The URL can be used to link to this page

Home My WebLink AboutBuilding Permit #405 - Bldg 30 12/30/2008 BUILDING PERMIT V%ORoTH qti bttt .,.•et•a TOWN OF NORTH ANDOVER 4 p APPLICATION FOR PLAN EXAMINATION 1� Permit NO: Date Received Area ACH�1`-+�� Date Issued: " o r7� IMPORTANT:Applicant must complete all items on this page LOCATION Z 6'00 -5 A �'A Print }. r PROPERTY OWNER 22144f- I Print. MAP NO: 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 DESCRIPTION OF V�IORK TO BE PR FORMED: v , 1/ 11i� 7 C. Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: 6M1 9 7 g-- o CONTRACTOR .Name: rlehone Address:,, Supervisor's Construction License:C-1Na R6Exp. Date d Home Improvement License: Exp. Date 5af d 17 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: $,L4��C0�IFEE: $_ Check No.: 2 0'P Receipt No.: �� 7 NOTE: Persons contractinwit unre 'stered contractors do not have access to th guaranty fund ignature of Agent/O Si nature of contractor �..g___ I Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/MassageBody 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 f r COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: g g 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) ❑- 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 PP 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 B Doc:Building Permit Application Revised 2.2008 i MpA�N q Brian Leathe Local Building Inspector to s y a� 1600 Osgood Street s„�„u° North Andover,MA 01845 Phone 978-688-9545 42 10:00 am,1-2 Pm Town of North Andovn office hou88 8530 am— handover.com Building®epartme Community Development Division Email BleatheotoWnofnort s The Commonwealth of hfassachusetts De artment o P f Industrial Accidents Office of lrnvestieations 600 d ,. Washington Street r;as Boston, MA 02111 t ww1N'-nzMs-,ov1dia Workers' Compensation Insurance-Affidavit: guilders/Contractors/Electricians/Plumbers Appficant Information Please Print LeQibIv NaII1e (Business/Organization/Individual): J�7,/0 170 f, O Y - City/State/Zip: �O/' �t1p0 �5 Phone#: f 60 Are you an employer?Check the appropriate box: 1.7 I an a employer with 4. ❑ I am a o E7. of project(requiredJ: general contractor and I employees(full and/or part-time).' have hired the sub-contractors New construction 2.❑ i am a sole proprietor or partner- listed on the attached sheet Remodeiina ship and have no employees These stab-contractors haveworking for me in any capacity. workers' comp. insurance. ' ❑ Demolition [No workers' comp. insurance 5. ❑ We are a corporation and its 9• ❑ Building addition required-] officers have exercised.their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.7 Plumbing repairs or additions myself. [No.workers' comp. c. 152, §1,(4) and we have� no 12 insurance required.] t employees. [No workers' 12.[] Roof repairs comp. insurance required_] 1.3.�Other e f 1C/Lp Sr *Any applic ant.that checks box#I.must also fill out the section below showing their work t Homeowners who submii,ti[is a$idavit indicatin_81ey apt Built_a:' &,id Ehzai hire o ¢tside caniracters'compensation policy iniormaiion.s a new atnrinvit indicating s omuni submii tContrac[ors that check this box must attached an additional shit showing the name of the sub, 0trtors and their workerscomp,poi ic} information' I am ant employer that is providing workers'compensation insurance_for ng'emp information loyees. Below is the policy and job site Insurance Company Name: p � Policy#or Self-.ins. Lic.#: Expiration Date Job Site Address:16�D 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 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 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. do hereby cer46)under the pains and penalties ofperjury that the information provided above is true and correct S i artaturA Date: — Phone#: Of use only. Do not write in this area, to be completed by city or town off ciaL City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbin]Insp]ectlor 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 enrpinyee 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`pan individual,partnership;association, corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and includirrg 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'Ghat—every state®r local licensing agency shall withhold the issuance or renewal of a ficense 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." Appficants Please fill out the workers' compensation affidavit compi-etely,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 Liabiit, Partnerships(LLP)with no employees other than the members or partners,are not required to cant' workers' compensation insurance. If an LLC or LLP does have _ employees, a policy is required_ Be advised that this affidavit maybe submitted to_the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to si-n anddate the.affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regardin.0 the law or if you are required to obtain a workers' compensation policy,please call the Department at the ntuaiiber:Iisted below. pelf insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the"affidak 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 permitAicrose number which will be used as a reference number. in addition,an applicant that must submit multiple permit/heense applications in arty 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 starnped 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 burnleaves 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: The ComrnonWtEdth of Massachusetts Department of Industrial Accidents. Office of Investigations 600 Washington Street Boston; MA 02111 Tel. # 617-727-4900 ext 406 or 1-977-MASSAFE Revised 5-26=05 Fax 4 617-727-7749 V^W.I.rrlass.m ov/dia ACORD CERTIFICATE �F LIABILITY INSURANCE DAT�� n 121038008 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Cowan Insumme Agency,Inc. ONLY AND .CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 359 Main Street ALTER THE COVERAGE AFFORDED BY THE hQLICIES BELOW. Haverhill MA 01830 INSURERS AFFORDING COVERAGE NAIC# INSURED last Coast Cubicle Corp INSURER A. Employers_Mutual Casualty Company 224 Blake HIII Road INSURER B: National Union Fire_ Ins Northwood NH 03261 INSURER D; INSURER E `� y i COVERAGES I THE POLICIES OF INSURANCE-LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATI o. NOTIMTHeANDING 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, INR 4017L PODGY NUMBER Y EPOLICFFECTIVE POLICY EXP) TIONImm LWITS GENERAL LIABILITY EACH OCCURRENCE S i,000,000 MAOE TO RENTED DA A x COMMERCIAL GENERAL LIABILITY 3D62170 0813112008 08/31/2609 ld1.8I:6AEL= 2100 000 CLAIMS MADE xI OCCUR MED EXP An i;m pom No PERSONAL$ADV INJURY $1,000,000 GENERAL AGGREGATE S Z014,000 l GEN'LAGGREGATE LIMIT APPLIES PER PRODUCTS•COMPIOP AGG $2X0,000 X7 POLICY P LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT A ANY AUTO 3E62170 0112008 84112009 (Ea wxMnt) a 1,000,600 ALL OWNED AUTOS BODILY(Pat peroem)INJURY 6 X SCHEDULED AUTOS ,,. X HIRED AUTOS BODILY INJURY S X NON-OWNED AUTOS (Per wmano PROPERTY DAMAGE S l (Peraoddem) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT. ANY AUTO OTHER THAN GA ACC, $ AUTO ONLY. AGG EXCUSIUMBRELLA LIABILITY I EACH OCCURRENCE 6 1000 000 A X7 OCCUR ❑CLAIMS MADE 3J62170 .081.31120.08 0813112009 AGGREGATE a 1000 040 s i DEDUCTIBLE $ I RX RETENTION S`101000 wORKER9O0MPl;NSATIONANO x A STATU. DTH EMPLOYERS'LIAHILR7 B 1NC5341013 0910912008 09!0112009 E.L.EACH ACCIDENT =1000000 ANY PROPRIETORIPARTNEWEXECUTIVE OFFICERIMEMBER EXCLUDEb2 No E,L,DISEASE-EA EMPLOYEE'a 1 660 S EC GeeCllbe undue h01dk E.L DISEASE-POLICY C141IT $1 000 OTHER DESCRIPTION OF OPERATIONS I LOCATION5 I VEHICLES I ExGLUSIONS ADDED 9Y ENDORSEMENT I SPECIAL PROVISION9 978 685 2344 Moveable office PaMon Installations. CERTIFICATE HOLDER CANCELLATION 914OULD ANY OF THE ABOVE 0MR19ED POLIC11%BE OANCELLEO 6EFORH THE 11 W RATION Fimpro DATE-r4mcF,THe ISSUING INSURER VALL ENDEAVOR TO#TAIL 10 DAYS WRRIYN 1800 Osgood Street NOTICE TO THE CERTIFICATE H090 NAMED TO E LEFT.BUT FAILURE TO DO SO SHALL IMPOSE NO OBUGATWN ORCIABILITY OF D UPON THE INSURER ITS AGENTS OR North Andover,MA Of ltd REPRESMA7ANS. AYTHOR�REPRES THE ACORO 25(2001l08) ®ACORD CORPORATION 1998 Dec 17 08 04:47p ECC 6039428294 p.1 East Coast Cubicle, Corp. Attention: Lee lDeVito Quote 224 Blakes Bill Rd Northwood,NH 03261 Date Estimate# Phone# 603-942-8270 Fax# 603-942-8294 12/3/2008 124 Name 1 Address location Firepro Inc. Firepro Inc. 100 Bum Rd. 100 BUM Rd. Andover,MA 01810-5920 Andover,MA 01810-5920 i i I Description Quantity Rate Total Quote to dismantle and set-up workstation according to print supplied by Firepro.All panels to be steam cleaned.ECC to run data,customer will terminate.All product to be checked for damages. Est Workstation;(6)manager stations,(4)double workstations,(2)4-seat workstations.All work to be done during regular business hours,site to be ready. Total 1 5,400.00 5,400.00 Moving of all case goods to be done O$30.00 por hour,per man,if needed or requested by customer. I i Any questions please don't hesitate to call Tom T.@ 603-765-8626 or Mike M.978-360-7214 I i I I It's been a pleasure working with you! Tota $5,400.00 i • - I Signature t.%ORTH Tovm of Andover No. 0"0 dover, Mass., L A It. COCHIC HEWICK 0RATED P' BOARD OF HEALTH Food/,Kitchen PERMIT D Septic System BUILDING INSPECTOR .................. .................................... ........................... THIS CERTIFIES THAT............... Foundation has permission to erect........................................ buildings on ...16.. ............. 1. ............................. Rough to be occupied as........................iox'/r" .. ........... ... ...... 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 UNLESS CONSTRUCTION STARTS f ELECTRICAL INSPECTOR 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. Location &,!�-o o s�— No. �U , Date �aRTM TOWN OF NORTH ANDOVER 10? ° • 09 + Certificate of Occupancy $ t4�' Building/Frame Permit.Fee $ 6� .1 CHUS Foundation Permit Fee $ ,— Other Permit Fee $ TOTAL $ Check # a 2 , 7i4 Building Inspector