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HomeMy WebLinkAboutBuilding Permit #623-2017 - 116 CROSSBOW LANE 12/8/2016 BUILDING PERMIT 4.,.,P. •fi. 8 TOWN OF NORTH ANDOVER '- APPLICATION FOR PLAN EXAMINATION Permit No#: " Date Received • • ~�;` RSSACFIU`�fi Date Issued: BUORTANT:A bcant must coin fete all items on this a e ~LOCATION• .I fr' C90.Z fiJ k19Allier - ,�Z.i STIe/ X19 PR®WRTY OWNER - - - - - Print ' O�+Year�Stnfeture ,+ ,yes` no PARCEL:; ZONING'DISTRICT:" is#oric DiStnet :yes no Machine Shoo Village:• yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential ❑New Building XOne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑Commercial Repair, replacement El Assessory Bldg ❑ Others: ❑Demolition ❑ Other ❑Septic ❑Well ❑Floodplain ❑Wetlai its El Watershed ©istrict ❑Water/sewer / DESCRIPTION OF WORK TO BE PERFORMED: _ !�C 60LACL ?WO J-V,6- W &2QQUA S: O IV I"ORC fl Identifiication- Please Type or Print Clearly' OWNER: Name: U,L1� S Phone:9S3`y,3 �o Address: 1 Contractor Name: Phone: Address: Supervisor's Construction•License:_. Exp. Date: Home Irnproygrneht License: Exp. Date:: ARCHITECT/ENGINEER Phone: w Address: Reg. tato. FEE SCHEDULE:BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COSTBASED ON$925.00 PER S.F. ,Total Project Cost: $ X00.0 D FEE: $ _� Check No.: l I Receipt Nod NO 1t'e>sorzs�eztracting with unregistered contractors do not havesaccess to the guaranty fund X < gn' �e 6f/1g�nt/Owi�er ' ��� Signature of coiitracfioi"? I OORTy t_ BUILDING PERMITtLED TOWN OF KORTH ANDOVER o APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received SSACHUS�� Date Issued: EM PORTANT:Applicant must complete all items on this page - �LOAA,TI®N1 ��/(o C/1oSSCU/� f1NL _ _ +x: i -- __ _ __ �... -- _ 1 (PR®PERdT�Y®WNER' V Z f L _y -AQA. _ __ __ , ,1 •�. ., - Pnnt� �(1DORYea Structure ~Eyes. - 'no h-MAP) 9PARCEL�- _. ZONINGjDISTRICT�y'_ � �tHistonc�Distnct�. yes� ,tno T ; �� 't= { "'~. Nlachine'Shop,�Village yews _no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building XOne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 0 Septic ' ii-Well" ❑ Floodplain D Wetlands ' ❑ Watershed Disfrict o.l-ater/Sewer. _ Y, ;k 3_: DESCRIPTION OF WORK TO BE PERFORMED: �C 0OZAL�. 7w�0 i-V,!5- W&Oow S A= s>ORm 0209 O tv i�o�ec t-f Identification- Please Type or Print Clearly' OWNER: NameZU,_/E Phone:9��-��3''y3S(o Address: .Contractor Name: Phorie: - -•, - .� _—� .; •.. w - _ .. _. -q. .yam'. •a.�T-•.�t•�':}�"t. -µ+�i+'...yy..w.-.� _. 'Address: `� ".r.�--- " vim-• __ . __',r.: _�- _ : -z r SupervisorsxConstructionlLicense .j , 7f-•*y 72. Homejl�mrovementJLicense + _ :�:;: Exp; Date 3 PL ARCHITECT/ENGINEER Phone.- Address: Reg. oto. FEE SCHEDULE.BULDING PERMIT. $92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. �_ ,Total Project Cost: $ dyVO.O D FEE: $ Check No.: Receipt No.,- NOTE: o.,NOTE: Persons contracting with unregistered contractors do not have.access to the guaranty fund Sigr%atue_of_Agent/Owner Signature of contractor : ': �,e.t��. � ^�'�-u�•,:-�:>.�'m+eml'.'_;C!,r,.�.k'r.���.^. ^+� s.;,.�'.�,�, .stN-as.-c�• -�I -, Location 'YC o 5 S t'5aw L ry No: lna - a's! Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ �) Foundation Permit Fee $ Other Permit Fee $ TOTAL $ r Check# .4 ; f . / Building.inspector . Plans Submitted ❑ Plans Waived ❑ L-orti►ti✓d Plot Plan ❑ Stamped Plans ❑ TypF OF SEWERAGE DISPOSAL Public Sewer ❑ Tanuing/Massage/Body Art ❑ Swirnming 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 PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature r COMMENTS II Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date DrivewaV 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 limension 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.$10041000 fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email ate Time Contact Name Doc.Building Permit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. r 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/Cross Section/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 o f' Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products 40TE: 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 Doe:Building Permit Revised 2014 h t%O Til E � ve" 'o No. Z 3_ , -� _ ..K. h ver, Mass, A = . A- coc Nlc Kl WlcK V� 7�A�'�ATEO 0"' S U BOARD OF HEALTH PERMI .T LD Food/Kitchen Septic System THIS CERTIFIES THAT ...... ..0 M �. .. .� ......... BUILDING INSPECTOR Foundation has permission to erect ..................... .... buildings on`......11 .......C.0.01S. .�........N' Rough u h to be occupied as . ..... � li........"'f}C.:�[t .�. '........ �..I .................................... chimney provided that the person accepting this permit shall 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 nA y MONTHS Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION S S Rough .... Service ................... .. ....... ....W.... ................. Final BUILDING INSPECTOR 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. NORTy . TOWN OF NORTH ANDOVER OE - �,? OFFICE OF 0 0 ' L % BUILDING DEPARTMENT .,a* 120 Main Street North Andover,Massachusetts 01845 SC _ Donald Belanger Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION Building Permit Application Please print DATE: a JOB LOCATION: ✓I RpSS6GU �- N� Number Street Address Map/Lot HOMEOWNER ( L 8-S 3 y� �o Name Home Phone Work Phone 4 PRESENT MAILING ADDRESS g CAIIL (�C Le9 N� To `C q �02� c City Town State Zip Code The current exemption for"homeowners"was extended to include owner occupied dwellings of one or two family dwellings and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be, a one-or.two-family dwelling,,attached or..detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner. (780 CMR Section I IO.R5.1.2) The undersigned"homeowner"assumes responsibility for compliance with State Building Code and other applicable codes,by-laws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Department = minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 9/16 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 1. (ltw � � t 'TO11 ;ti orr oid7i ANDOVER z OFFXF�OF' BUILDING 6EPARWENT" a 120 Stain Saw 1 fax, ' •�ntxdi�[qtr a� lieatioo,'�'i. -.. 1i�1(,f,�''1�'1t➢�`:' /lei .` � �� ,�'`�, �` � � d IfO!►tEi7iA tl�cl#ti;? 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Eastern Standard Time From: iulieestrada(a)-comcast.net To: GStankie(cD_aol.com George, Here is the signed permit. Let me know if you need anything else. 1 dont have a scanner so I had to take a picture of my signed copy. Thanks, Julie On December 5, 2016 at 5:30 PM GStankie@aol.com wrote: Forgot to send the attachment Monday, December 05, 2016 AOL: GStankie .Z' ♦� __ ` _ Ae Commonw•e4h gf9&0chusetts Depwtfnet ofIrtdusf rWAcci 1mts I Congpess street,SzWf i 100 " - b Boston,HA 02114-2017 www.Pd msgory1&a YyPQ kens' G:9ComPensaxUB�laoiaxnmWmc6AfEdavitsBmlderls Onixacfox8/ lccia�cxans/�'1 extis,,.UTSOZ2T�'Y D WxTSTk �'Y2NATLN • .