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Home My WebLink AboutBuilding Permit #66-11 - 117 PLEASANT STREET 7/15/2010 BUILDING PERMIT TOWN OF�N°ORTH ANDOVER c APPLICATION FOR PLAN EXAMINATION n b T Permit NO: Date Received q'q�T.o'�� SSACHUs�t Date Issued• ((fddd IMPORTANT:Applicant must complete all items on this page 1:QCATION .._ . , � 'Ca P.nnt_ - P C)PERTY L-0WNE!R g Fl P int s ` I Ae n = PARCEL ZONINGDJSTRICT �stonc C3istnct es ti w 3. Vlach�ne Shop Village es ;mii TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial Repair(,eplaceme Assessory Bldg Others: DemoI ti0 Other #ic; U1lell == Fio ttplair Wet#ands 111 ter`s ed D ste�ct Water�Sewer:. ! Aan-ic DESCRIPT�10IO OF,IVORK TC BEP ORP gp: f S f � P r(i //�� j ` -I B?DY Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: COIfiC`I"Olt ,Name� phone I �c Ii!t W is- Addr' ss.` .� Super isor's�C6r�struct on�Lacense :I -1 � I=xp: Daitea a Hcir»elrpprount license Date: . . w_ 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: $ , � y FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access Vtohguar my and i nature�of A` ent�Owner r ' 7777777Sgnature3of contractor 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 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.DEPA',TME:NT ernp Dumpster on slte es oa Located,at 124:MaantStreet,' _ r Fire De artmeints-ignatellate 4 GOMIIEfiITS � � 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 AA OVt i i ❑ Notified for pickup - Date 1 Doc.Building Permit Revised 2010 i Building. Department MµY ro 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. _1 ❑ 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 I New Construction (Single and Two Family) I� ❑ Building Permit Application ❑ Certified'-Proposed Plot Plan ❑ Photo of HJ.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 Li Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit f - 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 s Doc:Building Permit Revised 2008 i 3 Location No. Date d r NORT1y TOWN OF NORTH ANDOVER F • Op Certificate of Occupancy $ 7�s,ust. Building/Frame Permit Fee $ �. Foundation Permit Fee $ y— Other Permit Fee $ �TOTAL $ Check # � 23107 Building Inspector The ComMonwe"th of Afassachusetts Department o f£radustrial Accidents Office of£nvestigadons 600 Waslzinpon Street Bostorz, M4 02111 N'►+'W-rnassgov/dig Workers' Compensation Insurance An licant Information �clavi�: Builders/Contractors/Electricians/Plumbers Please Print Legibly Name (Business/O)rmnizat;on/individual): Address: City/State/Zip: �GVt Phone#:_It10 Are an employer?Check the appropriate boa: 1. I am a employer with 4. ❑ I am a a Type of project(required): employees(full and/or part-time). have general contractor and I 6. ❑New construction P fired the sub-contractors 2.❑ I am a sole proprietor or partner- lis on the attached sheet 1 7. ❑Remodeling ship and have no employees These sub-contractors have working for me in any capacity. workers coin . ' 8 ❑Demolition p insurance. [No workers'comp. insurance 5. ❑ We are a corporation and its 9. ❑Building addition 3.❑ required] officers hake exercised their 10 ❑Electrical I am a homeowner doing all work right of ex repairsor additions emption per MGL 11. Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4) and we have no ❑ insurance required.] t employees- � , 12.❑Roof [No workers �� Pomp.insurance required.] I3:❑ Other t aY appIfc,:at*5at chi box#it mus aso ii'r:cut the Section b_ioQ• homeowners wao submit this affidavit indicating they,are de --Vpnb aortas'comp.. —im p^z; r 'Contractors tb--t check this box�:•_,�;attached an additional saee€showing�a��,o de con*?nct t{. ;mit x new affidavit indicting such. the name of the sub-contractors and their workers'comp.policy,information. I o an employer that isproviding workers'compensation insurance for my employees Below is thepoficy and job site information. Insurance Company Name: P,o rvr�i v Irl-4n-C .� Policy#or Self-ins.Lic.#. Expiration Date: Job Site Address: I cto� j r ' �, 1 City/State/Z �r Attach a copy of the workers' compensation policy declarativn.page(showing �. 1�.J(9N Failure to secure coverage as required under Section 25A ofM wn�the Policy number.and expiration date). fine up to$1,500.00 and/or one-year imprisonment,as well Glc. 152 can lead to the imposition of criminal penalties of a of up to 5250.00 a day against the violator. Be advised that a co penalties m the form of a STOP WORK ORDER and a fine Investigations of the D for insurance coverage verification. this of this sta_ment may be forwarded to the Office of I do hereby certify u er the pains enalti So.fP er , that the information provided above is true and correct i�ature: Phone#: G !