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HomeMy WebLinkAboutBuilding Permit #368 - 100 ANDOVER BY-PASS 11/9/2007 BUILDING PERMIT pORTy q TOWN OF NORTH ANDOVER 32 4 ..''.- _�'.'° �0 APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received74�°R4rev 0, qsS ES Date Issued: — -v gCHUs IMPORTANT:Applicant must complete all items on this page LOCATION /,00 A i hn ve.2 v 1 i9 s S Print PROPERTY OWNER MPSi'�'t bP la got Print 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— Alteratiqff7pNo. of units: Commercial epair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: coy r (�,�,7 Identification Please Type or Print Clearly) OWNER: Name: A//IA.,eq_ -� ,�a�� Phone: Address: Ygo l,owe _1L 5,7 pnh,,Ch. i& CONTRACTOR Name:.& 71(9b h 144&'` Y Phone: 600 -:5'/,;)L-9'e3 2 Address: 414'20 1.,-,ue1 ( 57- v►�. Cfi rs�� hL Supervisor's Construction License:_0!o ;;k Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER �7�v�, � 7��1,et1 Phone: Y/ 5--? Address: 5-7 5 7r C--Ceemri e-]& M.4 Reg. No. ! FEE SCHEDULE.BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ /f OzPO FEE: $ /Sa- 00 Check No.: v 0 Receipt No.: (� © � NOTE: Persons contracting with unregistered contractors do not have access to the gua anty fund Signature of Agent/Owner Signature of contrac j Location l/�U ��� � 2 No. Date NORTH TOWN OF NORTH ANDOVER - to " Certificate of Occupancy $ ��s'•^ E<�' Building/Frame Permit Fee $ ACNUS Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 207 6 Building Inspector 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 i 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 DATE REJECTED DATE APPROVED i CONSERVATION ff i COMMENTS I DATE REJECTED DATE APPROVED HEALTH COMMENTS I Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes � I Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer ConnectioniSig nature&Date Driveway Permit Located at 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster on site/yes_ no Located at 924 Main Street , Fire Department signature/date COMMENTS L i 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 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) ru ii I ❑ Notified for pickup - Date I + Doc.Building Permit Revised 2007 i 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 u Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks h ❑ 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) o 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 j ❑ 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 4 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 Doe:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 f Revised 2.2007 4 i NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: 4 s is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 1 OA. The debris will be disposed of in: - mac 2 `h i cat e . C�-2 �07 w h�a it 904& _A)c �4�►d1ov�•L. (Location of Facility) Signature of P it Applicant 9/0 7. Date XA TH Town of : Andover O . :.w .:. . ? VO NO. J 6 8 o '� dover, Mass... o COC HIC HEWICK A00ATE S BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System 6 BUILDING INSPECTOR THIS CERTIFIES THAT.........M..ri►......�..... .. ............................ ... ..... Foundation has permission to ere buildings on .. �..... ........... . . ........... . ..... low Rough Chimney to be occupied as....... . .0..... ��.. ............. .......... ...a.�...�w...�.............................. y provided that the per accepting this perm 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. ���T �'l�� —IST jr-10,01e,- PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final OW PERMIT EXPIRES IN 6 S ELECTRICAL INSPECTOR UNLESS CONSTRU ST S 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. The Commonwealth of Massachusetts Department of Industrial Accidents s Office of Investigations ' d 600 Washington Street A Boston,MA 02111 E www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / Please Print Legibly Name (Business/Organization/Individual): T � Address: 9 millet- s*ret7 i q City/State/Zip: 4ud(ou) 1n4 p lo-5-k, Phone#: Z 5`1-7 -I.15'rV Are.you an employer?Check the appropriate box: Type of project(required):, 1.54 I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time). * have hired the sub-contractors 6. New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition workingfor me in an capacity. employees and have workers' Y P tY• 9. E]Building addition [No workers'comp.insurance comp. insurance.1 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 11.❑Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.E] Roof repairs insurance required.] t c. 152,§1(4),and we have no employees. [No workers' 13.