- _ _ :fleas® i - g 7� •-ol ��caut�ormaiaon ,p I y ' - Address �� ��:�l��i� ,urs � - s � s city/state, 1i . Phone# 3 , . 'AAreyou an ewpIoper?G'he die aBpropriata box: Type of project( eQun e 1.[]ram aemployerwith cmplaYee?(fiiIland/orpacwtiuna):� 7- N&`corrstaiicl30ias 2.QYamttsola ot*rorpartnessh�paridhav03W04l4Yees`ijp .formoin 8. []REIItadeliix PmP ... mm m uued] cq o-M'&zs'..comp msurnn 9. ❑Demolition auY,... �4 IN _ 3.[]Y am ahomeowaer doingallworlcmysel£[Novi6s comp:wSuoncoiequurd] 10[]Btu-ldiag addi#on_ alxovico*nar andwM by firing eonttectars to;oondnct all wo on my Pr�p S' TwIII cal r § ar ditiops e havovmrioera'compensnhan msurnaoa or aro solo_ ( � _., � t ensurotiiat all coatzu re or 8.dditiolag propidefinayrhhno�l�}�ye� ZQ_ $ P ' bottlieciors isintloritbc atfao3zed sheet • Itoff _•eai� 5.[]I�agcnoml coukg�9.�; ;Xbilediho cub _ ; 13:0.. - - I eos andbmwlI email ma=ummeo. Thesasnb-conttecbgrslmv� p oY _.- 14. and xtgoSicon;have w= isadihou iglu of tote PtianPor MQ.c. 6.pwa ; onflCOMP:; a STD. o Oql por hon: ° epP �Y?katchoasbf�#Y�e1s�lfillotrtttwseahonbolawshowmg. oi ��Y4IIlBOw1IC4891110snbmibttvsai�iatmltindicanngthayam omgallVIC'. thenhueoufsidoao rao`.ozsmustsnbinStanan�affdmatmdicetraa�sack.:. t('ontiiictcriiffiatcbeck$u Boi iliusfiittgcTa hn�nlditionslshcetsh6wingtbsmm�oo esaobcontract Viand,dutiswbethorofgotlhosap itjrsl�vo: , th iimsst ividetheir'�aodcers p p GY - . el'that 4s have emPloSi3 ey . ..p em�loyees..Iftheapb-comrs�ct _ _.._ rovidingwork0s'conTensadon irrsurarzce forTrey employees. below is thepol�uy and jani site I am an employ P inforPmadom Insurance Company Nalnio:' Policy#or Self-ins.Lic.#: __.,__•. _ ExpusfionDide,:. .._ Job Sife Address: C Istat - A tsicli;A co ' ho�volrkexs'conn ieipsstt►on poIxc ,dectaxR d1i p(skowiaag#izepolxcgnn er and( ixatxon date) . Pailure"to secuxe coverage as requnceduntivrMQL UP o ].52,§25.A:as a c�pnninalvuolaisonpumsTudilebya"ftti ...t"500 00 andlor om gem imprisonnoion ae wolf as crvil prnaltta3 xn the form of a s P W01tT ORDI attd a fin­-f oup#o $250;00 a ,andday against ea impis A-aop}�offlu§sfsinr entrriay:infirhardedtoihe,62 c©ofln c0ii*tonsoftb.®DIAlbr asMrano9 coverage verification. - I do;]sereby certify r er tliepaans fmdpersaliles ofPeduU that the inforrnadOn provided above is tare a td correct .:Dain -- - _ - : hon®. Official rase only. Do raottvrite in this area,to be completed by city or town officiaZ Permimcense#. City or Town: _ TssinngAvt7jdidty(circle one): � peector X.X3oaxcl af.I ealitu;2.Duildixtg Department 3.CRyJTown Clerk 4.Electizcal Insetor -S.Plumbing 6.Other RhoxContactx'exson: -. . - - ii The Commonwealth of Massachusetts Department oflndustrialAceldents X Congress Street, Suite 100 - d Boston,MA.02114-2017 q~ www.mass gov/dia Wo kers'ComipensationlusuranceAffidavit:BnildexslC��a�ORTTY.trrcians/�lumbexs. TO BE MED Yam THE PER pleasePrint Ledb l A '•licanf Information Name(Business/Oiga7vzaiionlIndividual): V �� Address: C Iq e�Ss&w I N �/� }J ��Y;2 # Phone#: 7� - 9 3 r 13s� City/State/Zip Type of project(required); Axe you an employer?(heck the appropriafe box: y 1. em to ees(full and/orpar-time).- 7. ❑Nem constriiotion I am a employer with P e c.- od lm• ❑ S. Rem g orme in rkin � 'tor or arfnerbipandhavenoemployeesWo g ❑ ole ro ne p 2.❑Iamas p P any capacity.