HomeMy WebLinkAboutBuilding Permit #202 - 102 LOST POND LANE 9/15/2009 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: goL Date Received
Date Issued: M14,01
IMPORTANT: Applicant must complete all items on this page
LOCATION 102 Los—L Pngr) L.1i
Print
PROPERTY OWNER C- 1`S_ . `-rET12Lk&A
Print
MAP NO: Z6 Vz PARCEL: Z/ ZONING DISTRICT: Historic District yes no
Machine Shop Village_ yes no
TYPE OF IMPROVEMENT PROPOSED USE
Resident'al Non- Residential
New Building Q,0ne family
Addition Two a family Industrial
AUara on No. of units: Commercial
Repair, eplacement Assessory Bldg Others:
Demolition Other
Septic Well ' Floodplain Wetlands Watershed District
Water/Seger
DESCRIPTION OF WORK TO BE PERFORMED:
ahAus knm�� 't kIt4 &Oa iib a�LT i
X40 ecsa W (/a oucs
Identification Please Type or Print Clearly)
OWNER: Name: e-`I7—Vi e&2,: Phone: q16661
Address: 1o2
CONTRACTOR Name: } MASlRM-41tFU Phone 0196 14 -"+2-
s
Address: - - - if-A — M01 tnu
Supervisor's Construction License: 5^ Exp. Date: 3 ~4 ,. 2OI b
Home Improvement License: 1 '+2t) , Exp. Date: 6" C
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BA/SED ON$125.00 PER S.F.
Total Project Cost: $ - FEE: $
Check No.: / ` Receipt No.: c
NOTE: Persons contracting with unregistered contractors do not have access to the g ra fund
5 nature of Ager-t/Owner = Signature of contractor
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
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
❑ 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: Doc.Building Permit Revised 2008
TYPE OF SEWERAGE DISPOSAL
Public Sewer 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
DATE REJECTED DATE APPROVED
PLANNING &DEVELOPMENT
COMMENTS
i
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Sianature
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
K
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 dro re uir
Electrical Inspector Yes p q es approval of
No
DANGER ZONE LITERATURE: Yes
MGL Chapter 166 Section 21A—F andG min.$100-$1000 fine NO
NOTES and DATA— For department use
i
i
i
❑ Notified for pickup - Date
............-_-.................._....................__...................__...............
Doc:-Building Permit Revised 2008
Location �V/
No. o-2, _ Date
NORTH TOWN OF NORTH ANDOVER
F s
• � , " Certificate of Occupancy $
„•
NUS Building/Frame Permit Fee $ `f
n1�
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
224' 14
building Inspector
✓ate 7�anvmo�.u�� n�'✓T�.atau,/use�a
Board of Building Regulations and Standards
I Construction SupervisorLicense
License: CS 57754
Expiration: 3/4/2010 Tr# 20207
Restriction 00
WILLIAM D HOPE
589 CHICKBRING RD REAR
N ANDOVER,MA 01845 Commissioner
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 101730
Expiration: 6/29/2010 Tr# 267903
Type: Private Corporation
HRH CONSTRUCTION INC.
William Hope
589 CHICKBRING RD.REAR C; ? Q.a�
N.ANDOVER,MA 01845 Administrator
r
NORTIy
Town of Andover
1 No. 2.,-d
2.
10,
co
ydover, Mass.,
lCHICHEWICK
ADRATED
`S BOARD OF HEALTH
PERM-IT T D , Food/Kitchen
Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT
Foundation
has permission to erect........................................ buildings on .............................. Rough
to be occupied as...................... . eiv� vcJ •'u`1... ...... Chimney
............ .................... .{'.:.................... .........!� ....
provided that the person accepting this permit shall in every respect conform to the terms of the application on.flle 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
ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION STARTS Rough
................ Service
BUI� 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 BeDone FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
SEE REVERSE SIDE Smoke Det.
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IF ARRANY 8;,A1�TK 3P CSSM
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. , b CoutmderArbitration.
The Home hupowunent Contractor Law provides homeowners with the right to mitiste an arbitration action(as an
altaaaiive to coot action)if ihey bave a.disputs v 0 s o The Sam dot ismantomaticalbY afftded to a
cur,however. no contractor would have to resolve any dispnoe hehtie lois wriWa homeovfr in court unless
MA parties agnea to the optional chose VOYtded belaw. Tbts clanse wwM give tLa'caat==the same right to
arbitration as is afforded to the bomeaww by the Home Improvemedr. Law.
