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Home My WebLink AboutBuilding Permit # 4/22/2015 i I TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: Z- r,-� IMPORTANT: Applicant must complete all items on this page LOCATION r PROPERTY OWNER x - MAP NO PARCEL ZONING DISTRICT Historac Distract yes no `,Machine,Shop`\tillage yes nq, , .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 BldgOthers: ❑ Demolition ❑ Other []Septics Well Floo plains �UVetlands ❑ Watershed District ❑Water/Sewer ; ~� rti'��1�.,': ,. DERICRIPTIOV OF WORk TO BE PERFORMED: t , r ix Nxoa }!�® fur / - A Identification Please Typ4 dr Print Clearly) 6f W OWNER: Name: 2-,o _41" Phone: �- 5 Address: �ILo ( ` 1 CONTRACTOR° Namehe �� ,,. o F, Address r ,. Supervisor's Construction License Exp Date Home Improvement License , , Exp. Date ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12 00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASEP ON$125.00 PER S.F. Total Project Cost: $ FEE: Check No.: :�EReceipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor Plans Submitted Li Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Plans Submitted ❑ Plans Waived ❑. "Certified Plot Plan ❑ Stamped Plans ❑ -: TYPE OF`.SEWERAGED3SP.OSAL Public Sewer ❑ Tanning/Massage/Body Art ❑. Swimming Pools ❑ Well ❑ -Tobacco.Sales _❑ -Food Packaging/Sales ❑ Private(septic tank,etc._ ❑ Permanent Diunpster on Site ❑ THE:FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM _:_ DATE REJECTED DATE:APPROVED PLANNING & DEVELO MEN-r C] ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Si nature r� CO NTS MME M. w... a. 4� Zoning Board of Appeals: Variance, Petition No: Zoning Decisionlreceipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water&• Sewer Connection/Signature& Date Driveway Permit DPW Todv:: Engineer: Signature: Located 384 Osgood Street FIRE`DEPARRTI �a�9T -Temp Dumpster an site yes no •Located at 124 Mair, Street - -Fire Depart eFit signafiu a/date COMMENTS NORTH Town of It Y.." Andover 0 LAK h ver, Mass ! � COCMIC Nl WICK APP-1V AERATE® ,'PP,`�5 S U BOARD OF HEALTH tiERMIT T LD Food/Kitchen Septic System THIS CERTIFIES THAT BUILDING INSPECTOR ............... !.. ....... i .'��....................................................... ovoFoundation has permission to erect . ........................ buildings on .. ... ... �.�. .........,....�,,.,,,,.,. Rough tobe occupied as ........ ....C! .... . ....C, . .............................................. chi provided that the person accepting this permit shall in every respect conform to the terms of the application inal on file in 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 IT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR LESS CONSTRUCTIO STARTS Rough Service .............I...... .'........... .................... nal BUILDING INSPECTOR GAS INSPECTOR ceupaney Permit Required to Occupy Building 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. Smoke Det. Department of Public SafetyLicense#: MA-011 License to Operate Amusement Devices Expiration Date: 6/15/2015 Certified Maintenance Mechanic Larry Cushing Enterprises,LTD Lawrence H.Cushing,III Lawrence H.Cushing II Cushing Amusements 196 Wildwood Street Marion V.Cushing Wilmington MA 01887 (978)658-3928 1"S.1:T): ff 17M'ic-p U.S.I.D. 11 Device 10802 Hampton Combo 07066 Truck Stop 10842 ',High Lite Swing 10002 Go Gator Musical 10003 Taxi Jet 10853 Dizzy Dragon 13345 Fcrris`.Wheel 10004 Round Up - 10006 Sizzler 13473 Casino 10007 Merry-Go-Round 13751 Wisdom Gravitron 10009 Super Slide 1002 y855 WackArch Bounce 10010 Rio Grande Train I002856' Fire Dog Belly Bounce 10153 Zipper 10154 Bungee Jump 10513 Gladiator Funhouse- Scooby Shack 10566 Tea Cup 10567 Tempest 10602 Roll-O-Plane Commissioner ofPublic Safety I sued Me Page 1 of I S ItBi AN) POLIG'f i IBFOM iTm RBl�AI. T PROWCM: Agit# 1 mer' Allied Specialty Insurance Inc. T.H.B. Insurance Com 10451 Gulf Boulevard 10451 Gulf Boulevard Treasure Island. FL 33706 Treasure Island. FL 33706 (Carrier Code: 40851) t Carrier policy #: VM44495. Carrier prior policy #: VM34213 t 1. The Insured: Larry Cushing Beterprism..�Ltd. Wailing Address: 196 Yildwood Street Yiladngton, WA 01887; { Fein: 042714871 File #: 900000000243414 Other sorkplacas not shown above: y Type of Buslume: Corporation BBB SCHIMS OF OPCS Rick ID: 91322b186 to 12:01 au. on 5/2712015 at the issured's soiling address: 3. A. Yarkers Conation. Iasarance: Part One of t b e Policy dies to tbe Workers C, sats oa Lai► of the Staten listed here: WAMSMRI B. Beplayers Liability Itisarance: Part Two of tb4 policy applies to tock its each state listed in Itm 3.A. The limits of our jlability ander Part Two are: Bodily Injury by Accident $ 1-00e-800 accident Bodily' ThJury by Disease $ i.00Q.b00 policy lisit Bodily In9�9 b9 Disease $ 1.Oo0_oo4 each +rploses C. Other States Insaruae: All states amcepts4 CA DD. (a. VA. W. +sem Wf D. This policy includes these wudorseamts ani'�d s edules: 888 Sammm OF ORSB�lBafITS z } ms for this Policyy:L be dgtearataed aur Mauals of Rules. 