HomeMy WebLinkAboutBuilding Permit #106-14 - 400 OSGOOD STREET 7/31/2013 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATIO
Permit NO: O Date Received
Date Issued: 1
IMPORTANT: Applicant must complete all items on this page
LOCATION q'Jo O_Vasao 5T, AIM3-)+ 4,10,00-1, AA,
Print
PROPERTY OWNER ,- U,
Print 100 Year Old Structure yes o.
MAP NO: PARCELMb ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑Addition ❑Two or more family ❑ Industrial
Iteration No. of units: N-e-ommercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑ Septic ❑Well ❑ Floodplain El Wetlands lj Watershed District
❑Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
I&L1pd,c— 2- ofT—tet a �SMti�Pa--s t Gly Uc�usss, A, ..1 rsb 5
TM°.SC 5I0ftt5i
Identification Please Type or Print Clearly)
OWNER: Name: gra eke&ci Phone:c -FJ Y— L3 00
Address: 4411 05(,0-0 5'0 ^J"" r'bt f+-UU,C.A_
CONTRACTOR Name: T GA �� Phone:
Address: Ay �r> QIIcA Ccti� /f,,.tOjt5A, iAAA
Supervisor's Construction License: Exp. Date: ut( /moi
Home Improvement License: 144 75 Exp. Gate,
ARCHITECT/ENGINEER J Phone: '
p�
Address: �- UPG t h4C-Tla t SIP �G� . ,.AA,d � Reg. No. P?�
FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COSTBASED ON$125.00 PER S.F.
Total Project Cost: $ FEE: $
Check No.: Z�y Receipt No.: 0
NOTE: Persons contracting with unregistered contractors do not have access t the guaranty fund
Signature of Agent/Owner Signature of contractor
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
I
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF.SEWERAGE DISPOSAL
i
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
d
'Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sevver Connection/Signature& Date Driveway Permit
" DPW Tow; Engineer: Signature:
Located 384 Osgood Street
=FIRE-DEPARTMVIL-Nf - Temp Dumpster on site yes no
Located at 124 Mair., Street
Fire Department signature/date
COMMENTS_
I
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Rieger 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
El Notified for pickup - Date
Doc.Building Permit Revised 2010
i
Building Department
The foh.,wing is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofivg, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
❑ Workers Comp Affidavit
o Photo Copy Of H.I.C. And/Or C.S.L. Licenses
o Copy of Contract
o Floor Plan Or Proposed Interior Work
o Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
o Building Permit Application
a Certified Surveyed Plot Plan
o Workers Comp Affidavit
o Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Mass check Energy Compliance Report (If Applicable)
Li 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)
o Building Permit Application
o Certified Proposed Plot Plan
o Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Copy of Contract
o Mass check Energy Compliance Report
o 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 apt).-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submAted with the building application
Doc: Doc.Bui.ding Permit Revised 2012
Location oz>41
No. ^(� Date
• - TOWN OF NORTH ANDOVER ,
. Certificate of Occupancy $
Building/Frame Permit Fee $� .-
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
f
Check#
J
Z- v ►. J Building Inspector
Enter construction cost for fee cal - North Andover Fee Calculation
Construction Cost
$ 277752.00 m
$ - $ 333.02
Plumbing Fee $ 41.63
Gas Fee 100 comm. $ 100.00
Electrical Fee $ 41.63
Total fees collected $ 516.28
400 Osgood Street
106-14 on 8/1/2013
Tenant Fit Out
2 Bathrooms and 2 Offices
NORTH
own o : E ndover
0
No.
h 1 01
ver, Mass, l�
coc Hlc„ew,cw y1”
%
�d ADRATED
S U
BOARD OF HEALTH
Food/Kitchen
PERMIT T LD 1 Septic System
THIS CERTIFIES THAT ........ ..�......& s>!!�1 .'T. .................................................................. BUILDING INSPECTOR
-'
has permission to erect buildings on — w. V;�.. Q. 2& Foundation
Rough
4
to be occupied as ...?�...0. �.�?. ..�.. .... ...."..� . W�i.�............................ ...... Chimney
provided that the person accepting this permit shall in every respect conform to the terms of the application Final
on file in 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 NTH ELECTRICAL INSPECTOR
UNLESS CONSTRUC 0 T S Rough
Service
........... ........ ................................BUILDING..................INSPECTOR.. Final
GAS INSPECTOR
Occupancy Permit Required to Occupy Building 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.
Smoke Det.
