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Home My WebLink AboutBuilding Permit #201-15 - 100 DALE STREET 8/25/2014 NORT/i BUILDING PERMIT pFtt�eo bgti TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received �SSACHUS Date Issued: IMPORT��A__Nt(T: Applicant must complete all items on this page LOCATION Af 0 print PROPERTY OWNER �cc co-!!-5 L)00e C9,Q w Print _ 100 Ydbr Structure yes nU MAP �7 PARCEL:C_ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential /XNew Building XOne 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 DESCRIPJJON OF WORK TO BE PERFORMED: Ide tificat'on- Please Ty a or Prin Clearly 7 OWNER: Name: Ca� �(ctc� �' � Phone: e 8 Q Address: C '5C W ��X, �/� 61 0,2( Contractor Name �-�Ph� one: Address: Supervisor's Construction License: _Cs O7//�eq Exp. Date: Home Improvement License: 17 5 51 El Exp. Date: /y ARCHITECT/ENGINEER44 � 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: $ /0o 1 Check No.: Receipt No.: 2� S NOTE: Persons contract'ng w h unre ' red co actors do not have access t tl guar ty and -------- ;Signature of Agent/O Si re of contractor Location 100 4 No. Date51� . - TOWN OF NORTH ANDOVER • Certificate of Occupancy $ too Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL _ $ Check27945 # �� Bair ng Inspector Plans Submitted)K Plans Waived ❑ Certified Plot Plau,K Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer X 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 Reviewed On Signature_ o COMMENTS Ilei CONSERVATION Reviewed on Signature COMMENTS t'jy\ fop r HEALTH Reviewed on Signature COMMENTS M Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes r D/` l 7>767 Planning Board Decision: PG' z- Comments r Conservation Decision: Comme W)/A-�"�"triv)elay Water& Sewer Connection/Si nature& e4 Permit v DPW Town Engineer: Signature: Located 84 sgood Street FIRE DEPARTMENT - Temp p Aster on site yes-n . Located at 124 Main Street CJ' Fire'Department signature/date COMMENTS. Dimension Number of Stories: (:f—' Total square feet of floor area, based on Exterior dimensions.2 IG� Total land area, sq. ft.: �G/ 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 I NOTES and DATA— (For department use) ❑ Notified for pickup Call Email i 3 Date Time Contact Name -� 4oc.Building Permit Revised 2014 e 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 o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o 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 o Workers Comp Affidavit Li Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o 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:Building Permit Revised 2014 r 1 _ NORTH - - E 1 .c . . ve" ** No. r _iRW571 _ h ver, Mass,L AK [0[NIC"1W/CM y1' A044ArED PI? S U BOARD OF HEALTH Food/Kitchen PERMIT T L D Septic System c /ls�C FG�f BUILDING INSPECTOR THIS CERTIFIES THAT .......... ......U� �� .........p............ ...................... has permission to erect .............. buildings on ZG f ............... Foundation - Rough to be occupied as l "�'1' �.. .. y 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 CONSTRUCTIONARTS Rough //SJ Service ............ ........ . . .. ..................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy 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. Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-071149 JEFFREY S HORNS 156 BAREHILL BOXFORD MA 01921 lip Expiratior Commissioner 05/21/201: �f e�po�nzmwraruecc�Gta o�-C%UGaa�ccc�trrJe/ Office of Consumer Affairs&Busihess Regulation OME IMPROVEMENT CONTRACTOR egistration: -.*3,, 42 Type: xpiration: -11/2072014 Corporation HORNE CONSTRUCTION JEFFREY HORNE . , 1 156 BARE HILL RD BOXFORD,MA 01921 Undersecretary Jav- -He ComdonweaM of.Massaghusetts , - - �1e,�a�tmento•f.�ic��stvrc�LAcczc�ents • . O.ffiee offavesfigafeons 600 WasItiagtonStreet .Boston,.ltd 02111 -wwt�.mass:gov1dhz W(ockexgYs Comp o� n�r�a�c Affidavit::BuRders/ContractorsNIectriezanql* BKO . e . Please. u�L . 'bZ .A �zcant Worcan.�.�on P�z - UU Namo Cl3usvaosSlOrganization&&idad): Address: CRY/StateM.P. �� .ire your�m employer?Cheektlte appropriatehox: Type of project(regpirecl -1. am a employer with 4'V X am a general confxactax and l 6. ew const:uclzov. employees(�zllancl(oxpaxE time}T �avaWiedthe suli-contractors 2.E] I arca.a sole proprietor orpathiex listed on the attached sheet: `7• �[Remodeling BMP and`haveno•employees These snb-contxactorshave 8. Demolition workers'comp.insurance, g• Building addition working forme in any capacity. ❑ [No workers'comp.insurance S. ❑We are a corporation and its I0.0 Electrical repairs or additions requixed.� officers have exereised.their g.E] X am a homeowxter doing allwork right of exemption per1VSGL1..[(1'lumbing repairs or additions Myself [.IVoworkers'comp. c.152,§1(4),andwehaveno 12,PRoofxepairs insurancexe ed. i employees.[No workers' 1g•[]Otfier a comp,insurancerequired•] . w applicantthac checks box Of must also fiitovithesection belowshowingtheir workers'compeusationpoHcy information. i Homeowners who submitita aWdavitlndicatiugthey 2're doing allworlVandthen hire outside contractors must submit a new affidavit indicafiisg such. ?'Contractors that checkflus box Must attached Vin.adMcnal shoot showing the name of the sub-contractors andtfiekworkers'comp.policy information. arY�carr ernptayeN that ispovirlirig IorXfeYs'cornperisation irisaarariceforYray employee Below is t�iepalicy anrlrob site j— htsurance Cornp4nyl`1ame; Policy#or se7 3nsXG.