HomeMy WebLinkAboutBuilding Permit #83-11 - 1630 Osgood Street 7/27/2010BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: g
Date Received
'I
FO
'A
Non- Residential
New Building
One family
Date Issued: 117-e,"),-:7 --/-o "114- �ACII
I IMPORTANT: A-pWicant must comDlete all items on this t)aize I
LOCATION 114�7610 4,7-
11 Print
PROPERTY OWNER--�e-4 7
d. Ar
Pdnt
MAP 210 PARCEL: ZONING DISTRICT: Historic District yes
6
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
R�ir r�eplacement
Assessory Bldg
Others:
C%em-oliti-o�
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
Non k
4- e4ve o1xn,JI 1,11C 7—,4:f ,.,7 Ille r
Identification Please Type or Print Clearly)
OWNER: Name: Otgjt Phone:
Address: I (pCp os!Lego
A -
CONTRACTOR Name:
Phone: �eej Z r 7
Address:- i � ( 7C V-oAC L3eLa-%-,, D, YO)
Supervisor's Construction License: 0*!�!Q 7 41-d Exp. Date: /&f;zzo 1.4
Home Improvement License: Exp. Date:
ARCH ITECT/ENG I NEER 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: $ o/ 00o FEE: $
Check No.: ,�) 0 /--4, Receipt No.:
NOTE: Persons'contracting with unregistered contractors do not have access to the guaran
Signature of Agent/Owner Signature of contra- cfoV/"04) _�a
� It>-,
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
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
CQ� MMENTS
DATE REJECTED DATE'APPROVED
Reviewed on Si-qnature
Reviewed on Sicjnature
Zoning Board of Appeals: Variance, Petition No: . Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
FIRE DEPARTMENT - Temp Dumpster on site yes.
Located at 124,,Main Street
FireDepartment signature/date
COMMENTS
Located :384 USg00d Street
no
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 21 A —F and G min.$10041 000 fine
NOTES and DATA — (For department use
El Notified for pickup - Date
Doc.Building Permit Revised 2010
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
u Building Permit Application
Li 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
j Building Permit Application
Lj Certified Surveyed Plot Plan
Lj Workers Comp Affidavit
Photo Copy of H.I.C. And C.S.L. Licenses
L3 Copy Of Contract
u Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (if Applicable)
Li Mass check Energy Compliance Report (If Applicable)
Li 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
Li Mass check Energy Compliance Report
Lj 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: Building Permit Revised 2008
Check #
2 3 '2' 6 1,
Building Inspector
".,./ Cff%516 /jj
Location./oW
a< -5"3z),./
No.
Date
TOWN OF NORTH ANDOVER
0
Certificate Occupancy
SACMUSt
of $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
2 3 '2' 6 1,
Building Inspector
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The COMMOnweizith of Massachusetts
Department qf rndustrial Accidents
Office Of r1n vesz�,azions
..600 F�'ashington Street
Bostoyz, M4 02111
Workers' Compensation
3plicant Tnfnrm-mi-;__ Insurance -Affidavit: Builders/Contractors/Electri.
cians/Plumbers
----------- TIT - - - -
Name (Business/organiza6,,/Indiidual):
Address: / �; , �-, �: 5
City/State/Zip: Phone ?k V3
Are You an e io 9 r1L. — —
—f' .7,1 . eck Lae appropriate bA
I.El lam a employer with 4. 5 IlL a)&erneral contractor a I nd I
2. F7employees (ftill and/or —part-time). have hired the sub-c(mtractors
I am a sole proprietor or part]2-,r- listed on the attached shcet I
�p Ildve no employees
working for me in any capacity.
[No workers, comp. insurance
required.]
I am a homeowner doing aU work
myself [No workers I comp.
insurance required-] t
a.
Ise sub—cOntractors have
workers' c0MP- insurance.
5. 11 We are a corporation and its
Off1cers llave exercised their
right of e'�-'emPtiOn Per MGL
c. 152, § 1(4), and we have, no
employets. [NO workers,
Type of project (required):
6- New construction
7. Remodeling
8. Demolition
9. Building addition
10.0 Electrical repair, Or�ddition,
11.7 Plumbing repairs oradditions
12.7 Roof repairs
13 F7 Of�
CC requ�rec_j -----------
*A _J
t �If check, b0X MUSj &18(,
Romeownets W,
1! ihe se --tion beii-ow
no 9 �� "V orkcrs� compr_-�_�
submit this affidavit indicatinZ tb,-y 111- doia� aE work and J �m
that --hcck thlis box== attached an additional sheet showi'm thm hire outside 00n1tact-On r -L --L submit a new afyidavit indicating such.
