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Home My WebLink AboutBuilding Permit #343-13 - 101 HERRICK ROAD 10/10/2013 L TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: l Date Received Date Issued: _L7 IMPORTANT: IMPORTANT:A licant must complete all items on this page LOCATION PROPERTY OWNER �� Cl int o%�-� Print 100 Year Old Structure yesCno MAP NO: i�0PARCEL: ZONING DISTRICT: _ Historic District yes Machine Shop Village yes 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: i ❑ Demolition ❑ Other ❑ Septic []Well ❑ Floodplain ❑Wetlands 0 Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification lease Type or Pri t arty)) OWNER: Name: LTe �� `�— /t3� Phone: Address: tl PleoeltCi a CONTRACTOR Name: I�De �� Phone: I �? Address. � � ..( C/ Supervisor's Construction License: �/ Exp. Date: _/ J Home Improvement License: / 35—8 � `�7 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: $ / 7t Fo o f, 06, FEE: $ �- Check No.: S0 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to t e aran �-��'�"`_• _� _ �- �� - � - � SJ =lature of contractor Signafure of Agent/Owner ,g ._. _. - ' Plans Submitted _Plans Waived ❑ Certified Plot Plan ❑ a ed Plans ❑ J Plans Submitted-[] Plans Waived ❑ .Certified Plot Plan ❑ Stamped Plans ❑ � _TI'PE OF'-:SEWERAGEDiSFOSA1; Public Sewer ❑ Tanning/Massage/BodyArt ❑ .. Swimming P001s ❑ Well El 0 . Tobacco.Sales E] Food Packaging/Sales ElPrivate(septic tank,etc.._ ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED: DATE.APPROVED f PLANNING& DEVELOPMENT ❑ ❑ i COMMENTS -CONSERVATION Reviewed on Signature I COMMENTS I HEALTH Reviewed on Si nature J COMMENTS !I � Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes i - I Planning Board Decision: Comments Conservation Decision: Comments Water & Sevier Connection's i nature Date Driveway Permit DPW To-ty : 1Engineer: Signature: Located 384 Osgood Street 'FIRE DEPARTM;E"NT -Temp Dumpster on.site yes no 16cated-at-124 Main Street:-,- . -:Fire-0 pa ure/daft' 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 21A-F and G min.$100-$1000.fine NOTES and DATA— For department use 0 Notified for pickup - Date t Doc.Building Permit Revised 2010 Building Department The foEswing is'a list of the required-forms to be filled out for the appropriate.permit to be obtained. Roofhig, 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) i ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit i ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract j ❑ 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 cans if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apo,-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submated with the building application Doe: Doc.Building Permit Revised 2012 ' ( cL - Location � Date f l • • TOWN OF NORTH ANDOVER . _ Certificate of Occupancy $ I Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# Building Inspector NORTH Town of . t : �T ndover No. Am ;3 = - ot^. h , ver, Mass, �C �oID. 261 C"Ic"tw.CK 1. p0RATE0 S V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT� ..A... 5.. . �Z � ,,,,,,,,,, BUILDING INSPECTOR . ...... .... 4 has permission to erect ............. buildings on ...11.6.1....... .... Foundation � Rough tobe occupied as ...�. .. 5.a\.....y. ..... ............l.M.:..................................................... Chimney provided that the person acce ting this permit sf�AI 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 CONSTRUCT ST TS Rough �! Service ............. .. ..... .... ...................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Fina` No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE Massachusetts-Departmim ent of Public Safety Board of Building Regulations and Standards Construction Supervisor CS-090414 License -trs LARRY J LEBI'�ANC� PO BOX 538S r, BRADFORD�" 1835 !�� r it Expiration COMmissioner 0112812014 c �ear�a�na�ccueu�t�o'C��crQocrc%u4efla Office of Consumer Affairs&Busidess Regulation ME IMPROVEMENT CONTRACTOR Type: eg istration: 135829 Individual a xpiration: 5/14/2014 ,.r LARRY LEBLANC LARRY LEBLANC 33 MEDITATION LANE g�= � ATKINSON,MA 03811 Undersecretary I I N:41401 • Page No. P.O. Loll,,5339 BRA0i:0,R[; 0,91S5 PROPOSAL SUBMITTED T)(:r- 4eDAT7 Ne 00 - 'ov JOB NAME /411 rCJTY,ST Ad Z JOB LOCATION ARCHITECT DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for: 00, el C? V0 We Propose hereby to sh material d bor com to in or ce with above specifications, for the sum of: 7, Ant to be made as o lows. dollars(S A11 ma(.rial is guaranteed to be as specified. All wok to be COMPIE manner according to standard practices. Any alteration or deviation from above specAtions Authorized involving extra costs will be executed only upon written orders, and will become an extra Signature charge over and above the estimate. All agreements contingent upon strikes, accidents 0 delays beyond our control. Owner to carry fire, tornado and other necessary insurance. 0urr Note:T�s pro?pall may be workers are fully covered by Workman's Compensation Insurance. withdrew, wn by us if not a ep!ted within days. Acceptance of Proposal —The above prices,specifications and conditions are satisfactory and are hereby accepted.You are authorized to do the Signa ure �M,6 work as specified.Payment will be made as outlioed aboye. Date of Acceptance: Signature V The Commonwealth ofMassachusetts Department ofI'ndustriglAccidents Office of Investigations qu 600 Washington Street Boston,MA 02111 www.mass gov/dia 'workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Apylicant Information Please Print Le 'bl Name(Business/Org ' ation/Individual): �/� -r- 3 p� Address: City/State/Zip: 6 W)q J one#: 7��` Are you an employer?Check the appropriate box: Type of project(required): 4. ❑ I am a general contractor and I ' 1. a employer with �j g 6. E]New construction employees(full and/or part-time).* have liked the sub-contractors 2111 am a sole proprietor or partner- listed on the attached sheet.x 7. ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for mein,any capacity. workers'comp.insurance. 9. E]Building addition [No workers'comp.insurance 5. ElWe are a corporation and its required.] officers have exercised their 10.[]Electrical repairs or additions 3.El 1 am a homeowner doing all work right of exemption per MGL 11.[]Plumbing repairs or additions myself. [No workers'comp. c.152,§1(4),and we have no 12.❑Roofrepairs insurance required.] employees.[No workers'• comp.insurance required] 13.❑Other *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 anew affidavit indicating such. (Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name:. ' Policy#or Self-ins.Lie. Ex iration Date: ` Job Site Address- /G1T; f Attach a,copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert der t ai penalties ofpe lury Aat the information provided above is true and correct. - Si afore: Date: /z) 6 Phone#: t� 75 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 ffast °uct ®n's 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 j oint 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 ofits 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 maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage, Also be sure to sign and date the affidavit. T'he 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-completeandprinted legibly: The Deparfinerit 1�as provided a space at the botfoin 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. Anew affidavit must be filled out each year.Where a homeowner or citizen is obtaining a license or'-permit not related to any business or commercial venture (i.e.a dog license orpermit 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: Tho Gomozlweali ofM-assachimutts Dopaftent of Zndustdal,Accidents O face ofhavestigatio.m 600 Washingtoja Street Boston,MA,02111 T01,#617-72.7-4900 W406 ox 1-877,MASSAk`.F Revised 5-26-05 FaY,#617-727-7749