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HomeMy WebLinkAboutBuilding Permit #782 - 339 OSGOOD STREET 6/3/2010BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: E?= Date Received Date Issued: 119 'IMPORTANT: Applicant must complete all items on this page LOCATION 3 06 a.n Print PROPERTY OWNER Print MAP -216 � PARCEL: .ZONING DISTRICT: Historic District yesn Machine Shop Village yes -q3p TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Buildingne famiI Addition Two°or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic WO -11 Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: , .'1c�%JAl-) SP/AAL� ArP)N S. Identification Please Type or Print Clearly) OWNER: Name: mond_( Address: CONTRACTOR Name.-hone:�7 -Phone: 7"' Address: ' Z2 - Supervisor's Supervisor's Construction License: > Exp. Date:. `�.. Home Improvement License: /7 Exp. Date:2-1 16 ARCHITECT/ENGINEER A Phone: Address: 77 Reg. No. FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ ` 011, Z60 � FEE: $ 402 e Check No.: 9-�-7,7 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to th an fuVd Sionature of 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 M ❑ 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: Building Permit Revised 2008 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 Reviewed on Signature COMMENTS 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: .FIRE DEPARTMENT - Temp Dun located at 1,24`Main Street Fire Department signature/date COMMENTS Located W4 Usgood Street site yes no 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 E Doc.Building Permit Revised 2010 Location 33� a No.� Date C12,110 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ ` Check # p t 23244 Building Inspector y m m C m m y mm CO) 10 CD� Z CD O ar dd CL .o CID o p CL Q CD a v CD cC CD CO) 110 CD 0 O CO) -2. C7 0 CO) d CD. _ CD CaO).CD CD CA I O O CD o - CD C C 0 0 so s 2 O �•N 0 C N EL 0 < O y CL Cl) O CD Z NC2ac ?-C CA 0. ,-► logo = * m N .11 ?ar.a o C —4O Cl) N c ti N0 m o C� 2>4 �, 0 r. 0 no 0 Nz:s• t7 ►� W =r ="a Fs c CL 0 0?: Cnm y cm o Go N C=L N Pf �+� � Q v .7 N � m a►+. Cn m :� N N N H Q O 3 mtoo Z 0 �.: zcooCD C2CD ? CDN C : CR e -;CA • �q cn cn7J p d a ^ 't7 'JO b 71 'IV Z 71 n 7J '77 n z M C/) c 91 \ x n G7 d c� I� Omi 0 0 c The Commonwealth Of Massachusetts Department of Fire Services Officef State Fire o the tat Marshal P. 0. Box 1025 Shite Road, Stow, MA 0I775 PERMIT Date: North Andover ]Permit No Dig Safe er ( City of Town) (If Applicable ) In accordance.with the provisions of A G.L.14 8 Chapter�a_ as 1 videed�insection-122—LMR�3 4 SDa This Permit is granted to:. �'� C'%g � m �l ,Zi a[� I P✓ j /� Full name of person, Firm or Corporation Permission to locate dumpster for construction/renovation/demolition of building. Comments: dumpster must be. 25' from structure if unable to place with required Restrictions: clearance dumpster must be covered with plywood or tarp end of work -day at v�� ©6-c�ic) ( Give location by street and no., or describe iu such manner as to provied adequate identification of location ) FeePaid$ 50.00 1 Fire Chief This Permit will expireQi "� ( Signature of otf ca granting permit) Offical granting permit ( Title ) The Con monweahYi ofMassacl:usetts 17epartment ofhidustrial Accidents Office oflnvestigahons 600 Washington Street` Boston, MA0.2111 ww.w. �nassgov/dia Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers plicant Information 6W126L, Mamo (Business/OrganizationlindividuM):(/�/r2. � ! 1l Address: P, d d Cj:, 4Q 7 Z A -kA. 6A(& Phone m F7 9j- Q SJ � 2f,8 Are Yp1hn employer? Check the appropriate box: I . am a employer with J 4. 0 _ I am .a general contractor and I employees (full and/orpart-time).* 2. ❑ I am a.sole proprietor have hired the sub -contractors listed or partner- on the attached sheet ship and have no employees These sub -contractors have working. for me in any capacity: employees and have workers' [No workers' comp. insurance comp. insurance.t required.] 