� Official use only. Do not write in this area, to be completedc , bJ,city or town official City or Town: I'ermit/License# Issi'ine Authority(circle one): L Board of Health 2.Build.inb Department 3. CitvlTown Clerk 4. Electrical Inspector 5.Piumbi>zg 6. Other b Inspector Contact Person: Phone. Information an d Instructions Massachusetts General Laws chapter 152 requires all employs 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,associ-axtion, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise,and including tie legal representatives of a deceased employer, or the receiver or trustee of an inaiviaual,partnership,association oxm other legal entity,employing employees. However the owner of a dwelling house having not more than three apartuuients and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintexiance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not be:<'--ause of such employment be'deemed to be an employer." MGL o 'hapten 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal' 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 co.1MpU=ce 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 ua-til 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), addresses) 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'comp cmation 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 inzuranse coverage. .Also be store to si=gn and date the affidavit. The affidavit should be mt'uaued to the city or'ovm`Meat the auulic=—ion for the pCri, t'or license i—s being requested,not the D eparr'ient.of Industrial Accidents. Should you havee any euPstions regardia-a the law or if you are:,Y^i:ired 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 pem iits 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 licease or permit to bum leaves etc.)said person is NOT required to complete q mp this affidavit- The ffidavitThe Office of Investigations would like to than you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. eP The D ariment s address,teI„ hone.and_fag.number. _ The Commonwc2lth of Massachusetts Degartmmt Of Industrial Accidents Office of Inuesfic, ons 600 Washing- n Street Boston,MA 0.2111. Tel. # 617-72.7-4900 eaft 406 or 1-877-NLkSSAFE Revised 5-26-05 Fa.):r 617-72,7-7-749 VrV,rV7.ma.m._zov/dia CONTRACTORS INVOICE WORK PERFORMED AT: I/ 9 7q ? -� TO: f-Irl f - DATE YOUR WORK ORDER NO. OUR BID NO. •, 1 1l6 r �-- - - rJ I • I r c 1 c, III A l C7r j G1 10,i/ sI. •! A j i f 'OfS - - I, i r f f Ck El IoN 4 e— J!fa IAA Ac OA v All Material is guaranteed to be as specified, and the above work was performed in accordance with the drawings and specifications provided forthe above work and was completed in a substantial workmanlike manner for the agreed sum of Dollars($ ). I ! This is a ❑ Partial ❑ Full invoice due and payable by: Month Day Year I in accordance with our ❑Agreement ❑ Proposal No. Dated Month Day Year Nc3822 CONTRACTORS INVOICE ' 4 I < ' I ORTH TO" of Andover . . WIII OV, *�K, o dover, Mass.,o1. I� COCMICHEWICK V ORATED �"`� S U BOARD OF HEALTH P� ormm Food/Kitchen Septic System Eti IT T D BUILDING INSPECTOR THISCERTIFIES THAT........ ..... ........- ..... .................................................................................................... Foundation has permission to erect........................................ buildings on ... � .�. ..... /�.. " ...° '. Rough to be occupied as Chimney provided that the person acceptin his permit shall in every respec 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 6THS ELECTRICAL INSPECTOR UNLESS CONSTRUC ON TS 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. '- I'Wassachusetts- Department of Pi1bI1C Safety vwjj Board of Building Re-ulations and Standards Constructiori�Stfp.ervisor Specialty License License: CS SL 10.1033 Restricted to:, RF STEVEN PEDATO 9 HEMLOCK DRIVE. DANVILLE, NH 0381'9 �- - ` Expiration: 7/7/2012 (•ummisiuncr Tr#: 101033 -_-__ �✓fie iq --_-__....�„�i � air�nzoa��e`e� ��/�acfEuaelCa it Office.of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR 7 Registration:,?147865 . Expiration: g/17/2011 + �TypesSupplement Card PEDATO&SONSI�ROOFING_ STEVEN PEDATO� 9 HEMLOCK DRIVE DANVILLE,NH 03819';`t_ - undersecretary