#: ExpirationDate: lob Site Address- AP /� City/State/Z7p: AA.ffa.ch,a copy of tyre worken,compensation-policy declaration page(showing ffie policy numher and expiratzon crate). Failure to secure coverage as required.under Section 25.A,of MGL o.152 can lead to the imposition of eriminalponalties of a fine up to$1,50 O.f)0and/or one-yeaC umprisoxnnent�as well as civilpenalties in the form.of a STOP WORK ORDER.and a time ofup to$250.00 a day agaiustthe violator: Be advised that a copy of this statem.entmaybe foxwardedto the Office of- Investigations o£tlte DTA for" anc coverage verification. rlo Xiereby eert zoic erg tli tains art penalties of perfury treat the informationprovided above is ft�ue antieorr~ect, - Signature: Date: l Phone#: $— offlcial use only. IDo riot write in this area,lobe coxrrpleted by city or town ofcial: City or Town: PermItMeense# Dsuing.Antftorify(circle bne): I.Board ofl teaIth 2.BuilclingXDepartment 3.CityMown Clerk 4.ElectAcalxnspector 5.PXumbbighspector d.Other ad Instr Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for tTi.eir employees. Pursuant to this sfatrite,an e�2proyee is defined as"...ever person iii fhe service o£another under any contract of hire, express oximplied,oral orwxitten." An eWfoyeiis deffned as"an.individual,parfnersbip,association,corporation or other legal entity,ox anytwo oxmoxe• oftbe foregoing engaged in a7oint enteipxise,and includingthe Iegalxepxesentatives ofa deceasedemplQyex,.orthe receiver oxtrusfee ofan individual,pattnexship,association ox ofher legal entity,employing employees, Sowever the owner of a dwelliughousellavingnotmoxethmfteo apartments and-who xesides therein,oxth,e occupant of Me dwelling house of another who employs persons to do maintenance,constmetionn,orrepair work on such.dwelling house or onthegrounds oxbuilding appuxtenantthereto shallnotbeemse of such employmentbe deemedto be an employe." MGL chapter 152,§25C(6)also states that"every state or local lleensfng agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings M the commonwealih fox any applicant'who has not pro duced-acceptable evidence of complianceWith the insuraazce coverage return ed;' Additionally,MGL chapter 152,§25C(7)states `Neitherthe eommonwealthnor any of its political subdivisions shall enter into any confract for the performance ofpublie workuntil aecepfable evidence of compliance with the insurance requirement ofthis chapter have bemu pxesentedta the contracting authority." Applicants. Please fitl out the woxScexs'comp onsa$on affidavit completely,by checking tlae boxes that apply to your situation and,if iieeegsaty,supply sab-contractox(s)name(s),addtess(es)andphonenumber(s)alongwiththeir certificate(s)of Insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LM)with no employees other than the, members oxpartaexs,axenotrequiredto can7workers'compensationinsurance. IfanLLC orLLP doeshave employees,al?olicyis xequixed. Be advisedthat-M affidavitmay be submittedto theDepartm.ent of Iudustrial Accidents fox confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should b e xe,tumdcdto the city or town.that the application fox thepemut or license is being requested,riot the Dqpaxtment of 1ndmtrzal Accidents. Shouldyou have any questions xugaxding the law or if yott are xeq*od to obtain,a Woxkexs' comp ensationpolicy,please call the Department atthenumber listedbelow. Selfinsuxedcompaniesshoutdenierttteir self"insurance license number on aa ppxopriato lice. City or Town,Officials Pleasebosurat ' hatthe affidavz�Lzs complete andpxinted legibly. The Department has provided a space atthe bottom ofthe aiEdavitforyoutoftll outinthe eventthe Office off- vestigatlonshasto contactyouxegardhgtho applicant Please be-sure to fill,luthe peamif/$cense number w1dob.will be used as a reference number, In addition,an applicant thatr6st submitmultiple pmMt/license applications in,any givenyear,need only submit one affidavit indicating cutxent p olicy xnfoxmation(i rfnecessary)and under"To b Site Address"the applicant should wxite"all locations in (city ax towir.".A:co r oftlie a� a th py d vz� athasbeeno,�xxciallysfampedoxmarkedbythecityoxtow.nmaybepxovidedtome applicant as pzoofthat a valid affidavit is an file fox fatuxe p ermits or licenses. Anew aifidavitmtist h e filled out each year.Where ahome owner or citizen is obtaining a license oxpennitnotrelatedto anybusiness orcomm ercialventure (i.e.a dog license orpeimit to burn leaves eta)said person is NOT xequixed to complete this afddavif. The Office of]nvesggationg would like to thank you in advance for your cooperation and should you have any questions, please do not hwAdfe to give us a call. The Depat-tm,ent's address,telephone aitd fax number. CQxr W. .-ealth ofMWgq cTiU PIt� DQIP-axtmunt QMduatxzal Accident,, (MOO off-weft aaVoxta 690 Waddhgm S xe maw" 02111 TCq, 61M-27-49,40 W406 Qx 1'-877- M _ Revised 5-26-OS Fax#617"M-7749 ' vw�.a�s,�Q•v�c�a