HomeMy WebLinkAboutBuilding Permit #886-12 - 374 OSGOOD STREET 6/11/2012BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: 2—. Date Received
Date Issued:
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"IMPORTANT Applicant must complete all items on this page
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TYPE OF IMPROVEMENT
PROPOSED USE
10
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Residential
Non- Residential
New Building
One family
Addition
Two or more family
Industrial
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No. of units:
Commercial
Repair, replacement
Assessory Bldg
Others:
Demolition
Other
PA-0--`T'
ARCHITECT/ENGINEER )&rl tup 2S
Phone: 78— Do 2
Address: 11 Anr1crJAA OoyE D(2—
Reg. No.
FEE SCHEDULE. BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
DESCRIPTION OF WORK TO BE PREFORMED:
A I eTA-1 k )P C. I JA 11(10
Identification Please Type or Print Clearly)
OWNER: Name: Phone -q76 543-6 ow
Address: 7 0S G'00J
10
ik4 -,� RA (A
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PA-0--`T'
ARCHITECT/ENGINEER )&rl tup 2S
Phone: 78— Do 2
Address: 11 Anr1crJAA OoyE D(2—
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: $
Check No.: -2-
Receipt No'�5
NOTE: Persons contracting with unregistered contractors do not have access _Wheg aranty fund
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 offfrom 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: INSPECTIONAL SERVICES DEPARTMENTMFORM07
Revised 2.2008
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
Plannii�, Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
. Located 384 Osgood Street
rt 2ra�, �a e -�, v r: ...,,of
�F.{IREDEPARTMENT,.Temppumpsteron siteyes-x�`�no����;'{+
1Ltocated at 124=NIain Street rx.� z
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
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
No
Location
No. Date
Check# 11,-1K -2-
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
TOTAL
25397 Building Inspector
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Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
Construction Super% isor
License: CS -063173
FREDERICK A�P C
PO BOX 606;
HAMPSTEAD 03841
Expiration
Commissioner 01/2112014
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Lnvestigations
..600 Washington Street
Boston, MA 02111
wwwanass gov/dia
Workers' Compensation Insurance Affidavit: Sunders/Contractors/Electricians/Plumbers
Ucant Information
Name (Business/Organization/Individual):
- - - - Address:
City/State/Zip:ANDP
Phone#: &3, 9'r- zf�e) 7
Are you an employer? Check the appropriate box:
1 • ❑I am a employer with
4. ❑ I am a general contractor
employees (full and/orpart-time).
2. ❑ I am a sole proprietor or
and I
have hired the sub -contractors
listed
partner-
on the attached sheet. t
ship and have no employees
These sub_contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. PlVe are a corporation and its
required.]
3. ❑ I am a homeowner doing
officers have exercised their
allwork
myself. [No workers' comp.
right of exemption per MGL
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp, insurance required.]
*A-ny applicant that checks box #1 -'athe section belov.
Tuo --
Type of project (required): •
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. El Building addition
10. ❑ Electrical repairs or additions
.11 ❑ Plumbing repairs or additions
12-ElRoofrepairs
13. (Other G Aa!2� e 0,,,Q'
meowners who submit thrs affidavit indicating they aredoing 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 came of the sub -contractors and their workers' comp, policy information,
I am an employer that is providing workers' compensation
information. insurance for my employees Below is the policy and job site
Insurance Compiny Name:
Policy # or Self -ins. Lic. #.
Expiration Date:.
Job Site Address:
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 ofMGL c. 152 can lead to the imposition of criminal penalises 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.
Ido hereby c undo the pains alzifjpenalties ofpernu,3, that the information provided above is true and correct:
�r1- �L/o
v,17zczai use only. Do not write in this area, to be completed by city or town official
City or Town:
Permii/License
Issuing Authority (circle one):
11
L Board of Health 2..Bu1lding Department 3. City/Town CIerk 4. Electrical Inspector 5. PIumbing Inspector
6. Other
M.r
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 6r 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 anotherwho_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=contractors) 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 datelhe affidavit. The affidavit should
be retl'srned to the city or town that the Fppl,ca lo-' for the pe-maj t or license is being requested, not the Dep artmani t 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 bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would'like to thank you in advance f6r 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. # 617-727-4900 ext 406 or 1-8.77M ASSAFE
Fax # 6.17-727-7749
Revised 5 -26 -OS