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HomeMy WebLinkAboutBuilding Permit #203 - 510 OSGOOD STREET 9/13/2007 bUILUIN" rr—MIVIi i o�3TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION d 6 Permit N0: — O Date Received s E sAc►+us Date Issued: IMPORTANT Applicant must complete all items on this page �. -� d :"� �`'Y'j sa:':.a -i '�k � II9Yy^�^� � ✓y " 'i, x x� °.'. � s a � ` W3 . � N " za aroX '^�"4�. _' '"^" � " �.r��r.y��� w x � p r��sa z� ^as •- TYPE OF IMPROVEMENT PROPOSED USE Residential, Non- Residential ❑ New Building ne family D Addition D Two or more family ❑ Industrial ❑ Alteration No. of units: 0 Commercial epair, replacement D Assessory Bldg ❑' Others: ❑ Demolition D Other 0 , �."x� �ir+��[ �Is� DESCRIPTION OF WORK TO BE PREFORMED: � 191 Ide tificati Please Ty e or P t Cl arly) P� OWNER: Name: Phone: - 5; Z Address 0 �u >�. _vl.' eta, x^y5 F $ �'.�F g"p MAP t Y'tY ;}�^� .x�t x5, ,z". : arm-"sir»' : r "" i. '.' �- }+?y� yT ✓" 's 9 d S`�-rz .dt - - �� Ad: rs� `� .+✓ b .'' x$.' ,g+ r:s� ,�.,;�''� s' ". 7 y., )a�.S z S"�y;�� .�`�"x,,,?�i� - r`" K y1,W"[j � u�,��=✓d �9� p�W' ?� ' ✓j rkt.� n, y" 1ww�+wS a ,z ,`-. �. 41 NHt �, Em ,ta W+ `* S1GNI ; i1f�i1 �.ItYYY�iO � 4�yr' ) .£,r. ,ti 3�3'. j.'Y„ 1"2' "4 ttYnFd 5 'qy. d n� F, .Nx',v'?^"a. G,x._.:x�ei,L Yua.-+%.a .n,.E�..M z „a ..Y .i.i .,,.,i •_``• ARCHITECT/ENGINEER Phone: Address: 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.: � Receipt No.: v NOTE: Persons contracting with unregistered contractors do not have access to the a anty nd Snaur `cfg�n / wncf ._ _.. �� a pt­ a Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swinvning 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 DATE REJECTED DATE APPROVED CONSERVATION ❑ . ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes 1 Planning Board Decision: Comments I Conservation Decision: Comments Water & Sewer Connection/signature & Date Driveway Per .it Located at 384 Osgood Street F� Z EPA IrIEx1�T Temp D1rn-� e Dn site located Fa# 74 Main #�eet j k x +3 Ar�e Depar�rne�n�s�ra�i�>t�re�-da`�e� �- � "��mL� "', � -+p'� �. '� 2✓r.s,�"�ty. ����� �4'x�� r �,�3� ia` ,� x A '�y"xg 4r'�" es.�_ ,� i n i � 'e � �i ..i ?w,,•.a¢ >g Z ..,... ..,., t�.>.,'.U" F.:�}x�:, T $"r,. '�' wai .� y v k:k §* r d,.4'�' A ',f., � 13 q� ,J, 7 g x 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 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 2007 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 ❑ orkers Comp Affidavit P oto 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 u 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 DEPARTMENT:BPFORM07 y Revised 2.2007 I %0RTIj own of _ . over O No. o , '� dover, Mass.,LAKEa COCMICMEWICK y1. 7d�oRATE 7 v ` BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THISCERTIFIES THAT......... ..................... ... .......................................................................................................................... Foundation has permission to erect... .................................. buildings on . � .. s .40.. . ........ r.0.................. Rough to be occupied as........ ....... �M Chimney provided that the pers n acc pting this permit shall in every respect conform to the terms of the application on file in Final 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 MONTHS ELECTRICAL INSPECTOR. UNLESS CONSTRUT TS Rough .......................... Service BUILDING INSPECTOR Final Occupancy Permit Required to 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. PROPOSAL PROPOSAL N0. Se A<'� p SHEET NO. ® t,..%' - ~05)_ DATE ff i PROPOSAL SUBMITTED TO: WORK TO BE PERFORMED AT: NAME ADDRESS ell ADDR SS 1910 0.6 j DATE OF PLANS f PHONE NO. ARCHITECT We hereby propose to furnish the materials and perform the labor necessary for the completion o t w. 6A 8C 01 AIAA A-1 t r ,. r r rr All material is guaranteed to be as specified, and the above work to be performed in accordance with the drawings and specifi- cations submitted for above work and completed in a substantial workmanlike manner for the sum of Dollar ($_ [ems ' with payments to be made as follows:—'-"—� ) Respectfully submitt Any alteration or deviation from above specifications involving extra costs t: will be executed only upon written order, and will become an extra charge" Per over and above the estimate. All agreements contingent upon strikes, ac- cidents,or delays beyond our control. Note—This proposal may be withdrawn by us if not accepted within days. ACCEPTANCEOF PROPOSAL The above prices, specifications and. conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payments will be made as outlined above. Signature Date ' Signature &-ems NC 3818-50 PROPOSAL ROPOS AL The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 z. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le0bly l�)Name (Business/Organization/Individual): ' Q T Address:W1 AA City/State/Zip: _ Phone #: 4� 4�—74 4i6—_ 0;5(,V 2 Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 1 am a sole proprietor or partner- listed on the attached sheet. + Remodeling l/ "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 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12,❑ Roof repairs insurance required.] employees. [No workers' 13.0 Other comp. insurance required.] *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. TContractors that check this box must attached an additional sheet showing the name ofthe sub-contractors and their workers'comp.policy information. I am an employer that is pro ' ing orkers'compensation insurance for my ees. Below is the policy and job site information. Insurance Company Name: `� M,1. Policy#or Self-ins. Lie.#:—nq Expiration Date: .lob Site Address: .51 S 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 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 certy under the pains and n ti erjury that the information provided above s true and correct. L / Si nature: Date: Z 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.Plumbing Inspector 6.Other Contact Person: Phone#: �ie �anvnw�zsu o�✓l�aaaar/zuaetta BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 064384 Birthdate: 04/24/1957 Expires: 04/24/2008 Tr. no: 25498 �1 -- Restricted: 00 KEVIN M BROUILLARD SR 101 EVERETT ST G- c, LAWRENCE, MA 01843 Commissioner ---�_ -.�' _ ✓fie 1°anvrrtooeusealCf o�✓l�Caaaat,�ucaP,ft I Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 137695 Expiration: 19/2008 Tr# 124418 T)e: Individual KEVIN M BROUILLARD KEVIN BROUILLARD SR. 101 EVERETT ST LAWRENCE,MA 01843 Administrator I ACORDDATE(MM/DD/YYYY) TM. CERTIFICATE OF LIABILITY INSURANCE 05/22/2007 PRODUCER Phone: (978)475-0400 Fax: (978)475-2171 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION THE HOWE INSURANCE AGENCY ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 4 PUNCHARD AVE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ANDOVER MA 01810 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: National Grange Mutual K M BROUILLARD REMODELING INSURER B: C/O KEVIN BROUILLARD INSURER C: 101 EVERETT STREET LAWRENCE MA 01841 INSURER D: INSURER E: 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 ADD'L POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LTR INSR TYPE OF INSURANCE DATE MM/DDM' DATE MM/DD LIMITS GENERAL LIABILITY MP017108 04/14/07 05/11/07 EACH OCCURRENCE $ 500,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 500 000 PREMISES(Ea occurence) i CLAIMS MADE a OCCUR MED.EXP(Any one person) $ 10,000 A PERSONAL&ADV INJURY $ 500,000 GENERAL AGGREGATE $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER:POLICY I PRODUCTS-COMP/OP AGG. $ 1,000,000 PRO- LOC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY (Per person) $ SCHEDULED AUTOS HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR 1:1 CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION$ $ WRY LIMITC S L,.,- OTHER WORKERS COMPENSATION AND TOS EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE j OFFICERIMEMBER EXCLUDED? j E.L.DISEASE-EA EMPLOYEE $ If yes,describe under E.L.DISEASE-POLICY LIMIT $ SPECIAL PROVISIONS below OTHER: DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS" CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS BUILDING DEPARTMENT 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, IT'S AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Attention: J45&ristine J. range ACORD 25(2001/08) Certificate# 3106 ©ACORD CORPORATION 1988 Location � �✓''KK�_ No. r O Date o HORTM TOWN OF NORTH ANDOVER � . O Fr • • `9 - Certificate of Occupancy $ _ - �'7s'•'•°•E<�' Building/Frame Permit Fee $ swCHus i Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # �- 205 ; 3 Building Inspector