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Home My WebLink AboutBuilding Permit # 3/18/2015 OORTH Of, BUILDING PERMIT 0 TOWN OF NORTH ANDOVER 0 'A 'APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received 1sgIAre. Date Issued: r"(nj� ( �-- I \ - CHUS IMPORTANT: Applicant must complete all items on this page g -,A N 'N"",rr. /,1 1791/1/1711 N WINME 0 IN N/ NY JVIA"K'n"I"N' TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential El New Building [] One family 11 Addition 11 Two or more family El Industrial "Iteration No. of units: El Commercial /❑ Repair, replacement F1 Assessory Bldg 11 Others: 11 Demolition 11 Other -2 0 c7 2 C2 Identification Please Type or Print Clearly) J(A,1 OWNER: Name: Phone: Address: 1411q ............ 11/5 rr SIMEON, ARCHITECT/ INEER Phone: �-) Address: 0, / Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED 0 $125.00 PER S.F. - "I D Total Project Cost: FEE: $ Check No.: v-t Receipt No.: --4 NOTE: Persons cotrtracftn with unregist edco actors do not have access to the guaranty fund Signature of Agent/Owne Signature of contractor 7°�- 1 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 ❑ ❑ COMENTS i 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/Signature& Date Driveway Permit Located at 384 Osgood Street :,FIREDEPARTMENT Temp Dempster ori slfe : yes no Locafecf�at'124�llatn�freet � , -Fire Deparfinenf signature/date �-�~ �..,� .� � � r�.❑ ---==� '.. COMMENTS w I V%®RTH to 0 �, own ot t : ,, Andover No. -soon ;O� _ h ver g a 15 o L.K. 7 MaSS, coc"Ic Kl WICK °RATED �s u BOARD OF HEALTH } vLD 4 Food/Kitchen PERMIT T I Septic System ` 01 k_1L&#-"&4THIS CERTIFIES THATBUILDING INSPECTOR .......... ..... ....... ............... /11N� ............. has permission to erect .. 1 ,. �� Foundation .........................:buildings on .5.11F..... � .. .............. .. Rough to be occupied as .. M-04...,, .,,, .m.4 �,,, 1 .... ... .. ..... �.......................................... Chimney pr®vided that the person accepting this permit shall in every respect conform to the terms of the application on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Final 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 I P- UNLESS CONSTRUCT S S Rough Service x ............. Ad ................ s Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® Occupy Ruildinz 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 Approvedy the Building Inspector. Burner Street No. Smoke Det. I i Massachusetts -Department of Public Safety Board of Building ?equlations and Standards Construction Supen icor License: CS-092345 MATT PBRNTEL` 27 Boutwell Rd Andover MA 01810 Expiration Commissioner 05/04/2015 Initial Construction Control Document i u To be submitted with the building permit application by a Registered Design Professional t for work per the 8t'edition of the Massachusetts State Building Code, 780 CMR, Section 107.6.2 Project Title: EDGEWOOD RETIREMENT COMMUNITY Date: 02-11-15 Property Address: 575 OSGOOD ST.—NORTH ANDOVER Project: Check(x)one or both as applicable: New construction X Existing Construction Project description: Interior Renovations to combine two units 5302 and 5304 into a single unit. I Charles Cochran MA Registration Number: 6559 Expiration date: 08-31-2015,I am a registered design professional, and hereby certify that I have prepared or directly supervised the preparation of all design plans,computations and specifications concerning': X Entire Project X Architectural Structural Mechanical Fire Protection Electrical Other: for the above named project and that such plans, computations and specifications meet the applicable provisions of the Massachusetts State Building Code, (780 CMR),and accepted engineering practices for the proposed project. I understand and agree that I(or my designee)shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to: 1. Review,for conformance to this code and the design concept, shop drawings, samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable. 3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine if the work is being performed in a manner consistent with the approved construction documents and this code. When required by the building official,I shall submit field/progress reports (see item 3.)together with pertinent comments, in a form acceptable to the building official. Upon completion of the work,I shall submit to the building official a`Final Construction Control Document'. Enter in the space to the right a"wet"or V,I cNAA�' s f�Ot electronic signature and seal: �? cocHRA '55 ► -STFO V ®� A Phone number: 978-399-0240 Emai : ca T♦ earchitects.com Building Official Use Only Building Official Name: Permit No.: Date: Trial Version 10 09 2012 The Commonwealth of Massachusetts Print Form Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individual): Address: � � ( � Il City/State/Zip• f � Phone#: Are you an employer? Check the appropriate box: '� 4. ❑ I am a general contractor and I Type of project(required): I,Main a employer with 6. ❑ New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I L❑ Plumbing repairs or additions myself. [No workers' comp, right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 131-1 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. +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 is providing workers'cofnpensation insurance for my employees. Below is the policy and job site information. J� Insurance Company Name: \` �� %�2v0y `�'?�X � `'` t Policy#or Self-ins. Lic. #:��c��,��"Cx p ration Date: Job Site Address: 75�5 0 cZ cj S)- City/State/Zip:A n/H,7 f_V V&dz 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 cern y under the pains and penalties of erjury that the information provided above is true and correct. Simature: Date: 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#: VDAC F TFORD WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (6S60UB-2E62448-0-1 4) NEW-1 4 INSURER: HARTFORD UNDERWRITERS INSURANCE COMPANY NCCI CO CODE: 10456 1. INSURED: PRODUCER: PIMENTEL CONSTRUCTION CO INC EDWARD F SENNOTT INS 231 ANDOVER STREET PO BOX 457 WILMINGTON MA 01887 TOPSFIELD MA 01983 Insured is A CORPORATION Other work places and identification numbers are shown in the schedule(s) attached. 2. The policy period is from 12-20-14 to 12-20-15 12:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: MA B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in N item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident: $ 1000000 Each Accident Bodily Injury by Disease: $ 1000000 Policy Limit 0 Bodily Injury by Disease: $ 1000000 Each Employee N C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: ° COVERAGE REPLACED BY ENDORSEMENT WC 20 03 0GA M D. This policy includes these endorsements and schedules: SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE o 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: 01 -13-15 AK ST ASSIGN: MA OFFICE: ORLANDO DA HTFD 05G PRODUCER: EDWARD F SENNOTT INS 2562B 004286