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Home My WebLink AboutBuilding Permit #0784-2017 - 109 MAIN STREET 2/16/2017 I -a'111 AAA44i Lt- TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received 4 Permit NO: 7`-- Date Issued: L14PORTANT:Applicant must complete all items on this page LOCATION FFint;77 PROPERT�Y9®VI/NER: Me, _ 100�YearjOld!StVc*4rW . lyes: 'rio-' MAP NO',_ 'PARCEL ZONINGIDISTRICT:: Historic,jD.istncf yes no Mai iNpPViilage 'yes. nb TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ' ❑ One family ❑Addition ❑Two or more family ❑ Industrial IKAlteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic- g Well -19 Floodplain Wetlands. '. .0 Watershed District. : fJ Water/Sew_ _er: DESCRIPTION OF WORK TO BE PERFORMED: Me Identification Please Type or Print Clearly) OWNER: Name: mic'Ae"e J LdMCZY,i,a. Phone: 617F - P�o9 7? Add re g &n r� �T��C T �v�p aC- _ CTOR Name _ ieic� �` j? _ ten__. c Pho:ne � -OR- c2?— Ai _ �r / J dd ess: AvP. . r«f Al 1__ . T_-_.0G., 1. _ Supervisor's Corstructiori _.. •Home Impwrovement License Exp: 'Dafe ARCHITECT/ENGINEER Phone: ; Address: 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: $ C�J, 3 c? `5 `�� FEE: $ Check No.: �i- Receipt No.: NOTE: Persons contracting with unfegishered contractors do not have access to the guaranty fund g "nafure:of.Age Ovinetature;;of:.coIn ractor Plans Submitted �Pla s aived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE-OF-SEWERAGE DISPOSAL Public Sewer ❑ Swimming pools ❑ Tanning/MassageBody Art ❑�. 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 & EVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Si nature COMMENTS HEALTH Review on Signature COMMENTS Zoning Board of Appeals:Varian e, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature� Date Driveway Permit DPW Towz Engineer: Signature: Located 384 Osgood Street FIRE:DEPA'TMENT - Temp Dumpster on site yes no Located at-124 Mair.,Street Fire Departmer'it signatur&1date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions_ Total land area, sq. ft.: ELECTRICAL: Movement of Deter 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.$10041000 fine NOTES and DATA= (For department use lam/ El Notified for pickup - Date Doo.Building Permit Revised 2010 Building Department Tine fol[owing 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 ❑ Fioor/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 DOTE: 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 TOTE: 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; apn-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must bc- submAted with the building application Doc: Doc.Builiding permit Revised 2012 Location l� ``� �7' No. O-R4 7--06z- Date &Z • - TOWN OF NORTH ANDOVER u Certificate of Occupancy Building/Frame Permit Fee $ Foundation Permit Fee $ -- Other Permit Fee $ TOTAL $� Check# z� v Building Ins ector� L I � Enter construction cost for fee cal - North Andover Fee Calculation � Construction Cost $ 225323.00 m $ - $ 267.88 Plumbing Fee $ 33.48 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 33.48 Total fees collected $ 434.85 109 Main street 784-2017 on 2/16/2017 new seating i NORTH Town of 1.. a ndover O ...,_ 0 No. Z oh ver, Mass, O Z / COCNI[Nlw1CR 1' 1 7,9 q°R�rEo ►'P�\,��5 S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ..... ... ..R.� .`.. . ... .77P0010BUILDING INSPECTOR .... .... .......00, ......................... Foundation has permission to erect .......................... buildings on ....&.. .....�...��, ..o.. ....f ............... Rough to be occupied as . .. .. ....�i .1.� .. . .. .� */�.... chimne provided that the person accept' t is permit shall in every respect conform to the terms of the application Fin 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 CONSTRU IO4S1ARW,AT Rough ervice .............. Final BUILDING INSPECT 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. zi ---------- -r ( 00 00 r a ® . Z ----------- --- -- w u,+ - -- �; ! w r � i I I NEW ENGLAND FLOOR PIAN —#xxxx—ie SEATING BOSTON C H OWDA OPnON #' '02/08/2017 138 HAVEN ST. NORTH ANDOVER, MA NEW HAVEN, CT (203) 778-1118 Al _........................................................................ The Commonwealth of Hassachusetts Department ofkdusialAccidents M r 1 Congress Street,Sulte 100 1YXA 02114--2017 - Boston, c wrww mass gov/dia •a-iM SJyy4 wgvkers'Comp ensationbsuraxi-ce.A.ftidavit:Brdtdarrs/COAUTSOItT�X�cians/�lumbers. TO BE M �HTHE PEI Please Frit L "bl ApWicautwomation, e galmaton/Indivi&al): Ci► rlW l �rYl n Name(Basin ss/Oz . Address: o 1.2 aim �S'7L�t e te1Zi �O �n coo vP Phone �-- CitylSta P: ...< .. : Axe you an empIoper?Cb ecic tha appropriate box: Type of project(xequire�' o ees full and/or part-time)-' 7. ❑NSW`cocoon ,.[?r . I am a employer with_em tP y 2.E]I am a sole proprietor or partnership andhave no employees Working forme in 8. Remo de* any capacity.IND-Workers'comp.insurance regmred.] 9. ❑Demolition In I am ahomeowner doing myself.[Noworkers' o ancere d]' 10❑Building addition �d e co o f y operty. Iwi11 4.Q I am a g I1.❑Electrical repairs or additions ensure that all contrac}bi s e have s compensation insurance or e sole �'n:PibYlig repairs or additions proprietors witb-no employee. 5_n I am a general coutiactox aad Ihave hiredthe sob-contractors listed ontbe attached sheet 13•.[]Rb61-repairs These sub-contractors have employees andhaveworkers'comp.insurance.; 14.M Other e ereisediheir right cfexemption per MGL c. . a c oration and its,oif1ceshaPe x � _ 6. Vri e are orp insurance re 'ed] ❑152,§1(4),andyvehavanoemployees_[Noworkeis comp. 4� hcantthat checks hbic#1 most also fill out sectioubelovr showingtheirworkers'compensation policy mfomzation:' aPP are doing 8I1 work andthenhire outside contractors must submit a new affidavit mdica5ng such. T Homeowners who=u mit this affidavit indicatingthey g tConiractors that check this bii must attached as additioshe it weoname rkers'oomp.policy nnmbt��d state whether ornotfhose enfiiies ave employees. If the sub-con tractors have employees,they p worlters'comp ensation insur•ancefor•my employees Below is thepolicy arzdjobsite 'd' X am an em ployer•that is prova zng information. Insurance Company Name: ExpirationDate' Policy#or Self ins.Lic.#:. City/State/Zip: lob Site Address: Attach a copy of the workers' compensation p oliey declaration p age(sltowzng the policy number and expiration date). Failure to secure coverage as required under MGL c_152,§25A is a criminal vi'olatton'punishable by a tine up to$1,5 00.00 and/or one-year imprisonment;as well as civil penalties inthe form of a STOP WORK ORDER atld a$ne ofup to $250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for h3BUranoe coverage verification. X do hereby certify zzrzder tliepains andp Zties ofperjury that the informadon provided above is true and correct: , Date: l3 Si afore: `7 Phone#: -7 $ D official use only. Do riotwrite in this area,to lie completed by city or town official. • Perznit/License# City or Town: Issuing.A.nthority(circle one): ector 1.Board of ff eal-th. 2.Building Department 3.CitylTovvn Clerk d•.Electrical Xnspector 5.Plumbing 6.other Phone#- Contact Person• 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 ermipZoyen is d'eiined 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 receiv6for trustdd cif an individual,partnership,association or other legal entity,employing empl6yees..However the owner of a dwelling house having not more than three apartments and who resides therein,or the o ccu-pant 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"eveiT state or local licensing agency shall withhold the issuance or ,renewal of a license or permit to op erate a business or to construct buildings in the comm onwealth for any applicaAtwRd has not produced-acceptable evidence of compuancewith the insurance coverage regiz ed." 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 7n curaa ce 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-'contractox(s)name(s),address(es)andphonenumber(s)along with their certifcate(s)of insurance. Limited-Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are notxequired 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 ofinsurance 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 onthe appropriate line. City or Town Officials PIease 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 PORGY information(if necessary)and under"Tob Site Address"the applicant should write•"a11 locations i a (city or town)"A copy of the affidavit that has b eon officially stamp ed or marked by the city or town may b e 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 Department's address,telephone and fax number_ The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.#617.727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia