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HomeMy WebLinkAboutBuilding Permit #349 - 946 OSGOOD STREET 10/30/2009 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: D A� MPORTANT: Applicant must complete all items on this page LOCATIONqq6 3T pvmovL.-?33 PROPERTY OWNERPrint_ / �-� Print MAP NO: 141 PARCEL: 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 Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer _4,,DESCRIPTION OF WORK Tq E PERFORM D: S I hen- -D -D Ac� So Identificatio Please Type r Print Clearly) OWNER: Name: Phone: Address: CONTRACTOR Name: 1x\-\o a) —SK:L Phone: Address: ()1.� a&u i ' Supervisor's Construction License: // j Exp. Date: ZLZ /a ci Home Improvement License: . f l � Exp. Date: j r ARCHITECT/ENGINEER Phone: t 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: $--2 c-N- 66119-(7 FEE: $ .oa Check No.: /��6 Receipt No.: 2 2 ,�W' NOTE: Persons contracts with unre istered contractors do not have access to tho guaranty fund Signature of Agent/Owne Signature of contracto 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 IL Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes r G Planning Board Decision: Comments L Conservation Decision: Comments Water & Sewer Connection/Signature &Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS 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 t ❑ Notified for pickup - Date Doc:.Building Permit Revised 2008 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 ❑ 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: Doc.Building Permit Revised 2008 Location 9�19 4P>l1J1�- No. _��y / Date 6 NORTq TOWN OF NORTH ANDOVER 0 R +'e ; ; Certificate of Occupancy $ Its C" t. Building/Frame Permit Fee $ = Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check #/QQ 7 G `� L' U Building Inspector <; Board of Building Regulations and Standards Construction Supervisor License License: CS 31419 Expiration: 12/8/2009 Tr# 13125 Restriction: 00 ' MARK T CONNELL PO BOX 242 BELMONT,MA 02478 Commissioner Town ofAndover . 0 TO No. 3 0 dover, Mass.,— xcl�I-lel,09 0 L.rA 11 C ORATED C) BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System C��JBUILDING INSPECTOR Aeea% THIS CERTIFIES THAT............. T.9.....ex..23........................................... ......a../................................. ............... ...... .... . Foundation has permission to erect........................................ buildings on ......................... Rough to be occupied as...... ............................................ Chimney ............. ... provided that the person accepting 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 CONSTRUCTION, TART-So, Rough TARTS ............. ...........Lr.. .... .... ....... .......................................... Service B D SPECTOR 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 Pet. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA-02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Indiividual):JL�Address: �� a ro City/State/Zip: Phone#: Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. E]New construction riai ployees (full and/or part-time).* have hired the sub-contractors2. a sole proprietor or partner- listed on the attached sheet.$ ❑ Remodeling 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 10. Electrical re required.] officers have exercised their ❑ pairs 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.EE'Raofrepairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] k rti... 1that .. 1 G app icant checks bo,. 1:r=a.so ll out the section below showing their workers'comnenss—ation policy imfe Waarn- t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors in 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 isproviding workers'compensation insurance for my employees. Below is thepolicy andjob site information. Insurance Company Name: Policy#or Self-ins. Lie.