4. act The Classifications. Rates and Rating Plans. Alli required below is snb3_ to moa and change by audit. Classifications Code Fremiu:. as Rate Per Estimated 10. Total. Be� $100 of Annual. AnilRemuneratim Premium SO g( OF OFIRALIETM Total Estimated Anmal Prod=$ 5.700.00 4338_00 Winim m Premium $ 900.00 ; S ae Ca6stant $ We b0 00 01 A Comntersigned bg r Y F t BJP rig" 0 0 ), V I 1� �h-.rti Tile Common wealth of Massach usetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, Ili 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organizationtlndividual) C�d J4 Address: City/State/Zip: fir✓ / 1-7 Phone#: Are you an employer? Check appropriate box: Type of project(required): 1. 1 am a employer with_/J;/ 4• n I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. ❑Remodeling 2.❑ I am a sole proprietor or partner- These sub-contractors have ship and have no employees employees and have workers' 8. Demolition working for me in any capacity. 9. ❑Building addition [No workers' comp_insurance comp.insurance.1 required.] S. [] We are a corporation and its 10.❑Electrical repairs or additions �.❑ 1 am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself_[No workers'comp. right of exemption per MGL 12.❑Roof re irs insurance required.]t c. 152,§I(4),and we have no employees. [No workers' 13- Oth comp.insurance required.l *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- iContractors 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 insurance for my employees Below is thepoliey and job site information. ,/- . � 7 Insurance Company Name: I -�i22 Qom — y Policy# or Self ins.Lic.#:T y q y � Expiration Date: �� c3-7 d-6'/3 Job Site Address: d �.!" S City/State/Zip: I � lt/vr 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. 16 hereby certify under the pains dpenalties of perjury that the information provided above is true and correct Sinature: U Date: Phone#: L 7�� Sd/ 3% lr Official use only. Ito 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 M ALLIED SPECIALTY INSURANCE, INC. 10451 GULF BOULEVARD, TREASURE ISLAND, FL. 33706 Toll Free 1-800-237-3355 National 1-800-282-6776 Florida Certificate Number: 38 CERTIFICATE OF INSURANCE This certificate neither affirmatively nor negatively amends, extends or alters the covera e afforded by the policy(ies) described hereon and is issued as a matter of information and confers no right upon the holder. The polis (ies) identified below by a policy number is in force on the date of certifica e issuance. Insurance is afforded onl with respect to those covera es for which a .specific limit of liability has been entered and is sub 'ec to all terms of the policy having reference thereto. Nothing herein c=ained shall modify any provision of said policy. In the event of cancellation of the policy the company issuing said policy will make all reasonable effort to send Notice of Cancellation to the certificate holder at the address shown herein, but the Com any assumes no responsibilities for any mistake or failure to give such notice. Any insurance made a part of the policy includes as a person insured with respect to an occurrence taking place at a Carnivals site, N1 the fair or exhibition association, sponsoring organization or -committee 2 the owner or lessee there of (3 a municipality granting the Named Insured permission to operate a(n) Carnivals, but only as respects bodily injury or property damage caused by or contributed to by the ne1igence of the Named Insured while acting in the course and scope of their employment. NAME & ADDRESS OF INSURED: ADDITIONAL INSURED: Larry Cushing Enterprises, LTD dba Cushing Amusements Joseph N.Hermann Youth Center Inc. ,North 196 Wildwood Street Andover Youth Services & Town of North Wilmington MA 01887 Andover & Ozzy Properties Inc. as respects to the general liability pertaining to the NAME & ADDRESS OF CERTIFICATE HOLDER: operations of the named insured only. Joseph N.Hermann Youth Center Inc. 33 Johnson st.N.Andover Ma 01845 Ozzy Properties Inc. - DATES: to 1600 Osgood st.N.Andover Ma 01845 EXCESS08VER.AGE_27_2015 PRIMARY COVERAGE CE S CO Company: T.H.E. Insurance T.H.E. Insurance Company Company Policy Number: CPP0101485-04 ELP0010338-04 LIABILITY LIMITS BI/PD AGG: $5, 000, 000 $1, 000, 000 OCC: $1, 000, 000 $1, 000, 000 Excess of Excess of _Food Products: - $1, 000:, 000 1, 000, 000 Policy period: - From: 6/15/14 6/15/14 0/00/00 To: 6/15/15 6/15/15 0/00/00 - COMBINED SINGLE LIMIT Coverage shown herein applies only to those items scheduled on or endorsed to the policy: A ril 24, 2014