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Home My WebLink AboutBuilding Permit #FD 10392 - 575 OSGOOD STREET 6/19/2015BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION za ') Permit No#:FI2 L01617— Date Received Datelssued: C-19-rs '0 IMPORTANT: Applicant must complete all items on this page LOCATION 0s,"I Print PROPERTY OWNER 1�4�0 43040( Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Building 0 One family [I Addition 0 Two or more family El Industrial 0 Alteration No. of units: 0 Commercial El Repair, replacement 0 Assessory Bldg 0 Others: El Demolition 0 Other El Septic 0 Well 0 Floodple - tin ands E] Wetrl- 0 Waters hed,,D istrict o Water/Sewer -J DESCRIPTION OF WORK TO BE PERFORMED: FA -:L 1,44-1 2-19-1-S Av tDucj 6mb�� f-)vrn 6M- kel-'a L W/-te Me— P I , �J-(_ xf Vk ( '606 Identification - Please Type or Print Clearly OWNER: Name: Address: ContractorName: Per�"*,TPhone: Email: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGI NEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTWATED COST BASED ON $125.00 PER S.F. ';� 00 Total Project Cost: $ FEE: $ -30-03 e 14 Check No.: 7`7 Receipt No.: NOTE: Perso'ns c'on"tracting with unregistered contractors do not have access to the guarantyfund 5 ,/ -L 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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Ded:k� 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/Cross Section/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 '. OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ,6 Building Permit Application ,4. Certified Proposed Plot Plan 4. Photo of H.I.C. And C.S.L. Licenses 4� Workers Comp Affidavit ,4 Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (if Applicable) Copy of Contract 2012 IECC Energy code 4, Engineering Affidavits for Engineered products OTE: 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: Building Permit Revised 2014 Plans Submitted [I Plans Waived 11 Certified Plot Plan 0 Stamped Plans El TYPE OF SEWERAGE DISPOSAL Public Sewer El Taming/Massage/Body Art F1 Swimming Pools Well El Tobacco Sales Food Packaging/S�les �E] Private (septic tank, etc. Pennanent Dumpster on Site El THE FOLLOWING -SECTIONS. FaR.OFFICE USE ONLY INTERDEPARTMENTAL SIG - N - OFF - -' U FORM PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed COMMENTS Reviewed On Signature_ Sianature "I H15ALTH Reviewed on Signature 41 11 COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decisionfreceipt submitted yes Planning Board Decision: Comments Conservation Decisi Comments Water & Sewer Connectionisignature & Date Driveway Permit DPW Town Engineer: Signature: Locatea jo4 usgooa z:areet iM 41" 7577-777� fflro—g--a t �—eda 1, 1 ��24'1 J1 LA 9 i A ,t aMrKeet" 777 'Ni ID e p CFwij% De a �Nenl,sit h-atureffilato' "I zt 9-MESL -1-4 Number of Stories: Total square feet of floor area, based on Exterior dimerisions. 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-$1000 fine NO FES and DA I A — Wor dei)artment use I LJ Notified for pickup Call Email I Date Time Contact Name Doc.Building Pennit Revised 2014 „,o — NQ FD'1 03"”' Date TOWN OF NORTH ANDOVER RECEIPT 14 This certifies that .......................... ........ has paid ..... .......... 1,)r-,o4e4 ..................................... for ........ / Received by ......... Department..................... A. ...................................................... WHITE: Applicant CANARY: Department PINK: Treasurer The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibl Name (Business/Organization/Indi vi dual): D&D Electrical Contractors, Inc. Address: 10 Everberg Rd. : Woburn, MA 01801 Phone #: 781-932-0707 Are you an employer? Check the appropriate box: 1. 1 am a employer with 80 4.0 1 am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. 1 am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.$ required.) 5. F We are a corporation and its 3.0 1 am a homeowner doing all work officers have exercised their myself [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' insurance Type of project (required): 6. F_� New construction 7. Remodeling 8. Demolition 9. F_� Building addition 10. 0 Electrical repairs or additions 11. F� Plumbing repairs or additions 12.F� Roof repairs 131-1 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. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that isproviding workers' compensation insurancefor my employees. Below is thepolicy andjob site information. Insurance Company Name: Selective Insurance Corn Policy# or Self -ins. Lic. #: S2067317 Expiration Date: 4/26/2016 Job Site Address: 575 Osgood St. Citv/State/ZiD: North Andover, MA 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 here�y cer4 I , fy under thp, pains aqd,&naJties ofper/g.ry that the information provided above is true and correct Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # 4/10/15 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 #: D&DEL-1 OP ID: LK M1ODfYYYY) CERTIFICATE OF LIABILITY INSURANCE 04113/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Chase & Lunt LLC 65 Parker Street Newburyport, MA 01960 Marcos W. Shaner INSURER A: Selective Insurance Company INSURED D&D Electrical Contractors Inc INSURER 8: Independent Casualty Ins Co Diane Lynch INSURER CAtIantic Charter Ins Co 10 Everberg Road Woburn, MA 01801 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 978-465-6204 THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR PE OF INSURANCE ADDL SUBR JN= POLICY NUMBER POLICY EFF tMMIDD/YYYY) (MMIDDIYYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FKOCCUR S2067317 0412312016 04123/2016 EACH OCCURRENCE $ 1,000,00q DAMAGE TO REN nce PEEMISES (Ea occurre ) $ 500,00( MED EXP (Any one person) $ 15,00( X EBL retro:4/23/13 PERSONAL & ADV INJURY $ 1,000,00( GEN'L AGGREGATE LIMIT APPLIES PER: POLICYF_X PRO - ] JECT FR] LOC OTHER: GENERAL AGGREGATE $ 3,000,00( PRODUCTS - COMP/OP AGG $ 3,000,00( $ A AUTOMOBILE LIABILITY ALL OWNED SCHEDULED AUTOS AUTOS 'I ANY AUTO NON -OWNED HIRED AUTOS AUTOS 1 A9099099 04/2312016 04/23/2016 COMBINED SINGLE LIMIT (Ea socklent) $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ (Per accident) 1 $ A X UMBRELLALIAB EXCESS LIAB X OCCUR CLAIMS -MADE S2067317 04/23/2015 04123/20116 EACH OCCURRENCE $ 10,000,00C AGGREGATE $ 10,000,00( DED I x I RETENTION$ 0 $ B C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECLITIVE OFrICER/MEMBER EXCLUDE FN (Mandatory In NH) Wascrib under D RIPTION OF OPERATIONS below N/A WC1001 201 -00 - MA WC WCA005561-00 - NH WC 04123/2015 04/2312016 04123/2016 04/23/2016 PERTU H - x STA TJ713 E.L. EACH ACCIDENT $ 1,000,00( E.L. DISEASE - EA EMPLOYEE $ 1,000,00( E.L. DISEASE -POLICY LIMIT $ 1,000,00( A A Equipment Floater Crime S2067317 S2067317 04/2312016 04/2312016 04123/2016 04/23/2016 Leased 126,00( Crime 100,00( DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Town of North Anodver 146 Main Street North Anodver, MA 01846 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTA17VE Y,tt, y zj�k� .w-- (9 1953-2014 ACORD CORPORATION. All rights reserved. ACORD 26 (2014/01) The ACORD name and logo are registered marks of ACORD � 0 0 + 0 + .�� D��%JS��O�JF��I�O��SS�ONAL��iC��_�°1��1�� x :�•�a