HomeMy WebLinkAboutBuilding Permit #74 - 111 PEMBROOK ROAD 7/30/2008 BUILDING PERMIT o`NORTIytt,bo 06790
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
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Permit.NO: Date Received
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Date Issued:
IMPORTANT:Applicant must complete all it on this page
LtOCATION �� i<�� TTS,
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PROPERTYn6Y-A'Iiff
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-:M -'NO: =PARCEL: ZONING DISTRICT His#ocic.D stnct'.a des
q :Machine Shop Village yep,, Amo
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
New Building One family C/
Addition Two or more family Industrial
Alteration No. of units: Commercial
Repair, replacement Assessory Bldg Others:
Demolition oton Other
:'peptic Well `$ Floodplain
WWetlands P. 1Natershed Distrrct
zm _
ater/Sewed: ti _ _
DESCRIPTION OF WORK TO BE PREFORMED:
Zlfln 6 - f'r t
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
Address:
CONTR TRACTOR, Narne �t/ % x /l7 :Phor e: 1 �
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71
Address
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.Supervisor's C6hstruction'.License; ,rte ` Exp, Da#e::.
Ho elm.proveMent'License. ,`3 �ql li p. 'Date-
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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: $ FEE: $ �1
Check No.: 2— Receipt No.: 3(,g
NOTE: Persons contracting with unregistered contractors do not have ac s 9 t e i ty fund
W nature of Aden:– wnere. � k_ Signature ofTcontract r �£
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Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
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
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
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COMMENTS
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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
"1RE'.,DEPARTMENT -7empwDuinpster on site _ yes C a .,
Located at'1.24 Main"S Leet
1ire0epartrient s�.ignalurelte T
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RCOMME�IT,S
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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
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❑ Notified for pickup - Date
Doc.Building Permit Revised 2008
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
i 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2008
1
Location
No. Date
�aRTM TOWN OF NORTH ANDOVER
f 9
3
Certificate of Occupancy $
b+..
CMUsE<t' Building/Frame Permit Fee
Foundation Permit Fee $ {
Other Permit Fee $
TOTAL $ t
ill
Check #
2
369 v Building Inspector
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FORTH
Tovm of Andover,
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No•
LAKE o dover, Mass. - 3O • y�
�J COCHICMEwICK y^
RATED i' �� ._
BOARD OF HEALTH
PERMIT T D - Food/Kitchen
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Septic System
BUILDING .INSPECTOR
THIS CERTIFIES THAT............... 4. /).
Q..L/���L-................. e7..A.................................................................... Foundation
has permission to erect. ..................................... buildings on ..///.... 4.r .......�`7ri�...:................ Rough
.. .7 — a y
to be occupied as — Chimney
provided that the person accepting this permit shall in every respect conform to the terms of the application-on file 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 CONSTRJ ONT Rough
Service
...... ................................................... ._ ..........
BUILDING 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 Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
SEE REVERSE SIDE Smoke Det.
*
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PUBLIC HEALTH DEPARTMENT
Community Development Division
NORTH ANDOVER BOARD OF HEALTH
- ORDA LETTER
UNFIT FOR HUMAN HABITATION
Issued under the provisions of the State Sanitary Code, Chapter II, Minimum Standards of
Fitness for Human Habitation, 105 CMR 4H.000.
Date: June 1.2, 2008
To Owner of Record: �loperty Location:
Louise Conte (11 Pembrook Road
111 Pembrook Road VOrth Andover, MA 01845
North Andover, MA 01845
An authorized inspection was made of your zy at the above referenced address by North
Andover Health Department personnel and r ►apartment of Public Health on June 12, 2008.
re!
This inspection revealed violations of certain, ai
as listed on the attached Violation Form. Yore alations of the State Sanitary Code, Chapter.II,
p hereby ORDERED to correct these violations
' and to refrain from living in the dwelling or ur.
approval. Failure to comply may result in furlheion thereof until the board of health gives its
action by the North Andover Board of Health.
You have the right to request a hearing before the BL
be modified or withdrawn. A request for said heanng,d of Health if you feel this order should gust be made in writing and received by
the Heath Department within seven (7)days from the
will be given an opportunity to be heard and to present eeipt of this order. At said hearing you
to why this order should be modified or withdrawn. Artnesses and documentary evidence as
date, time and place of the hearing and of their right to
affected parties will be informed of the
the matter to be heard. You may be re resen '.,' ,spect and copy all records concerning
y P ��_. Yan
F_ - t4omeg,_ You heti 4 the ri=ght to insptct
and obtain pies of all relevant records concernn theinatt
� er to be heard:
/�Su an Y. Sawyer, REHS�
Public Health Director
1600 Osgood Street,Northldover,Massachusetts 01845
Phone 978.688.9540 Fox 978.688.85 Web www.townofnorthandover.com
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An authorized inspection of 111 Pembrook:Ave was performed by Board of Health staff
on June 12, 2008 at which violations of 105 CMR 410.000 Chapter II of the State Sanitary
Code, Minimum Standards of Fitness for Human Habitation were found. Failure to
respond within the allotted time period may result in a Board of Health finding that the
dwelling is unfit for human habitation.
This premise is currently unfit for Human Habitation. According to the State
Sanitary Code 105 CMR 410.831 (D), 'T at any time the board of health determines in
writing that the danger to the life or health of the occupant is so immediate that no
delay may be permitted,then the board of health may immediately issue a finding
that an occupied dwelling or porfion thereof is unfit for human habitation without
providing the notification or hearing specified in 105 CMR 410.831:"
No portion of this dwelling shall be occupied without the prior written permission of
the board of health based upon the board's written finding that the dwelling or
portion thereof to be occupied is fit for human habitation. All violations listed below
must be corrected.