#: 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 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 certify under the pains d penalties o perjury that the information provided above is true and correct Signafore. Date: ?C2 Phone#: d J . 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#: 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 or 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 another who 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 Vocal 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-contractor(s)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 date the affidavit. .The affidavit should be returned to the cit;,or to 1. that the application for the permit or license is being requested,not the Department 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 for 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: a The Commonwealth.of Massachusetts Department of Industrial Accidents. Office of Investigations 600 Washington Street Boston.,MA. 0.2111 Tel. 4 617-727490.0 ext 406 or 1-877-MASSAFE Fax 4 617-72.7-7749 Revised 5-26-OS vt­A,u,.mass.gov/dia _ ,rAIVDARD 335 Crossways Park Dr. PREMIUM FINANCE AGREEMENT ".ACCOUNT NO. Woodbury, NY 11797 Please check one box: FL h'DI.�'G CORP. (516) 364-0200 ® Commercial Lines ❑ Personal Lines Quote: 51133 AGENT(Name and place of business) INSURED(Name and place of business) CASH PRICE $ (TOTAL PREMIUMS) 4,164.44 STRASSMAN INSURANCE AGENCY,INC TRIPLE 3 CONTRACTING & ROOFING 12 POST OFFICE SQUARE 4 WALNUT ST CASHSHARON, MA 02067 DOWN PAYMENT $ SHARON, MA 02067 0000 SS or FID# 1,172.36 PHONE 781 784-8444 PHONE . 781 784-2650 DEFINITIONS: STANDARD FUNDING CORP.will be herein after referred to as STANDARD. The words"the insured","I","you","me","my"mean the person borrowing the money to pay for the insurance policy(ies)listed on this PREMIUM FINANCE AGREEMENT. PROMISE TO PAY: In consideration of the funds that are being advanced to pay my insurance on the policy(ies) listed below, I promise to make monthly payments as shown. I will make these payments until I have paid the full amount advanced for me, plus the finance charges and any other charges I may owe as shown on this agreement. I understand payments will be made to: STANDARD FUNDING CORP.,335 Crossways Park Drive,Woodbury,NY 11797 and will be deemed made when actually received by STANDARD. TRUTH IN LENDING DISCLOSURES AMOUNT FINANCED FINANCE CHARGE TOTAL OF PAYMENTS ANNUAL PERCENTAGE RATE The amount of credit provided to The dollar amount the credit The amount you will have paid after you The cost of your credit as a yearly rate. you oron your behalf. will cost you. _ have made all payments as scheduled. $ 2,992.08 $ 196.53 $ 3,188.61 15.50 YOUR PAY.MENT Number of Pavments Amount of Pavments When Pavments are Due(MonthlviQuarteriv/Annuallv): SCHEDULE WILL BEGINNING: BE: M 9 354.29 07/22/09 SECURITY: I am giving STANDARD, its successors and/or assigns a security interest in all unearned premiums which may become payable under the financed insurance policies as well as any loss payments that reduce the unearned premiums. I agree not to assign the policy(ies)except for the interest of mortgagees or loss payees,without written consent of STANDARD.its successors and/or assigns. DELINQUENCY CHARGES:For installments which are in default for a period of ten days or more(five days or more in Montana), I agree to pay a deliquency charge of from$1.00 to a maximum of 5%of the delinquent installment($500 maximum in New Mexico&$5 maximum in Delaware and Montana and North Dakota). If the insurance listed in this contract is for individual,family or household purposes,the charge may not exceed$5.00(no maximum in Minnesota &. $15 maximum in Lousianna). The acceptance by STANDARD of one or more late payments from me shall not prevent STANDARD or be construed as a waiver by STANDARD to exercise any or all of its rights hereunder in the event of any subsequent late payment made by me. FRETA HENT.i mGy prepay the fuli amount iu,-un ihis-egrec .en`and recede a rebate cf the`.