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Home My WebLink AboutBuilding Permit #812-12 - 119 HIGH STREET 5/11/2012 ttoRTH BUILDING PERMIT I„ to ” 3? a '6 0 TOWN OF NORTH ANDOVER O a .» - . p APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received _ A�Aw7en .cy* 9SSACHU`�� Date Issued: IMP RTANT:Applicant must complete all items on this page s PROPERTYz OVUNEaRI A;.77 - c MAP. NO PARCEL:' ZONINGDISTRICT.... _ ti, ->Historic District es no 1 , _ ,.,,.yes - ','Ma_ c`eine Shop'.Village es , ono TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: emolition Other Septic_ V11ell SFloodplain� {' Wetlands VU aatersiied,Dist�ict ,Water,Sewer. � �� . � y :4 DESCRIPTION OF WORK TO BE PREFORMED: Identification Please Type or Print Clearly) OWNER: Name: Phone: 60S 7Y7L-/ Address: 'CONE iRACTOR Name x" z .Rhone: SZT!?7.S,,f4 % _ t Address ! ✓ { - . �-�G�c. Supervisor's CoristructionaLicense G'F579O' Xp! Date: 4Home Improvpment,.,License. - /, Exp. ARCHITECT/ENGINEER Phone: r Address: Reg. No. s FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ /�S�(� O FEE: $ 3D•t' Check No.: � � Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner. Signature of contractor 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 Hydraulic Calculations (If Applicable) o 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 Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public SewerSwimming Pools Tanning/Massage/Body Art `l Well Tobacco Sales Food Packaging Saldss ; 1 Private(septic tank,etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM j 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 a ,Conservation Decision: Comments Water & Sewer Connection/Signature&Date Driveway Permit DPW Town Engineer_. Signature: Located 384 Osgood Street FIRE DEPARTMkNT �Temp'Dumpster on site yes �;. no {.. 'Fire De artmentsi natureFdate. �0,. .- _ , � ,.a• COMMENTS. i 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) ❑ Notified for pickup - Date I _.............. Doc.Building Permit Revised 2008 Location No. j ! 2 Date • - TOWN OF NORTH ANDOVER O Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee TOTAL $ Check# 25293 f Building Inspector NORTH Town of o , lover, Mass., // z COCMICMEWICK S RATED PPa�.�S BOARD OF HEALTH Food/Kitchen PERMIT _T -- D Septic System �fBUILDING INSPECTOR THIS CERTIFIES THAT.......X ...... / �... `�t .:. "... ` . ....... d �......... .. �!!�;......................... ........................ Foundation has permission to erect........................................ buildings on .........9... ... ...... ................. ............................................. Rough to be occupied as A�� ....... 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 CONSTRUCTIONS ARTS Rough ... :k......:.'r.rF••••�/�••"� �`, ':.*....... 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 Mall To Be Done FIRE-DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. T �`�` - — -- ✓1ze -Panvnzoozureal�l o�'✓l�,aasa�,lzueetta Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration:,.-fl Type: ,ter, •. .' Expiration —1311612013 Individual TODD WOEKEL TODD WOEKEL 52 SHEPHARD RD\ '�� ' •r, PELHAM,NH 03076 Undersecretary Massachusetts-Department of Public Safety Board of Building Regulations a - nd Standards C'anstructiun \Beier isur License: CS-09906AIIL 2 K TODD B WOL 52 SHEpHAR�j ROAD. PELHAM NFi 036 - � I Commissioner Expiration 09/28/2013 • l r` Agreement This agreement is entered into between Todd Woekel and Avatar Properties-Receiver for the removal of a deck in the rear of 119 High Street,No. Andover,MA. The cost of the job is$1500.00. Payment will be made at the completion of the project. All materials will be taken offsite at the contractor's expense. Todd Woekel Avatar Properties-Receiver NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: is that the debris resulting from this work shall be disposed of' a properly licensed solid waste disposal facility as defined by MGL c11, S150A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section I OA. The debris will be disposed of in: (Location of Facility) Signature of Permit Applicant 1 Date ,pe ed- kys % �5SOC 7, c� 2e 4 ��e The Commonwealth ofMassachusetts , - Departmentof lndustriglAccidents Office oflnvestigations 600 Washington Street Boston,MA 02111 vmmassgovIdia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/.Plumbers .Aublicant Information Please Print Legibly Name(Business/Organ'rzation/lndividual): � Address: City/State/Zip: Phone#: J—er F9 7 S– Are you an employer?Check the appropriate box: Type ofproject(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. D New construction employees(full and/orpart time)* have liked the sub-contractors 2. sole proprietor or partner- listed on the attached sheet.x 7. ❑Remodeling ship and:haveno employees These sub-contractors have 8. ❑Demolition working forme in any capacity. workers'comp.insurance. 9. F1 Building addition [No workers'comp.insurance 5. F1 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 wehave no 12.❑Roo repairs insurance required.] employees.[No workers' comp,insurance required.] 13.❑Other 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 7 Homeowners who submit this affidavit indicating they gie doing all work and then hire outside contractors must submit anew affidavit indicating such. }Contractors that check this box must attached an additional sheet showing the name ofthe sub-contractors and their workers'comp.policy information. X 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 tleclaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL o.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. X do Hereby certIV nnder A pains and penalties ofperjury that the information provided above is true and correct. - Si�nature Date: vE / Phone#: F only. Do not write in this area,to be completed by city or town official.n: Permitiucense# hority(circle one): 73ealth2.Building Department 3.GVTownClerk 4.ElectricalInspector5.Plumbing Inspector son: Phone#: Information and Instruction's . Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...everyperson in the service of another under any contract ofhire,- 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 shallrlot because of such employment be deemed to bean employer." MGL chapter 152,§250(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or p ermit 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 chapterhave 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 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 cant'workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. BeadvisedthatthisaffcdavitmaybesubmittedtotheDepartmentofTndustrial Accidents fox 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. SeIf-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 ie on file for future permits or licenses. Anew affidavit must be filled out each year.Where a homeowner or citizen is obtaining a license or pemut 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: Gommonwoalt�ofM-assa6him tts - Depa tmeat of fndustriat,A,coldo its 4?ff�ee o�Zuvestzg�tiax� ' 6q�'��.$lai7agfia>�.Street Boston,MA,021 It Tell#617-727,4900 est 406 0T 1-877^MASSA XE - � Revised 5-26-05 Bay,0 617"727-7749