HomeMy WebLinkAboutBuilding Permit #133 - 95 OSGOOD STREET 8/18/2006 TOWN OF NORTH ANDOVER
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APPLICATION FOR PLAN_ EXAMINATIONo`'I"D 1"6 -
il �� j _D � ry
Permit NO: 7 Date Received cU— L5 -a
9q<o<wH..<w.[•y1�
oR^rto 0,
Date Issued: "!� �SSAc"Us��
IMPORTANT: Applicant must complete all items on this page
LOCATION _) S C� CX)!Q S
Print,PROPERTY OWNER CAM �7— �r
I/C� �� / t-� L
Print
MAP NO.: .- PARCEL: CI ZONING DISTRICT:
TYPE AND USE OF BUILDING HISTORIC DISTRICT YES -
TYPE OF IMPROVEMENT PROPOSED USE
Reside Non-Residential
❑New Building ne family
Addition ❑Two or more family ❑ Industrial
aeration No. of units:
❑ Repair, replacement ❑ Assessory Bldg ❑ Commercial
Demolition '
i] Moving(relocation) ❑ Other ❑ Others:
❑ Foundation only
DESCRIPTION OF WORK TO BE PREFORMED
Identification Pease Type or Print Clearly)
OWNER: Name: - IE-S, LC—Phone: 29 8-O
Address
CONTRACTOR Name: ria � �" /`7` Phone:
Address: 7 Julp /� r_lv_e L N)20
Supervisor's Construction License: .. Sl� Exp. Date:
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Name: Phone:
Address: Reg. No.
FEE SCHEDULE:BULDIN PERMIT:$12.00 PER$1000.00 OF THE TOTAL EST/MATED COST BASED ON$125.00 PER S.F.
Total Project Cost : 200o . x12.00=FEE:$ 94e ,
Check No.: J V ( Receipt No.: lis
Page IoP4
i
TYPE OF SEWERAGE DISPOSAL
Public Sewer anning/Massage/Body Art ❑ Swimming Pools 11
Well
Tobacco Sales ❑ Food Packaging/Sales ❑
❑
Permanent Dumpster on Site ❑
Private(septic tank,etc. U Electric Meter location to
project
NOTE: Persons con ratting` n gi tet d contractors do not have access t the g ar tyun
Signature of Agent/Own e Signature of contracto
Plans Submitted Pla s aived ❑ Certified Plot Plan ❑7 amped Plans
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF-U FORM
DATE REJECTED DATE APPROVED
PLANNING& DEVELOPMENT ❑ ❑
❑Water Shed Special Permit
❑ Site Plan Special Permit
❑ Other
t
COMMENTS
r
DATE REJECTED DATE APPROVED
CONSERVATION ❑ ❑
COMMENTS
DATE REJECTED DATE APPROVED
HEALTH ❑ ❑
COMMENTS
Zoning Board of Appeals: Variance,Petition No:
Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water& Sewer connection/Siiinature&D e Drivewav Permit
Temp Dumpster on site yes_no Fire Department signature/date
Building Setback (ft.)
Front Yard Side Yard Rear Yard
Required Provided Required Provides Required Provided
Dimension
Number of Stories: Total square feet of floor area,based on Exterior dimensions.
I
Total land area,sq. ft.:
NOTES and DATA—(For department use)
. 9
Page 3 of
Dur.INSPECTIONAL SERVICES DEPARTMENT BITORM05
Cieated.IMC.Lm._'006
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
Addition Or Decks
❑ Building ��Permit Application
❑ 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)
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
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
Dor:INSPECTIONAL SERVICES DEPARTNIENTMFORN105
Paur`.4 44
Location Ci-5 06,:2100d
No. 1:33 Date
NORTN TOWN OF NORTH ANDOVER
0?0•,"•O ,•,h00R
16.
Certificate of Occupancy $
�' b'•^°'�t�' Building/Frame Permit Fee $
,SJACMu
Foundation Permit Fee $ "
Other Permit Fee $
TOTAL $ �w
Check #
19501
Building Inspector
NORTH �
Town of
Nq,
*y Z o
Q L A dover, Mass.,
T �+ �.