❑ 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. r I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: kk Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: dsM City/State/Zip:_ya.4-nde X t—s-n .0 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 certify unnder1 the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: 1l _ 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#: I' I 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." I 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-contractors)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 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 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 year.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 Office of Investigations would like to thank you in advance for 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 02111 Tel.#617-727-4900 ext.406 or 1-877-MASSAFE Revised 11-.22-06 Fax 9 617-727-7749 www.mass.gov/dia - I 41 ULA IONS gpARD.F`B TION.SUPER TSOR License: CONSTRUC Number"OS. 068625 Birthdate `05!12/1962 Exp�re5, 0511212008 Tr.no 27631 Restricted t j00 JOHN J HARTY `400 LOWELL ST NH 03104/_-TG MANCHESTER, Commissioner I I i I l Date.!,................ ...... t NORTH '°:•�"° TOWN OF NORTH ANDOVER p PERMIT FOR WIRING y,SSACMUS� J -1517 This certifies that .............................................................. r. �.. ............... has permission to perform ....... ................................ wiring in the building of' '_ !. f��:.� .: rr•�r�-�. --:. r .. ............... ......... /! _�.//. ,.ter / ' at..... ........................,.................... �:�....... ,North Andover,Mass. Feek`.�..'�!:�..... Lic.No.J��u.4..r/..... `'..... ELECTRICAL I PE R Check # -- 7 7839 Commonwealth o Official Use Only x, Department of Fire Services Permit No. �U3 \. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked/ - I (Rev.09/05) (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC)527(CMR 12.00) (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date- 11_a_m City or Town of. North Andover To the Inspector or Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below: Location(Street&Number)I00 Andover Rvnacc Owner or Tenant__North Andover Imagine Telephone No. i Owner's Address same as above Is this permit in conjunction with a building permit? Yes ❑No (Check Appropriate Box) Purpose of Building Medical Offices Utility Authorization No. Existing Service__-AW Amps _I VNts_ OverheadElUndergrd ❑ No.of Meters i New Service AMP --YQtL Overhead ❑ Undergrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Renovations of medical office space 2000 sq feet No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans FNo.of Total -.. rmers KVA No.of Luminaire Outlets No.of Ho[Tubs ors KVA No.of Luminaires Swimming Pool Above In mergency Lighting round round = Units No.of Rece tacle Outlets No.of Oil Burners IREALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond.. Total Tons No.of Alerting Devices No.of Waste Disposers HeatPumpl Number Tons KW No.of Self-Contained Totals: I Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local E] Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security ty Systems:* No.of Devices of Equivalent No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: OTHER: No.of Devices or Equivalent Attach additional detail if desired or as required by the Inspector of Wires Estimate Value of Electrical Work: (When required by municipal policy) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) (Expiration Date) I certify,under the pains and penalties ofperjury,that the information in this application is true and complete- PRINT NAME: Universal Electric Co.Inc. oe LIC NO: #14149A Licensee: JAMES KENNEDY JR SignatureLIC Nn:#14149A (If applicable,enter"exempt'in the license number line.) 424 Tel.No.: 413-788-9473 �+ Address:59 OBSERVER STREET SPFLD MA 01104 Alt.Tel.No.: 413-246-5044 *Security System Contractor License required work;if applicable,enter license number here: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coySrage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one) owne►IJ owner's agent❑ Owner/Agent Signature Telephone No. PERMIT FEE:125.00 Ok '' d Date. NQto TOWN OF NORTH-ANDOVER • PERM&FOR PLUMBING ,SSACMUS14 � This certifies that .�. . . . . . . . . . . . . . . . has permission to perform . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . . . . . . . ... .. . 71. . . . . . .at .� "?? . . . . . . . . . . . : : . '� . ., North Anover, Mass. 1 Feel.-3�S°.Lic. No,�� �?. . . . . 4� �// . . . . . . . . . . . . . f� PLUKA8ING INSPECTOR Check y 7592 r • r 9 ta sass o W y, , �;• 1l/1Y11A Cto$LTmUVAvamill °O r ox"Tuss N $Rowan solo-s a � � disPopsas � a °�? •'ar• W •tAulI01111 TA�tYB t�i �� � gJ►sH./:ttte9. CbN�I. � .d „°, � � ,F ... � Nb4 WA4iA'tA►iRa rr TARRUSS � S , .....•• ,.. .a,. . - SLOP $INRs' _ p P1.bOA'aRRiNi Q IS• w �:-...•w. ... n t a H O -Q "• bAtNRiNo FOUNTAIN i� tf h r:s�,t r.' t: s t e� .v •; , 4109P aMIMI a Q M $ACKfL4W PlIRY. ,a ,:. aus tlxTultass , i] 0 o ro