HomeMy WebLinkAboutBuilding Permit #190-2016 - Suite 2101 8/13/2015 a 1 NORTH
BUILDING PERMIT O��tLEo 6
TOWN OF NORTH ANDOVER •6
APPLICATION FOR PLAN EXAMINATION d' - ' p
UR M ^`O
Permit V6i: / �� Date Received ASR tTED Ppy(�
gSSHCHUS�.t
Date Issued: o �\� \C5,
IMPORTANT: Applicant must complete all items on this page
/ L
LOCATION
Print
PROPERTY OWNER /6 C� �1
6,;9 ,\ Print 100 Year Structure yes no
MAP PARCEL: 0a I ZONING DISTRICT:= Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
0 Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
Septic ❑Well ❑ Floodplain ❑Wetlands
El Watershed District
❑Water/Sewer -- - -
DE7CRIPTION QF WORK TO BE PERFORMED, n
IC
I s n A
S� f- c
KC cation- Please T pe or Print Clearly
OWNER: Name: 1 o �L-Cr - Phone:
Address: �.
Contractor Name: Phone:
Email:
Address: f
j
Supervisor's Construction License: ® t4r C G Exp. Date:
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER /C Phone:
Address: S �J Reg. No.
FEE SCHEDULE.BULDING PERMIT.$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
Total Projec t' , �� FEE: $ �3
i
Check No.. ` Receipt No.:
�G1Zc)1
NOTE: Pers s co aracting with unregistered contractors do not have access to the guaranty fund
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
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Siqnature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes
I
i r P la fining Board Decision: Comments
Conservation Decision: Comments
Water& Sewer Connection/Signature& Date Driveway Permit
DPW Town Engineer: Signature:
- �_ 84
:FIRE5DEPA?TMENT temp Dum $ter onsite yes_. 3no�o .
oca e sgood Street
_ _x
�4
I
Fire�Department signature/date.
COMMENTS.
t _
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 q pp requires approval of
Electrical Inspector Yes No
DANCER 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 Call Email
i
Date Time Contact Name
Doc.Building Pennit Revised 2014
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
OTE: 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/Cross Section/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
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New ConstructionSin le and Two Family)
� g
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
2012 I ECC Energy code
Engineering Affidavits for Engineered products
OTE: 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 2014
��A-
Location v ow
No. V) 2-ok Date
• • TOWN OF NORTH ANDOVER
S LED' .
Certificate of Occupancy $
Building/Frame Permit Fee $ '
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check#
Building Inspector
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOS L
Public Sewer ❑ Tanniug/MassageA3ody Art ❑ Swimming Pools ❑
i
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 Reviewed On 73 5- Signature_
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
1
COMMENTS
Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes
s
da Planning Board Decision: Comments
i
a
Conservation Decision: Comments
Wafter& Sewer Connection/Signature& Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE,CEPAR�TMENT Tempi® ,yes_ tnoa .
um r ontsi
t
-
Fire Department s,i ta:W a/date. -:-�77
�...s.
041
O
BUILDING PERMIT t10RTN q
�tyeo
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION f `
Permi�o#: Date Received AOR,TEo^Pa �y
�SSACHUSEt
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION c0 d
Pri
PROPERTY OWNER f e 0 o S
Print C66Lab 1 00ea Structure yes no
MAP PARCEL: ZONING DISTRICT:-:-a 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
rl-Mteration No. of units: z Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑ Septic ❑Well ❑ Floodplain [I Wetlands ❑ Watershed District
❑Water/Sewer
DCRIPTION OF VVORK TO BE PERFO , MED:
C7
` - INA/ ✓
f
2,,Z-Z e-0 ae f.4
1
Identification- Pleas Type or Print 06arly
OWNER: Name: Z, hone: +
Address: _
Contractor Name: - ! hone: 4? ?
Email:
Address: .:2 ''7 -�
Supervisor's Construction License: Exp. Date: f
Home Improvement License: Exp. Date: �a
ARCH ITECT/ENGINEER _ Phone: !
jj Re- No.
Address: 7 "_�p a �2 �9
FEE SCHEDULE.BULDING PERMIT.$12.00 PER$10000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
cJ
Total Project Cost: $_�� �.� FEE: $
Check No.: Receipt No.:
NOTE: Persons contractin 'h reregistered contractors do not have access to the guaranty fund
Enter construction cost for fee cal - North Andover Fee Calculation
Construction Cost
$ 66,881 .00 m
$ - $ 802.57
Plumbing Fee $ 100.32
Gas Fee 100 comm. $ 100.00
Electrical Fee $ 100.32
Total fees collected $ 1,103.22
1600 Osgood Street
190-2016 on 8/13/15
Tenant Fit Up Second Floor
- � NORTI-�
Town of t E ndover
2 ib`4'�
C h ver Mass
2
COC NICNl W�CN ���
x.95 4ATEID r'Pp��(5
U BOARD OF HEALTH
Food/Kitchen
PER-MIT -T L D Septic System
THIS CERTIFIES THAT .......S .d ��� BUILDING INSPECTOR
....