A- COCMICMEWICK V
ORATED P' ��
S BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT.. i.. .A.`�..��..... ... I .1.1�... .....LLC........................... Foundation
has permission to WeA4.14k.... r .I.As. buildings on .............11 .. Q.1�..� % Rough
......... .........................
to be occupied as.... ......4...... .�NOV. 1A...... I...it.........A
. �.�..�........... .. 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 andy-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
q6W.
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTIO TS Rough
Service
................ .. .....
B G INSP R
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.
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N AMDp;j jER
MA 01$45
I 00-35,000 cf enclosed space
(MGL C.112 S.60L) I
1A-Masonry only
1G-1&2 Family Homes
Failure to possess a current edition of the
Massachusetts State Building Code
is cause for revocation of this license.
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DIG SAFE CALL CENTER: 888).344-;7233 d
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REVISED: 09-30-04
SHEET CONTENTS: ADDITION FOR: THE JEFFERSON DATE: DRAWN BY:
cn ROOF FRAMING PLAN LOT#95 OSGOOD STREET 05-05-04 BERNARD
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GERARD E. WELCH, INC. P.O. BOX 248 N.ANDOVER, MA. 01845 TEL.978 794-9191 FAX 978 794-4798
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REVISED: 09-30-04
SHEET CONTENTS: ADDITION FOR: THE JEFFERSON DATE: DRAWN BY:
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REVISED: 09-30-04
SHEET CONTENTS: ADDITION FOR: THE JEFFERSON DATE: DRAWN BY:
c, 05-05-04 BERNARD
m ROOF FRAMING PLAN LOT#95 OSGOOD STREET SCALE: CHECKED BY:
NORTH ANDOVER, MASS. 01845 1/4":1'-0
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GERARD E. WELCH, INC. P.O. BOX 248 N.ANDOVER, MA. 01845 TEL.978 794-9191 FAX 978 794-4798
08/15/2006 11:13 978-738-0014 M H 0 C PAGE 01/02
The Commmostveuhh uj,llasstrchusetts
Department of hithlstrial,t ec idents
Office of tnvestigtrtiuns
+� 600 Washilr1iK on Street
8ostun, _tit,-! OZl/l
1cww.nmsc.guv/dia
"'eskers" Compensation Insurance .1l'fidali(: IJuilders/CtrntratctorsiElectricians/Plumbrrs
.\ lic:snt information t'leWill Print Lt: ibi
'`;t111t'I t)u:,itt►>4 Ur�!anir;;ti++t,lrnlih i�send): ,
City Statelip. ����. Phone 7 ,.0 ~7
Are>ou an Oyer?Check the appropriate hom Type of project It required).
1. a anplo}zr with�, t• ❑ I am u gt nt sal contractor and I 6. ❑New consinlctiun
cmploycus(Full and`orport-time).• . have hired the sub-contractors
�.C3 I tem a role proprietor or panner- listed on the attached;heel. ` ' ❑Remodeling
;hip and have no emptoyets Thcsc'sub-contractors have 3. [] Demolition
working for ine in any rapacity. workers'camp, insurance. 9. ❑Building addition
'No tiwrkrrs'comp.insurance 5. (] We are a corporation and its
required.] officers have exercised their 10'0 Flectrical repairs ur additions
1 3.❑ l-an a homeoW ncr doing all wcrlt right of exemption pip MUt, I I.Q Plumbing repairs or additions
lf. N '
nt seo workerscomp. e, 152.§1(4),and we have no
} � D 110 Roof repairs
in:iurance required.)t cr„ployct:s.[No wurkers 13.0 Other
comp.insurance r;quirdl
nr gplicant Ihtt;Lecke Mht.�1 nhun also lilt,:all iN:astkin heloN •hw.ing their workers'cunipen;stem policy uilkniatiun.