^an__ charge in acccrdenoe vrth the rule of 78ths Cr such other method as authorized by law. Refunds of$1.00 or less will not be made. n R NOTE:See both pages of this agreement for any additional information about non-payment,any required payment in full before the schedule date, and any prepayment refunds and penalties. You have a riht to receive at this time an itemization of the Amount Financed. I do do not M want ap itemization. POLICY PREFIX EFFECTIVE DATE SCHEDULE OF POLICIES (NAME OF INSURANCE COVG. POLICY POLICY AND NUMBER OF POLICY COMPANY AND GENERAL AGENT) TYPE TERM PREMIUM BINDER 6/22/09 MAX SPECIALTY INSURANCE C GL 12 3836.00 QUAKER SPECIAL RISK Fin axes / Fees 153.44 Ern axes / Fees 175.00 TOTAL: $ 4164.44 ACCEPTANCE: I UNDERSTAND THAT THE BROKER OR AGENT WHOSE NAME APPEARS BELOW IS NOT A REPRESENTATIVE OF STANDARD AND HAS NO AUTHORITY TO PROMISE ANYTHING ON BEHALF OF STANDARD. I ALSO UNDERSTAND THAT STANDARD MAKES NO WARRANTIES OR REPRESENTATIONS CONCERNING THE FINANCED COVERAGE NOR HAS IT PLAYED ANY PART IN THE SELECTION, STRUCTURING OR ACQUISITION OF SUCH COVERAGE. This agreement shall not be valid until accepted by STANDARD. If my down payment is made by a check,I understand that it is accepted subject to collection and that if the check is dishonored,this agreement shall be,deemed not to have been accepted, even if a notification of acceptance has been issued by STANDARD. The insured understands that STANDARD may transfer and/or assign this agreement to another duly licensed premium finance agency,bank or financial institution. NOTICE: 1. DO NOT SIGN THIS AGREEMENT BEFORE YOU READ BOTH PAGES OF IT OR IF IT CONTAINS ANY BLANK SPACES. 2. YOU ARE ENTITLED TO A COMPLETELY FILLED IN COPY OF THIS AGREEMENT AT THE TIME YOU SIGN. 3. UNDER THE LAW, YOU HAVE THE RIGHT TO PAY OFF IN ADVANCE THE FULL AMOUNT DUE AND UNDER CERTAIN CONDITIONS OBTAIN.A PARTIAL REFUND OF THE FINANCE/SERVICE CHARGE. 4. KEEP YOUR COPY OF THIS AGREEMENT TO PROTECT YOUR LEGAL RIGHTS. 1, THE INSURED, HAVE READ THIS AGREEMENT, UNDERSTAND IT CLEARLY AND AGREE TO THE TERMS AND CONDITIONS ON BOTH PAGES (ALL INSUREDS DESIGNATED IN THE POLICY(IES) MUST SIGN. IF THE INSURED IS A CORPORATION, AN OFFICER MUST SIGN). I ALSO ACKNOWLEDGE THE RECEIPT OF AN EXECUTED COPY OF THIS AGREEMENT AT THE TIME OF EXECUTION THEREOF AND REPRESENT I HAVE THE AUTHORITY TO SIGN ON BEHALF OF THE INSURED. BLANK SPACES: I hereby allow STANDARD to fill in those spaces which refer to the ame of the insurer,the policy number(s)and the due date of the first installment if the insurance policy(ies)have not been issued at the time of my igning this agreement. INSURED NAME SIGNATURE OF THE INSURED OR AUTHORIZED REPRESENTATIVE TITLE DATE SHE AGENT OR BROKER AGREES TO THE TERMS AND CONDITIONS ON BOTH PAGES OF THIO PREMIUM FINANCE AGREEMENT =NT OR BROKER SIGNATURE OF AGENT OR BROKER TITLE DATE 7-04(DE, LA, MA, MI,MN,MT, NM&ND) PAGE 1 OF 2 C1TY O BOSTTO:NA -BOARD OF EXAMINERS MAYOR -' i --:CERT.- S '•' .: . ' NUNO D DOSOUT'O IS DULY LICENSED 70 TAKE CHARG5 OF ,+1ORK UNDER PROVISIONS OF THE ACAS OF 1938 CHAPTER 479.AS APAEND8D G-4-5 7181091$110 r ,� 90AP0 OF EXAMINERS p� ✓k TDorrv�nan .dd o�✓luWa¢c�ucael�4`.. Board of Building Regulations and Standards L HOME IMPROVEMENT CONTRACTOR Registration:.,160096 i - - Eioirat on:: 6/23/2010 Tr# 269937 �� Type :DBA .; DO SOUTO N CONTRACTOR _>} NUNO DOSOUTO, � 68 WINTER ST. E.BRIDEGWATER,MA 02333 Administrator •