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HomeMy WebLinkAboutBuilding Permit #758-13 - 1075 SALEM STREET 5/14/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: y / Date Received Date Issued: 6 -( Y—LJ IMPORTANT: Applicant must complete all items on this page s '( ( `7 SP:L. M S�t' AD�y SPA C39�45 4�aS. - a - - -- - Panty PROPERTVOWNER - MsS BEET S (�SGH , MIT 511� G -i 9--x. Print+ 1003Year d StruetureryT -y yes, no MAP1'NQ`-1O6.A,FARC.EL C�2S9 ZONING�DI$jTRIG : 1ZZ Histone Dlstncti es; no =_ Maching Shop;Vlllage: yes no_ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 56 One family ❑Addition ❑Two or more family ❑ Industrial X Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septics ❑Welli 'Floodplaln ❑Wetland`s ❑. WatershedDistrietf . E*,Water/S;ewer, _ DESCRIPTION OF WORK TO BE PERFORMED: F1 ti415HA-t-J5-� BASEMEWT, EmEQGF_-NC,Y' ESCAPE- ,A147J RISC UE 1 L TO 8310 LEVEL ©S1= &- JOUGVA To GARP,GE 1--LOoR , 1N(DWESTERIQ WALL- .GRIZAGE �OOIZ OR- Identification RIdentification Please Type or Print Clearly) O BF-TWEEt�4 TWO GAP-p,C.E DoogS. OWNER: Name: M{s . GfF_TP\ Phone: 9-7E3- 88,6-46-G3 (C) Address: AQ�S f LM STREET CPTH A-t-ADoVEZ, gip, M;54S_— Z908 CONTRACTOR Name: _ _ Phone:. Supervisor=s;C,onstrucfion�Llcense.: _ ExP . Date: - - - -- HIO.rre,lm,provement License_: EpD"ate 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: $ 110 b o. 0 0 FEE: $ 132. 00 Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund eSignature of,�Agent/®wner .q g aturerofwco--ft 'tor, Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ 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 o Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract o Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy, of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Crossection/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 o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o Mass check Energy Compliance Report o 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 app:al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm'Ated with the building application Doc: Doc.Buil Jing Permit Revised 2012 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Swimming Pools ❑ Tanning/MassageBodyArt ❑ 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 COMMENTS i HEALTH Reviewed on Signature rt COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes-.- Planning es ._Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit _ DPW Towz Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at'124 Main Street , Fire Departmerit.sig iatutbldate " COMMENTS on ®irnensi 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 Notified for pickup - Date 14 Doc.Building Permit Revised 2010 Location �a � 1 No. Date= l ti s TOWN OF NORTH ANDOVER C Certificate of Occupancy $ Building/Frame Permit Fee $� .....-- Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# 26386 Building Inspector Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $1 1:1000'.00 m $ - $ 132.00 Plumbing Fee $ 16.50 Gas Fee 100 comma $ 100.0.0 Electrical Fee $ 16.50 Total fees collected $ 265.00 1075 Salem Street 758-13 on 5/14/2013 Finish Basement NORTty own of No. 1 y5'_ t _ - ��K. h ver, Mass, �— I � . COCHIC"VMC.1 y1. x.95 RATED U BOARD OF HEALTH Food/Kitchen PERMIT T L D Septic System THIS CERTIFIES THAT.......... .....S � 4....... .......... . ...... ........... BUILDING INSPECTOR ..... .. ...... Foundation 'has permission to erect ........................... buildings on /. ......5�. ......�-.................. .. Rough to be occupied as &f-WV7V1 ReAM_, .. C y .......... ..... .............. ......+....... ..... ... .................:: Chimney provided that the person accepting this permit shall in every respect conform to the terms oPthe 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 S TS Rough Service ................................................................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — DQ 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. SEE REVERSE SIDE TOVN OF NORTH ANDOVER � b>'-��j °fi OFFICE OF BUILMG DEPARTMEN :••1600Osgood StmotBuUding20,-Suite 2-''36 , North Andover°Massachusetts 01845 SA�nus�. Gerald A.Brown Telephone(978)688-9545 Inspector of.Buildings - Fax (978)688-9542 . HOMEOWNERUCENSE EXEMPTION 13UMING PERMIT APPLICA'T'ION Please print DATE: 0 1.3 ' JOB LOCATION: 10-75S�LEt\t ST. Number Street Address 11-S Map/Lot IMMEOVMR(- E ETA SIN G H 88-12 8 617— 878—.6-715 Name Home Phone WorkMone PRESENT MAILING ADDRESS 107-S , S A L�P 1�A 5T R EET 'W3RTH MA ©184 — 490 Zip Code The current exemption for"•homeowners"was extended to(include owner-occupied dwellings to two units-or less and to allow Bubb ho?meoZ.iners to engage an in lividual•for hire who does not ossess a 7�'cense provided that the owneractsassup vsor). SlateBuilding (Code Section 108.3.5.1) • DEFINITION OFROME OWNER Pelson(s)who awns a parcel of land on which he/she resides or intends to reside, be,a one or two farrrily structures. A person who con which there is,or is intended to onstructs more that home in a two-yearperiod shall not be considered a homeowner. The undersigned"homeowner"assumes responsibility for compliances with the State Build' Applicable codes by-laws, mg Code and other y ws,rules andregulations, � The undersigned"homeowner"certifies that he/she understands the Town of Forth Andover Building Department minimum inspection procedures and requirements and that he/she will comply with,said procedures and requirements, HOMEOWNERS SIGNATURE Ljf� , APPROVAL OF BUJIDING OFFICIAL Revised 7.2009 Form Homeowners Exemption "30ARD OFAPPEALS 688-9541CONSERV r ATION 688-9530 HEALTH 688-9540 • PLANNING 688-9535 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA.02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Narne(Business/OrganizatiorAndividual): r 1E E T P, S Zt,4 C Address: 107-5 SAL Eft 5-MEET City/State/Zip: H• A,14 V /E R, 'M A 0484S Phone#: 9 7 8 — B'0,6-- 4 66-3 9a i Are you an employer?Check the appropriate box: Typo of project(required): L❑ I am a employer with 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.# �• 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 12.0 Roofrepairs insurance required.]t employees.[No workers' q ] 131J Other comp.insurance required.] !Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they sire 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:. Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: 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 Ido hereby cero under the pains and penalties ofperjury that the information provided above is true and correct. Signature: 6`k:,�- Date: 1 o M Ate( 2 013 Phone#• 978 688 C1'7- 870- 0`71 8 Cw) 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.PIumbing 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(ifnecessary)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 burn 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.0.21 It Tel,#61.7-727-4900 oxt 406 or 1-8777MASSA.k`B Revised 5-26-05 Fax##617-727-7749 www-mass,gov/dia -