTWITHSTANDING.ANY REQUIREMENT.TERM OR CON€?ITION OF ANY CONTRACT OR OTHER DOCUMENT LATH RESPECT TO WHICH T'Hl;
C=RTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED,BY THE. POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS
EXCLUSIONS AAD COF wiT,D-NS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.,
ILT R TYPE OF i - POLICY EFF POLICY EXP
LTR . taSUf.ANCE PODGY N"SER 1 M LIMITS
GENERALL4ABiLITY / / / / E-.ACH:OCCURr(E,NCE: ._... ..S 1000(
Y COMfiAEFL'IA GENE':RAL L€AHt€..ITY / I I / D I A EE TG N TED
PREMISE Ea coy ranee $ 5 0(
CA,M4tlA[)E OCCUR J-CGL00D0000696-01 11/12/2011 1/12/2022 MED F.:.XP(An one person) 3 1(
PERSONAL&ADV INJURY $ --_1000f
GENERAL AGGREGATE $ 2000(
7GEN'LAGGREGATELIMIT,%PPLIESPER / � / , PRODUCTS,.COMPIOPAGO $ 20001
I POLICY PROT LOC
3
1AUTOM0131LE LIABfUTY / / I I CUMBINED SINGLE LIMITEe accide 10 0 0;
$ ANY AUTO / I / / HOUILY INJURY(Per pe=' 5
ALL OV,NED SCHEDULED I52038197/16/2.011 7/16/2012
AUTOS AUTOS : 8011LY INJURY r+araccracntj 3
HIRED AUTOS AUTOSED PROPERTY DAMAGE ....
Per acc3d [5
UMBRELLA L€AB � i OCCUR / / / I EACH 0C:(;:IRR-NCE $ 5000
C £XCESSLIAH CLAIMS-MADE 3.SC50000040 1/12/201111/12/2012 AGGREGATE 5 5.000
OED MENTIONS / I /. - / $
WORI(ERSCOMPENSATION / / / r Vv'C;STAT'U- O[H'
AND EMPLOYERS'LIABILITY Y i'N
XNY PROPRIETORIPARTNERIFXECUTINE / I I /
III OPFICERiMEMSE<R EXCLUDED N I A El EACH ACCIDENT M 1000
T (Mandatory In NH) [001-60-2396 08/28/201108/28/2012 E.L.DISEASE•EAEMPLOYEE $ IQQQ
>i*es.describe under / / / /
IIESCRIPTION OF OPERATIONS be9m E L,DIS ASE POLICY LIMIT 5 1000
DESCRIPTION OF OPERATIONS i LOCATIONS f VEHICLES (Attach ACORD 101,Additional Remarks Sehedule,.'rt more space is requiredl
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED B'EPOI
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED
ACCORDANCE WITH THE POLICY PROVISION$.
AUTHOR€GEt)REPRESENTATIVE
p J�j
ACCIRIJ 25(2€310105) Q 1988.2010 ACORD CORPORATION. All rights reser
INS025(^r,,DD5I n, The ACORD name and logo are registered marks of ACORD
N1.
a n t 1
Corlstrucl,
IC'r
CS 78130
RICHARD J LAMBERT
94 PICADILLY RD
HAMPSTEAD, NH 0384
ExPirat"on: 6/2/2012
30062
9/4
IwOfflee of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
o Tr# 290268 -
Reqistratiol��:449221
Expiraftb%J2�&goj 1
Typei!�i�-,--j
LAM13ERT R,0004$0-
RICHARD LA
'M
265 WINTER R
T gE
S
HAVERHILL,MA 016T Undersecretary