I1c,acewncrs Mil.aMtlu this altidavit tndicatins the)are Ahms all weak and lhun hie�,alside c,;niauog nuut;rutlmil a new 2
1'tithevIt indwAiing twh.
+ .a lr;iO4;f%All cheek thk het olid.utuched an.uldilu•oat•hent Aleivinn the mane-if rhe'•nh-cantrmtnra and their policy ag;amoUon,
J 18tH an employer thud k prnvirling rvurkers'curltpenrrdlun invurunerfidr my eagrlureet. 8,elow is rite policy rime jub sire
inJmnrutianM
(n essence t'umpany V,unc: t ' u:_„ —_-•- �._ `�!G
/ /
Polis} 'rx1Fins.Lic. i'_ (�- N•2 75 �1_ Expiration Deme- �^( ^^�� b
_l._._.__.
!;bSiw.ldJress: �SQwc� _ City State.ti
illmh a copy of the workers'comps inn policy declaration page(showin 8the ►liex number:md er irrtlon'trq[e.
i.ailuro to.cn:oocuvuraj;4 as required usidrx Suction 23.1 of MMOL e. 151-can luld to the imposition ufrriminal Fcnaltirs ur,a
ins'up to 1i LJW.00:end ur int:-'•':ar imprisonment as urll as civil penalties in the rima ofa STOP V�ORK ORDER and a lint
4 up 10529.0a dui against the violator. Be advi;xd that a cupy of this tatMant mnty be forwarded to the t{ftice(if
rnsc'rlp:atiUnS h:f r DLA forins r►ntt rotrr;lnr teritication.
1 !u f ruby ;0 r l t rr pr ' .r. penalties uj perjury drio.he injuriarrllon prwvWrtl,Visa's is Irue and correct
rr ,fe t 1.41' .11,
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08/15/2006 11:13 978-738-0014 M W 0 C PAGE 02/02
WORKERS COMPENSATION AND EMPLOYERS'LIASILTY
INSURANCE POLICY INFORMATION PAGE
INSURER: POLICY NO: 26W> ND 4795 01
NORFOLK AND DEDHAM MUTUAL FIRE
222 AMES . STR,EET RENEWAL OF: 26NZND 4795
AEDKAM, MA 02026 NCCI Company No: 21059
Account No:
FEIN: 04-3236213
ITEM 1. NAMED INSURED AND MAILING ADDRESS: AGENT NAME AND ADDRESS;
GERARD WELCH INC INTERNET INS AGENCY, INC/20155
PO BOX 248 522 CHICKERING ROAD
N •ANTOVER MA 01645 NORTH ANDOVER MA 01845
AGENT NO.: 011.1155
LEGAL ENTITY: CORPORATION
OTHER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Classification Schedule)
ITEM 2, POLICYPERIOD: From: 11-17-2005 To: 11-17-2006
Effective 12:01 A.M. Standard Time at the Insured's mailing address.
ITEM 3. COVERAGE:
A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the
states listed here:
MA
B. Employers'Liability Insurance: Part Two of the policy applies to work In each state listed in Item 3.A. The limits
of liability under Part Two are:
Bodily Injury by Accident: $ 100, 000 each accident
Bodily Injury by Disease: $ 500,000 policy limit
Bodily Injury by Disease: $ 100,000 ' each employee
C. Other States Insurance; Part Three of the policy applies to the states,If any,fisted here:
SEE ENDORSEMENT WC 20 03 06 A
D. This Policy includes these Endorsements and Schedules:
See Schedule of Forms and Endorsements.
ITEM 4. PREMIUM: The premium for this Policy will be determined by our Manuals of Rules, Classifications,Rates and
Rating Plans. All Information required on the Workers Compensation Classification schedule is subject to
verification and change by audit.
Total Estimated
Minimum Premium: $ 168 Annual Premium: $ 874
Audit Period: ANNUAL
Issued At: 01
Date: 09-27-05 Countersigned by
WC 00 00 01 A copyngnt 19x7 Nammi eounco on compamoon IrAurence
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