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Home My WebLink AboutBuilding Permit #550 - 10 SURREY DRIVE 4/22/2009 BUILDING PERMIT 01 No oTh qti 6 ,TOWN OF NORTH ANDOVER o� APPLICATION FOR PLAN EXAMINATION « .. � �w09 1e Permit N0: 6Date Received gSSACHUs�� Date Issued: Z�V IMPORTANT: Applicant must complete all items on this page LOCATION �5v -''r<.I to E %fN A v-, Print PROPERTY OWNER C C +c5 art Prin 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 WORK TO BE PREFORMED: r' Identification Please Type or Print Clearly) OWNER: Name: c tje a Phone: Address: + CONTRACTOR Name: �e! it% Phone: worp 3rf , Address: Supervisor's Construction License: L S 3..5-' %A 7 Exp. Date: C 3o •-1,2o'9 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 BASED ON$125.00 PER S.F. Total Project Cost: $ � FEE: $ Check No.: Receipt No.: U NOTE: Persons contracting kith unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor 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 A COMMENTS HEALTH Reviewed on Signature t 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: 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 2 1 A—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 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 Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 Location No. Date MORTIy TOWN OF NORTH ANDOVER 41 D Certificate of Occupancy $ Building/Frame Permit Fee $ �6 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # �D 2s960 Building Inspector t%O RTFj own of _ , _ 4 over No. Sj 00 o dover, Mass., 0c. HE WICK �� ORATED PP t` �5 `S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT UG C° 1/C ,r �p/y .. Foundation has permission to erect........................................ buildings on ./O....... /...b.C. .............. Rough .............. . .. ........................ to be occupied as......................... .`��'�� .(...../.,�.ei.t. ......`. 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 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. Board of Building Regulations and Standards x — HOME IMPROVEMENT CONTRACTOR Registration ,.133972 Expiration:-9/,4/2009 Tr# 133251 Type ''DBA KAMBERALIS REMODELING-;' ,t, JOSEPH KAMBERALIS`,' 18 BEECH WOOD DR. ,�Q-p�-� DANVILLE,NH 03819 Administrator Board of Building Regulations and Standards� Construction Supervisor License Licenses, CS 35247 Oirthdate 6/30/1960 CEXpiratlo�n 6/30/2009 Tr# 15973 Restriction` 00'I JOSEPH M � KAMBERALIS , ,,'i•� 18 BEECHWOOD DR '✓ e %�c� _ �y DANVILLE,NH 03819 �y�L -. Commissioner The Commonwealth of Massachusetts kj ! Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, M4 02111 www nzass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leoibly Nanie(Business/prgatJizatiotd[ndividual);_ � • � �� l�,/ Q �iS Address: City/State/Zip - = Phone#: . /y c Are you an employer?Check.the appropriate box: 1.❑ 1 am a employer with 4, Type of Pre.1�(require[): ❑ I am a general contractor and I �nployees(full and/or part-time).* have hired the su&contrac tars 6. ❑New construction . 2.(]"I am.a:sole proprietor or partner. Iisted on the attached sheet.= 7. ❑Remodeling ship and have no employees These sub-contractors have 8. Q Demolition working for me.in any capacity. workers' comp.insurance. [No workers con . insurance 5. 9• ❑ Building addition p ❑ We are a corporation and its required.] officers have exercised their 10.F7 Electrical repairs or additions 3.El req am a homeowner doing all work right of exemption per MGL I I.Q Plumbing repairs or additions myself.[No•workers'comp. c. 152, §1(4),and we have no insurance required.]t 12.0 Roof repairs eq ] .employees. [No workers' comp, insurance required.] 13-El Other 'Any applicant that checks bmt*t must also fill out the section below showing their workeni'compensation policy information t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contactors must submit s new affidavit indicating such. ;Contractors that check this box mustaffaehed an additional sheat showing•tie name of t ie sub-con ttactms and their . .�:�. wvrkera`r.;n .... r r� � .n�m�atton. I ant ane , to er that is: ro ' mP Y p trrdt►t :workers co g ensation ►np insurance or a to information. f � niP yam: Below isthepolicy and job site Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: ------------ Job Site Address: . City/State/Zip- Attach a copy of the workers'cam nsatiota policy declaration (showing Po y page( owing the policy number and expiration Failure to secure coverage as P oa date). g tecluiTed under Section 25A of MGL e. 152 can lead fine to i 0 to the imposition of criminal penalties up $ ,5 0.00 and/or one-year imprisonment,as well as civ P of a civil penalties in the farm of a STOP WORK of t ORD up o$250.00 a da ER and a fine y against the violator. Be advised that a copy of this statement may be forwarded Investigations of di Y to the Office of � e DIA for insurance covers verification. ficatron. 1 do hereby ce7fify under the pains and penalties of perjury that the information provided above is true and correct Si tlir'e: n . Date: Phone#. E-h only. Do not write in fins area,to be completed by city or town ofciaL Town: Permit/License# hority(circle one): Health 2.Building Department 3.City/Town Cierk 4. Electrical Inspector 5.Plumbing Inspector son• Phone#: ' h 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 perforarance 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-contractors)name(s),address(es)acid phone numbers)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 for confirmation of insurance 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 nurnber listed below. Self-insured com.paries shoLild en*--+,heir self=insurance license number on the'appropriate tine. 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 ofthe 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 fidw-e permits or licenses. A new affidavit must be filled out each year. When 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 etxr.)said person is NOT required to complete this affidavit The Office of lnvestig=ations would like to thank you in advance fbr 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 Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 0111 TeL#617-7274900 ext 406 or 1-8.77-MASSAFE Fax#617-727-774 Revised 5-26-115 www.mass.gov/dia