5. We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp, right of exemption per MGL insurance required.] t c. 152, §I(4), and we have no employees. [No workers' Comp. insurance rerr" rrA i Type of project (required): 6- ❑ New construction 7. - ❑ Remodeling g. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11 -El Plumbing repairs or additions 12.0 Roofrepairs 13.[] Other ;Any applicant that checks box #] must also fill out the section below showing theirworkI compensation, t Homeowners who submit this trfBdavit indicating they are doing all work and then hire outside trac ors mugsubmitsulicy bmit as new affidavit indicating such, tcantractors that check this box must attached an additional sheet showing the name or the subcontractors and state whether or not those entities have employers. IFthecub-contractors have employees, they must provide their ,workers• comp, policy number. I aman employer that ispro injoing wor/ceirs' compensation insurance for my employees- Below is the policy and job site Insurance Company Name: Assooi tj&Z f J Policy # or Self -ins. Lic. #: Expiration Dete; � � 11 Job Site Address: � 3 D$C�� � �"� � City/State/Z''p .-��C A�, A 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 ofMGL 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 ag ' the . r violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA ce coverage verification. I do Hereby certify n d th pa ns pen Mes rjury that the information provided above is true and correct. signature: 3 Phone 5 24PDate: #: Official Ilse only. Do not write in this area, to be completed by city or town offccial City or Town- Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. Cit /Town Clerk b: Other .electrical inspector S. Plumbing inspector Contact Person- Phone #• ACORDM CERTIFICATE OF LIABILITY INSURANCEATE(1pDDlYYYY) ANY REQUIREMENT, 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Cowan Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 359 Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Haverhill MA 01830 INSURERS AFFORDING COVERAGE NAIC # INSURED Rondeau Construction Inc. INSURER A: Nautilus Insurance Company INSURER B: Associated Employers Insurance Company PO Box 522 INSURER C: Dracut MA 01826 INSURER D: INSURER E: 06109109 COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDT POLICY NUMBER POLICY EFFECTIVE DATE (MWDDr(YI POLICY EXPIRATION LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 O RENTEDncP $ 50'000 DAMAGE TFM ISE 'liOfdMERCIAL GENERAL LIABILITY CLAIMS MADE 7)bCCUR NC777713 06109109 06109/10 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER; PRODUCTS - COMP/OP AGG $ 1,000+000 ",POLICY I PRO- LOC AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT $ (Ea accident) BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY $ (Per accident) HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY- EA ACCIDENT $ OTHER THAN EA ACC ANYAUTO AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION AND ) C STATU- 0TH - r. EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? NO WCC50068M'12010 03(03/2010 03/03/2011 E.L. EACH ACCIDENT $ 100, 0 E.L. DISEASE - EA EMPLOYE $ 100,000 If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ 500 �� OTHER DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT /SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION Theresa Mendel 339 Osgood Street North Andover, MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR AUTHORIZED REPRESENTATIVE Board of Building Rtgolations and Standards `` T CO HOME IMPROVEMENT i• 1, NTRaCTOl2 . Registration: 137434 Expiration: 11/12/2010 Tr# 277580 i'', r' Type: Private Corporation ! RONDEAU CONSTRUCTION INC. i DONALD RONDEAU 25 CHUCK DR. #4 DRACUT, Iu A 01826 Adminisira#or Massachusetts - Department of Public Safcth Board of Building Regulations and Standards ConStructian Supervisor License License: CS 35313 Restricted to: 00 DONALD G RONDEAU PO BOX 522 , F DRACUT, MA 01826 Expiration: 5/2/2012 (`onunisiunrr Tr#: 25775