;HWwaow
trcmc and the homeowner heseby wxgu fy�in advance that in the avant the eonUactor has a dispute
ing this centrad,the contractor may submit the dis ift do hpmrate arbkmflonr first whicfi Ins been approved
o dffY of the Bmcvd re06rce of Caostmter!►ffirassad Btttdo Regnlatran
and the cunsnmer shall be
to ' to ch provided inMaesachuseft:General Laws,=oe
s Signature a Srgoatmre
NOT'ICL.The s of the paries Ow"a] i l!�to#he.agramamt of the parties, altarawe dtaputa
rewbuiaa mitiaioed bq tau color• The homeowner OW initiate alternative reaolotiou oven where this
swim is not wrnftm y signed by tba pubes.
Homeowner's Rights ant COWM*or Law(MGL aha W 142A)and other consumer
A homeowners rights tinder the flame]impto'vem .
protxtion laws(i.e.MGL,ca 93A)torny sat ba waived in anq way,Brea by agruanart. However,homeowners
ce a' ' ir*e oo�rador tboy d oose is eat propmrly regsbaed as presW'bed by law.
meq be excluded from agb>s are h►mtcturded fiam all Guaranty Food provisionsof
Hnnueowners�irhasocurc their awn I Rwm .mg permits 'bic fee OWWWng the work�described.in a
she gone Ili ovomeait Cpnb'amr
aw.-The po or is responst
timely and�maturer Homeow els meq be codded to ache.speeiha 100 sigbb if AM OMMu for
gni or provides an acpaess warranty for Or rls•.Ta addition to .
provided by the ambadw.all Pods sold in cuY ED,�10d` �n rty and fit�ss .
for a particular pmposs. An emnnengon of other mantas on which*a homeowner and cooft,abor isq+f°uy agme nsY
be added do tetrms of tlu coTmrast as kfog as tbey do outs restrict a homwwwes basic met rights. If you have
question abotrt your oonvirmalhamaowaer rigb% the Consumer information Ike ')'
Baton of Contract
The fact meat be executed in duoucde and should not be sigOd until a copy of all efdubtss and reef+e umnd
docnmetrts have bei Parties ar per'a u�to sign the document umh'!all bW*sections tam been
filled in or ma W.as void,deleted,or not VPlicsbla,.One origioat siped cm of the eaartcad with attachmatts is too
be givma to the ouvner and the other kegrt try►
e conttacW- Any moMcad"to rise arigmalsonhact meet be in writing
of
and agreed to by both patties.Contras wore my na ice°mM.botiu i have m0givW a fnRy executed�P7►
the centrad,and the three day recisston period ba ezpned.
paym�ts Wed on due in cases where the
A contractor may not demand paymams in advance of the daces spat payment d=ens hb lbasetf
homeowner deems himlhem f to be financially Wsacmre. f kmw r,.in ins'es w z contractor .
m be fitrancralty nsax e.the comftador.nuY that flue balatttx of fw¬ yet dna be placed m a,pmt a mw
&==t as a prerequisite V oo�nning the contracted wore. Vdb&awal of f®ds from said account would requite the
signatures of both parties.
Additional Wormation
If you bave general.queations or need additional h on nation about the Home lmprovemeA Contractor Law or other
consumer rights,or if you wish m obtain a free copy of."A Consume Guide to the Home Improvement Contractor
Law."contact
- Consumer hui'ormation 1<idrt'me
Fatecutive Office of Consumer Affairs and Business Rqp t m
One Ashbuubn place,Ream•1411,Boston,MA 02100
(611)727.7780
If you wad to verify the registration of a contractor off you ham questions or dad MOW�n�On y
about the cootactw O&bmdop cOmPona�of d Roma I=FOvemeat C'Q`acaoc . •
DkedW of Homo lmpmvement Contractor R
Bureau of ftaftRbpbdm and Standards
Ona A*bmton place,Roam 1301,Boston,MA 02108_
(617)727200.ears 25205 -
For assistance with informal mediation of d'uspaft or to reOAW.formal complaints against a business,call:
Consumer Complaint Section
Office ofthe Attorney Oweual
(617)727-8400
The Commonwealth of Massachusetts
Ln Department of Industrial Accidents
rsg Office of Investigations
UT 600 Washington Street
Boston,MA 02111
www massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):
Address: (7
City/State/Zip: --K1Ma t4& M(344 Phone#: 01
Are ou an employer?Check the appropriate box: Type of project(required):
1. I am a employer with 2— 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers' comp.insurance. 9. ❑Building addition
[No workers' comp,insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ I 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.❑Roof repairs
insurance required.] t employees. [No workers' 13.ROther� OQS
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 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: fi W/4_ iSQA
Policy#or Self-ins.Lic.#: Expiration Date:_ 12-
F C1�1 �5
Job Site Address: 10
_.
LAA, City/State/Zip: 60—h4
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 un r the p s penalties of perjury that the information provided above is true and correct
Signature: Date: SI s+ 0�'
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#•
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-contractor(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 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
Fax#617-727-7749
Revised 5-26-OS www.mass.gov/dia