"C't'RL
the n=e of the sui>-c
r 0M-ctorszmdtber* Wnrl--l
� �4 u1nPA(lyer 1.4w IS . __ , LLWUUU.
informadol . L Prov4di". workers I COMpensadon i?zSztranccJor MY enTloyeas. Below is the policy andjoh site
Insurance Company Name:
Policy # or Self -ins. Lic.
Job Site Address: EXPiratio . n Date: -----------
City/State/Zip:
."-ttach R COPY Of the Workers' compensation Policy declaration paye
UuMberand exPiratioin date).
Failure to Secure coverage as required und r Section 25A of MGL c. (Showing the policy
fine up to $1,500-00 and/or one -yew irnprisonmen� 152 can lead to the imposition of c - rinlinal penalties of a
Of up to S250.00 a day against the violator. Be advis as well as civil penalties in the form of a S
ed that a cc>_py of this TOP WORK ORDER and a fine
Investigations of the DIA for insurance coverage verification. statement may be forwarded to the Office of
I do hereby cerdfy-#ndcr the pains and
Signature: 041 z I
PcrJLUY thW the informl2fiOJ7 P?-Ovided abo,,e is "e and correct
ione �Datc:
Officiat use only. Do not w*e in this area, to be completed bj, cit�, or town officiaL
City or Town: _� I" ermitUcense
Issuing Authority (circle one):
L Board of Health I Building, Department 3. City/Towla
6. Other Clerk 4. Electrical Inspector S. plumbine
Inspector
Contact Person:
-Phone'#.
Information an- d Instructions
Massachusetts General Laws chapter 152 requIrt"s all 'employ C--rs to provide workers' compensation for their employ=&.
Pursuant to th� statute-, an employee is defined as "...ev rson in the service of another under any contract of hire,
ery pv---
express or implied, oral or written."
An employer is defined as "an individuaL partnership, associaLtion, corporation or other lezal entity, or a . ny two or more
of the foregoiag eagned in a Joint enterprise. and including t1ae lezal representatives of a deceased employer, or tIL-
re----ivcr ortruste-, ofan individuaL partnership, association Dx- other legal entity, empl
OYIng employees. However the
owner of a dwelling house having not mom than three aPartax ents and who resides therem, or the occupant of the
dwelling house of another who -employs persons to do mai�mance, construction or repair work ou such dwelling, house
or on'the grounds or building appurtenant thereto shall not bt--c--ause of such, employment be deemed to be an employcr."
MGL chapter 152, §25C(6) also states that "ever -y state or 6cal ce an, ncy s wi old the issuance or
li using we hall thh
renewal of a license or permit to operate a business or to ctanstruct buildings in the commonwealth for any
applicant who has not produced acceptable evidence Of co3mpliance with the insurance coverage requked.."
Additionally, MGL chapter 152, §25C(7) states "Neither the c--OTnTnonwealth nor any of its political subdivisions shall
enter into any contract for the performance Of public work MTE acceptable evidence of compliance with the insurame
requir=ents of this chapter have bcen presented to the contraLcting authority."
.kpplicants
Please fill out the workers' compensation affida-vit completel:31, by checking the boxes that apply to your situation and. if
necessary, supply sub-contractor(s) marne(s), address(es) and phone number(s) along with their certificate(s) of
kon-ance. Linait:.d Liability Companies (LLC) Or Limited Liability Partnerships (LLP) with no employees other f1= the
members or partam, am not require -,d to carry workers' comp, ensation 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 confinnation of insurance coverage. Also be &xre to sign and date the affidiLvit. The affidavit should
be mturn-�-` to the city or town thatt the apph-ca-luor. for the pp
rriait or Ecen-sein being req=stted, not -,=--nt of
Industrial Accidents. Should yon. have any questions m-gardin-z la -w or
if you are to obtain a work:ers3
compensation policy, please call the Department at the numbe--i- listed below. Self-insured companies should -enter flieir
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed leglbl3,. 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 ffie pennittlicense number which will be used as a reference number. In addition, an applicant
that must subnut multiple permit/license applicatIOUS M. any given year, need only submit one affidavit indicating cunmt
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 offiici�lly stampf--d or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for &ture perlmits or license&. A new affidavit must be filled out =h
ycar. Where a hLomt owner or citizen is obtaixting a license or Pen[nit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etr.) said person is NOT required to complete this affidavit.
The Office ofInvestigations would like to than you in advance or yo o0p on d sho d you v y qu o
f ur c erati an ul ha e an esfi ns
please do not hesitate to give us a call -
The Department7s address, telephone.and.,fam.-nuniber....,.
TBe CommonvircalthL Gf Ma&3a&jjseftS
DePaTtmmt Of Industrial Accidents
Office Gf Investigations
600 -Washington st-tet
Bostom, M -A 02111
Tel. # 617-727-4900 = 40.6 or 1-8 7/7-NLkSS-AFE
Re-viscd 5-26-05 Fax #7 617-72,7- 7/749
mm-Al.mass-gov/dia.