[Novrorkers'comp.insurance required] j, ❑Demolition 3.❑I am a homeowner doing all work myself[No workers'comp.insurance required]' 10❑Building addition to conduct all work on my property. I will s Ot additions actors e _ be confr Electrical r_ ,aax' , d will. g I1. _ P er an , eown ❑ ahom 4. I am anon insurance or are sole 'compensation ensrn e that all contractors either have workers P 12.[]:Plumbing repairs or additions . proprietors with no empl6yees. 5.❑I am a general conizactor and I have hired the sub-contractors listed on the attached sheet. 13.❑Rbof Xe airs These sub-contractors have employees andhaveworkers'comp.insurance# 14. ]Odle /11��W-S (,•❑We are a corporation and its.of&&e1s have exercised their right of exemption per MGL c. inse required] � � S�D �O 152,§1(4),and vte have no employees.[No workers'comp. uranc a hcantthatchecksbbX#1 must alsofilloutthesectionbelowshowinghreirworkers'compensationpolicyinfomiation` Homeowneh�k����attach'ed an addition shegshowing the name of the sub-contractors and state wh ther or new nadavit fhose indicating have •Contractor rovidetheir workers'comp.pofieynumber .. ..__.. _ employees. Ifthe sub-coniiactors have employees,they must p - _ .: ; , X am an employer'that is p�'ovidzng7-vo�keNs'eompensc�tion insuxanee for°my employees. Below is the policy cznd�o�i site information. Ins rance Company Name: Expiration Date• Policy#or Self-ins.Lie.#:. City/State/Zip- Job Site Address: olicy declaration.page(shoving the policy number and expiration date)_ Attach a copy of the Workers' compensation p aixon punishable by a fine up to$I,SOO.QO Failure to secure coverage as required under MGL c.152,§25A is a criminal viol and/or one-year imprisonment,as well as civil penalties in the f to the Officrm of a STOP e O XnvOestig�°n s of the DIA for insuranco a day against the violator.A copy oftbis statement may be forwarded coverage verification. X do Hereby certify under tliepains andpenalties ofperjury tl"zat the information provided above is true arad correct Date: Si ature: Phone#: official use only- Do notwrite in this area,to he corlrcpleted by city or toren official. Permit/License# City or Town- Issuing Authority(circle one): p ector 1.Board of Health 2.Building Department 3.CitylTown Clerk 4.Electrical.has ector 5.Plumbing Insp 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 bite, 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 trastde cif 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 ado 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 applicafit who has not produced-acceptable evidence of compliance with the insurance coverage ieq'yjx"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 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 certificates)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 confrmbiion ofinsurance coverage. Also be sure to sign and date the afCzdavit. 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' compensatiori policy,please caJJ 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 thatthe affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to El 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 submit that must sub 't multiple erlit/lie nse 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 futureermits or licenses. A now w 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-AIASSAFE Fax#617•-727-7749 Revised 02-23-15 www.mass.gov/dza