Foundation
..........................
has permission to erect buildings on ..,� ...................... ........G'................ ...........
p 2 ,o) Rough
to be occupied as '/�� ....°�r�
................. ....................................................................................................... Chimney
provided that the person accepting this permit shall in every respect conform to the terms of the application Final
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
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTI N TARTS Rough
........... Service
........ ...... .... . (�.. .... .z
/ Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Buildinz 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.
DOWGIERT CONSTRUCTION CO. INC.
616 ESSEX STREET
LAWRENCE, MA 01840
978 685-0306 fax 603 458-1090
CONTRACT
Customer
Name 1600 Osgood St-LLC Ozzy Property Mg _ Date 8/11/2015
Address 1600 Osgood St. _
City North Andover State MA_ ZIP 01845 Job Name GSA space
Phone demo walkway
Description Unit Price TOTAL
Qty-------- --
Remove and dispose of existing interior walls and
flooring and ceilings. Save ceiling stock and lights to be
reused later.
Cut an opening in exterior wall for new entry.
Install new concrete walkway to new entry with bollards.
Total Contract Price $66,861.50
"Price does not include architectural or engineering costs
and is based on plans dated 7/9/15. If changes are made,
pricing will be adjusted accordingly.
-- —"J
SubTotal $66,86_1.50
Shipping & Handling $0.00
TOTAL $66,861.50
- 7 Office Use Only
Initial Construction Control Document
To be submitted with the building permit application by a
d Registered Design Professional
for work per the 8a'edition of the
Massachusetts State Building Code, 780 CMR, Section 107
Project Title: ' Date:
Property Address:
Project: Check one or both as applicable: ❑New construction >I:�xisting Construction
Project description: LON7 kl�,//
I �eredesignprofessional,
MA Registration Number: Expiration date: ama
regand I have prepared or directly supervised the preparation of all design pl ,
computations and specifications concerning:
r�Architectural [ ] Structural [ ] Mechanical
rr] Fire Protection [ ] Electrical ( ] Other
for the above named project and that to the best of my knowledge,information,and belief 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.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107.
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 buil ® al Construction Control Document'.
U
Enter in the space to the right a` vet"or d
� E�
electronic signature and seal: "
Phone number: (41y) '�� V ✓1 •
Buildin O al Use Only
Building Official Name: Permit No.: Date:
Version 06 11 2013
The Commonwealth of Massachusetts
Department of IndustrialAccidents
tea. : d X Congress Street,Suite 100
Boston,MA. 02114-2017
:y,Wt www mass.gov/dia
yV• Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE, FILED WITH THE PERMITTING AUTHORITY.
Applicant.Information Please Print Le 'bl
Name (Business/Organization/Iudividual):
Address: -�
City/State/Zip: -5,Phone#: r 7,-!2
Are you an employer?Check the appropriate box: Type of project(required):
1 I am a employer with` employees(fulland/or part time).- 7. ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in $, g�_effo ej g
any capacity.[No workers'comp.insurance required.]
I F1 am a homeowner doing all work myself,[No workers'comp.insurance required.]t
9. ❑Demolition
10 F1 Building addition
4.F1I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees. 12..0 Plumbing repairs or additions
5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
❑ � 13.[j Roof repairs
These sub-contractors have employees and have workers'comp.insurance.
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El Other
152,§1(4),and we have nq employees.[No workers'comp.insurance required]
*Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information.
Homeowners who submif 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-coniracfors fiave employees,they must provide their workeis'comp.policy number.
dam an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site
information. //r''
Insurance Company Name: 6,<_t_
Policy If or Self-ins.Lie.#: 12
Expiration Date: t
Job Site Address: O City/State/Zip:
Attach a copy of the workers' compepsation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c.152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
d do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature: / �'"" Date:
Phone# -Z `2g- Lir- Z, 9 -22—
Of
ficial
,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#:
Information and. Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee 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"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including 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 that"every state or local licensing agency shall withhold the issuance or
renewal of a license 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."
Applicants
Please fill-out-the workers' compensation affidavit completely,by checking the-boxes that apply to your situation and,if
necessary,supply sub-contractoi(s)name(s),address(es)and-phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation 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 foi•confirmation ofinsurance coverage. Also be sure to sign and date 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 regarding the law or if you'are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should'enter-their '
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit 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 permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any 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 stamped 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
yeax.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 bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel.#617-727-4900 ext. 7406 or 1-877-AIASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supen�isor
License: CS-048040
TADEUSZ DOWGAR `
175 BRADY AVE. °
SALEM NH 0" #� "
NO
Expiration
Commissioner 10/29/2015