SEE REVERSE SIDE
0713012013 10:11 Milner Insurance Agency,Inc. OAX)7813919448 P.0021002
ACOl4 . CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDNYYY)
07/30/2013
PRODUCER (781) 391-9449 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
MTLNER INSURANCE AGENCY, INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
121 MYSTIC AVENUE ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
SUITE 2R
MEDFORD MA 02155— INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURERAMAIN STREET AFRICA ASSUR
MICHAEL MEDEIROS INSURER W ZURICH INSURANCE
DBA THE CARPENTER r S EDGE INSURER C;
697 WAVERLY ROAD INSURER D:
NORTH ANDOVER MA 01845— INSURERS
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, p
ATG MM/DD/YY
71
INSR UL TYPE OF INSURANCE POLICY NUMBER PDATE MMPUD YY!
1 PSN LIMITS
A GENERAL LIABILITY bWS6260G 04/30/2013 04/30/2014 EACH OCCURRENCE a 1,000,000
DAMAOENTED a
X
COMMERCIAL OENERAL LIABILITY PREMISEST REeEc=on • S00,000
CLAIMS MADE ❑OCCUR / / / / MED EXP(Any one on 0 10,0
PERSONAL&ADV INJURY 0 11000,000
GENERAL AGGREGATE 0 2,000,000
GEN%AGGREGATE LIMIT APPLIES PER: a 2,000,000
POLICY 7 PR - LOC
AUTOMOBILE LIABILITY / / / / COMBINED SINGLE LIMIT
ANY AUTO (Es sooldenl) 4
ALL OWNED AUTOS / / / / BODILY INJURY
SCHEDULED AUTO8 (per person) 0
HIRED AUTOS / / / / BODILY INJURY
NON-OWNED AUTOS (Per eeaieerd) 0
PROPERTYDAMAGE
(Per&=kmM) 0
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT 0
ANY AUTO / / / / OTHERTHAN EA ACC 0
AUTO ONLY: AGO 0
CXCP_SSNMBRELLA LIABILITY / / / / EACH OCPVRR9N.QE0
OCCUR ❑CLAIMS MADE AGGREGATE 0
e
DEDUCTIBLE
RETENTION S 0
B WORKERS COMPENSATION AND 5933630A 04/12/2013 04/12/2014 3{
EMPLOYERS'UASILITY
ANY PROPRIETOR/PARTNBRIEXECUTIVE E.L.EACH ACCIDENT
OFFICER(MEMBEREXCLUDED? / / / / E.LDISEASE-EAEMPLOYEE B
If yes,describe undor
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT 0
OTHER
D880PJPTION OF OPERATIONSfLOCATIONSMEHICLP&EXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS
CERTIFICATE IS SUBJECT TO POLICY TERMS, CONDITIONS, AND EXCLUSIONS.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
D�4 RITTEN NOTICE TO THE CERTIFiC HOLDER NAMED TO THE LEFT,BUT
TOM OP' NORTH ANDOVER FAILUps TO SO SHALL IMPOSE NO o2l I ON R LIA@ILITY OF ANY KIND UPON THE
BUILDING DEPARTMENT IrJsuReR ENT3T7R71E An Es.
NORTH ANDOVER TOWN HALL T
NORTH ANDOVER MA 01852—
ACORD 29(2001108) 0 ACORD CORPORATION 1988
NS025(nioe).on Page 1 of 2
-\ Initial Construction Control Document
To be submitted with the building permit application by a
Registered Design Professional
o for work per the 81h edition of the
Massachusetts State Building Code,780 CMR, Section 107
air
Y
Project Title:Home Grown Lacrosse Alterations at 400 Osgood Street Date:30 Juy 2013
Property Address: 400 Osgodd Street,North Andover
Project: Check(x)one or both as applicable:New eenstfuetien x Existing Construction
Project description:Relocation of toilet rooms, new tenant separation between an expanded tenant#1 and an expanded tenant#4(see plan),
demolition of existing(non bearing)office partitions,
I,Stephen Jensen,MA Registration Number:AR9020, Expiration date:31 August 2013 am a registered design professional, and I
have prepared or directly supervised the preparation of all design plans,computations and specifications concerning':
X Architectural struetur-al A&elanie-al
Fife Prate Other:
for the above named project and that to the best of my knowledge,information,and belief such plans,computations and specifications meet the
applicable provisions of the Massachusetts State Building Code,(780 CMR),and accepted engineering practices for the proposed project. I
understand and agree that I(or my designee)shall perform the necessary professional services and be present on the construction site on a regular and
periodic basis to:
1. Review,for conformance to this code and the design concept,shop drawings,samples and other submittals by the contractor in accordance
with the requirements of the construction documents.
2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable.
3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and
to determine if the work is being performed in a manner consistent with the approved construction documents and this code.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107.
When required by the building official,I shall submit field/progress reports(see item 3.)together with pertinent comments,in a form acceptable to
the building official.
Upon completion of the work,l shall submit to the building official a`Final Construction Control Document'.
Enter in the space to the right a"wet"or
electronic signature and seal:
�EREO ARI-
DOUG
RI-DOUGTF��
o Lu No. 20
Ln BEVE
cu
OF
S5
Phone number: 978-232-0326 Email: sj@blueskyarch.com
Building Official Use Only
Building Official Name: Permit No.: Date:
Note 1. Indicate with an `x' project design plans,computations and specifications that you prepared or directly supervised. If`other' is
chosen,provide a description.
r•
The Carpenters Edge EStICYIat@
10 Greenbriar Circle
tr s DateEstimate#
Andover, MA 01810 --
07/15/2013 1156
(617)594-3350 Exp. Date
thecarpentersedge@gmail.com
Address
Bryan Brazil
Home Grown Lacrosse
400 Osgood St.
North Andover,MA 01845
Activity Amount
•Contract For Office Build Out
The scope of work included in this contract are for the construction of two new offices,both measuring 20 ft by
14 ft,and two new restrooms,both measuring 8 ft by 8 ft,
and all finishes included in those spaces.Also included in the scope is the addition of anew viewing window
in the wall between your existing space and the newly
acquired space.No costs associated with permits have been included which will be billed separately.
Defined Scope of Work:
Frame walls
Provide 1/2"gypsum wall board with veneer plaster smooth finish
Provide vinyl cove base on all new walls
Install ceiling grid--reuse existing materials
Install carpet in offices
Install file in restrooms
Install viewing window
Misc finish carpentry:
a.installation of cabinets
b.install countertops
c.install(4)prehung existing six panel doors
Contract
Owner: Bryan Brazil
Home Grown Lacrosse
400 Osgood St.
North Andover,MA 01845
Continue to the next page
I
0 '
Page 2of2
Activity Amount
Contractor: The Carpenters Edge
Michael Medeiros
10 Greenbriar Circle
Andover,MA 01810
HIC Registration 166755
The Carpenters Edge agrees to perform the above scope of work and provide the said materials for the sum
specified as$27,752.00
All costs to obtain building permit is the responsibility of the owner
Coordination of building inspections will be provided by The Carpenters Edge as an agent of the owner
Any documentation needed to acquire permits is the responsibility of the owner
All materials will be stored in accordance with the manufacturer in a neat and orderly fashion
Work area to be left neat and orderly at the conclusion of the work day
All work will be in accordance with MA State Building Codes
All products to be used will be installed according to manufacturers specifications
Payment Schedule
Commencement of work: $10,000
Upon completion of work: $10,000.00
On or before October 1,2013: $7,752.00
Proposed Start Date: 7/25/13
Estimated Completion Date: 8/30/13
Warranty
The Carpenters Edge warranties the above stated work for a time of(1)one year after the completion of the
project. This warranties labor and material from defect.
Any damage caused by severe weather or misuse may not be covered
Contract Acceptance
Upon signing,this document becomes a binding contract under law.
Total
r
Accepted By Accepted Date
J
i
The Commonwealth of Massachusetts
Department o,flndustriglAccidiints
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/EIectricians/Plumbers
Applicant Information Please Print Leaibiy
Name(Business/Organization/Individual): &S
Address: /y 6t0N.9AAA-*_ Ce,4,-
City/State/Zip:- _Ag/ A4,f- Phone#: U 1 -4) 3-`/L/— 33,E
Are you an employer?Check the appropriate box: Type of project(required):
1.4I am a employer with Z-- 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have lured the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet.T � I�-6-modeling
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 1011 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roofrepairs
insurance required.]i 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 2i e 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.
I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site
information.
Insurance CompanyName:. �C 1..l3vilAzlf`�
Policy 4 or Self-ins.Lie.9: J — I L� Expiration Date:
Job Site Address: 5 A- City/State/Zip:++l?41 - dl Yl Klr_
Attach a.copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as requiredunder Section 25A of MGL o.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 maybe forwarded to the Off-ice of
Investigations of the DIA for insurance coverage verification.
Ido hereby cerci y der tliepains andpen lties ofperjury that Elle information provided above is rue and correct.
Signature: ✓// Date:
r
Phone#:
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 5.PIumbing Inspector
6.Other - -
Contact Person: Phone 0:
ift Massachusetts -Department of Public Safety.
Board,of Building Regulations and Standards
Construction Supers icor
License: CS-106061.
SCOTT M'IROMBLY '.
N
26 CUSHMAN STREET
Watertown MA 02472
J � �
Expiratioi,
Commissioner 04/04/2015