ORDER LETTER
Violation Rezulatory reference Re-inspection
1) Kitchen
a. Floors unclean, excessive cigarette bums, 410.500
in serious disrepair from old fire near stove
- Owner must maintain floors.All floors mud,, be easily cleanable
Replace kitchen floor
b. Cabinet next stove burned 410.500 g
- All surfaces must be cleanable
Repair or clean as needed
c. Ceiling and walls with excessive nicotine 410.500
staining and soiled
Ceilings and walls must be cleaned k1l
Clean or paint as needed i
2) All Three Bedrooms
410.500
a. Floors unsanitary; food,dirt,ashes, cigarettes soiled etc.
All rugs unsanitary, burnt and filthy
owner must keep floors in sanitary condition.
Dispose of all rugs trash and debris and clean and sanitize floors
b. mattress unsanitary,burned and filthy 410.500
owner must maintainremise in sanitary anita condition
Dispose of mattress
c. Walls and ceiling with excessive nicotine 410.500
staining and soiled
Ceilings and walls must be cleaned_
Clean or paint as needed
3) Living Room/Dining Room
a. Floors unsanitary; food, dirt,ashes cigarettes etc. 410.500
All rugs unsanitary,burnt and filthy
1600 Osgood Street,North AndoverMassachusetts
01845
Phone 978.688.9540 Fax 978.688.8416
Web www.townofnorthandover.
com
i
owner must keep floors in sanitary condition.
Dispose of all rugs trash and debris and clean and sanitize floors
b. Wood Furniture with food and cigarette debris.Unsanitary 410.500
- Owner must maintain premises in clean condition
Clean and sanitize all wood furniture
c. upholstered furniture all found soiled,filthy and with excessive burn holes
Chair with arm burn hole the size of a fist. 410.500
Owner must maintain a clean and sanitary premises '
4) . Electrical- Found no working lights. May be bulbs or system 410.351
a. Concerned the electrical system have been compromised
From the-fire dept.response.
owner must maintain electrical system in safe order
Have electrician certify that the electrical system has had no damage from the fire
And is in good working order inat is not a- snger to the occupants.
5) No smoke alarms or Carbon Monoxide detectors observed 410.482
Owners shall provide and maintain in operable condition
smoke detectors and carbon monoxide alarms in every dwelling
that is required to be equipped with them
Consult with the Fire Dept and install detectors and alarms as recommended
6) Bathroom
a. Bath fixtures all unsanitary
-owner must maintain in a sanitary.condition 410.500
Clean all fixtures;tub,sink,toilet(ensure th:,, all work properly and repair if needed
b. Floors unclean
- Owner must maintain floors
Clean and or replace floor as needed
7) Throughout home piles of soiled clothing,trash and debris were found 410.602(B)
The occupant of any dwelling unit shall;,r,responsible for maintaining it a clean and sanitary condition
and free of'garNage,"rubbish, oehcr filth .:c casuse of sickness
Dispose of all trash and.garbage and deb s.Sanitize.
4
The above mentioned items all contribute to an odor problem. Throughout the dwelling there
was a strong,stench of old food, tobacco, burnt materials, urine etc. Once all damaged materials
are removed, all surfaces should be cleaned and sanitized.
Please submit a plan of action for the correction of these violations along with signed`contracts
of for any work that is to be conducted as well as the completion report. It is recommended that a
professional cleaning company be contracted as this dwelling is in a highly unsanitary condition.
1600 Osgood Street,North Andover;:Massachusetts 01845
Phone 978.688.9540 fax 978.688.8476 Web www.townofnorthandover.com
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Board of$adding egulatlons and Standard F
HOME IMPROVEMENT CONTRACTOR _
Registration 1 3951
expiration `51/2009 Tr# 12851
7 I
ype: IndiV illdual
j Ernest Piccirillo ' Yr rt;r' f
Ernest Piccirillo
14 Hampton St
Methuen MA Q1844 Administrit6ir
ofki Ming, a ionlan
i F I U Construction Supervisor License
License: CS 718 i
Expiration 12/10/2009 Tr# 8836
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strict on, OO.k i
ERNE ST PICCIRILLO
� 14 HAMPTON ST
METHN,MA01944` Commissioner p
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The Commonwealth of Massachusetts
c I Department of Industrial Accidents
V13�f i � .
,,L ; . Office of Investigations
NO, 600 Washington Street
- Boston, MA 02111
iw www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): �CC
Address:—,/-//
City/State/Zip:/1!1/SSS O47 V 5�- Phone #: ��� GSS^ 44'
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑ New construction
employees(full and/or part-time).* have hired the sub-contractors
2I am a sole proprietor or partner- listed on the attached sheet. $ 7. E] 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 I0.❑ Electrical repairs or additions
3.F_1I am a homeowner doing all work right of exemption per MGL ILEI.❑ 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'
comp. insurance required.] 13.0 Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
+homeowners who submit.titis aff idavii indicating they are suing all work aild 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. Lic.9: Expiration Date:
Job Site Address:ILI /ice i,-, �C-- 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 do her by certify under the ins penalties ofp fury that the information provided above is true and correct.
St ature: Date:
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#:
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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 definedi 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 dweliing 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.-LL-Cor 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 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 02111
Tel. # 617-7274900 ext 406 or 1-877-MASSAFE
F Fax# 617-727-7749
Revised 5-26-05
www.mass.g ov/dia
