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HomeMy WebLinkAboutBuilding Permit #72-11 - 1260 SALEM STREET 7/20/2010 BUILDING PERMITof "°pT" TOWN OF NORTH ANDOVER L .Iy r Y f APPLICATION FOR PLAN EXAMINATION Permit NO: —LL pa to Received q004reo�eaygy Date Issued: ' �d l �SSACHUS�� IMPORTANT:Applicant must complete all items on this page LQCATION ! Z6- slc nnt: PROPERTY OWNER5 't�'� i. 1Z2� a4, Pdd _ MAP 210 I a __PARCEL. 1. ZONING DISTRICT. Histone Distract yes no Machine,Shop Village yes, no TYPE OF IMPROVEMENT PROPOSED USE Resi Non- Residential New Building One family Addition wo or more family Industrial Alteration No. of units: Commercial Repair replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed D�sti`ct Water/Sewer_: DESCRIPTION OF WORK TO BE PREFORMED: 1� ll i 1 ,, I Identification PI a Type or Print Clearly) V OWNER: Name:_ ±LL=ftyn Phone: Address �2LC) SerL sl Q Ms CONTRACTOR Name .Phone. Address: Supervisor's=ConstFuction License:. '' Exp. Date;_ Home improvement License_ Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULD/NG PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $_ 7 Z80 FEE: $ 7•©0 Check No.: Receipt No.: NOTE: Persons contractin wit u r d contractors do not have access to the guaranty fund Signature of Agent/Owner Signature;of contractor Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/MassageBody 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 N 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 DEPARTMENT Temp DuMDster on site yes _ __ no _ . Located-at 1'24,-Main Street Fire.Departure"ntsgnaturb/date_ COMMENI"S _ 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 � i Doc.Building Permit Revised 2010 i 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 K.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.G..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 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:Building Permit Revised 2008 Location ley*_ / No. Date No�TM TOWN OF NORTH ANDOVER 60 b � 9 ' Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ f Other Permit Fee $ TOTAL $ Check # 23 • ► Q Building Inspector ORTFI o'" 0fAndover No.-- old, T` �O - LAKE -o dover, Mass., COCMICMEWICK 21,95°RATEo PP���S 3 BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System •�y BUILDING INSPECTOR THIS CERTIFIES THAT........ �i�..���. `...P.!!. �...,....�. ............. .... ..................... Foundation pg Z ........ .. ... . . g has permission to erectL--;�--'c ..... buildin s on .. . �i4114......... Rou h ....to be occu ied as.... 1 r! �. rChimney rovided that the ae tin this ermit shall in eve res ect con orm to the terms of th lication on file inP PP g P � P PP 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 CONSTRU T ...........................TS Rough ...........................:..... Service BUILDING IN R 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. •- f The Commonweizith of Massachusetts Department of£radustrial_9ccidents Office of Inveszio ations 600 Washineaton Street Boston, M,4 02111 Workers' Compensation Insurance Arlda assgov/dia An lieant Information �t: Builders/Contractors/Electricians/Plumbers Please Print Le_j)iv Name (Business/Organizationdndiv=, —� Z�� � L Address: 1 ZG O S L zvy`-Z j City/State/Zip: c7. \f� Phone#: 3-78 , 2C8 - I a6. Are you an employer? Check the appropriate box I.❑ I am a employer with 4. ❑ I am a Type of project(required): — general contractor and I 2•❑ employees(full and/or part-time).* have hired the sub-contractors 6 ❑New construction I am a sole proprietor or partner_ listed on the attached sheet x 7• ❑Remodeling ship and have no employees These suuconuractors have ❑ working forme in any capacity. workers coin . ' g' Demolition [No workers' comp. insurance 5. P insurance. ❑ We are a corporation and its 9. ❑Building addition X- 1 officers have exercised their 10 ❑Electrical repairs or additi°ns m a homeownerdoing all work right of exemption P�MGL ILsel£ [No workers' comp. c. 152 ❑Plumbing repairs or additions ,§1(4),and we have no insurance required-] t employees. [No workers, 12•❑Roof repairs r._ r t comp.msurance required] 13�Other�,>I,,,,,,9&A Z �p.tori that ch } box�, , O( Romeo onz aso rYu euf i:nc serdo�c�,oW ea IZZQLy�jE;C�vty� WnerS Who SnnIDIt ttlis affidavit indicating they am dC••- at wo r� R•Cr_ s'COM,—_- Vn r��•��r.�:...y,�.y:. +Contractors that check t-i box «..-� `€ rk and titm hire outside conaact •i;submit a new a— a ed an additional sheet showing the affidavit indicating such. name of the sub-contractors and their workers'co 0 I am an em P e , P mP•P ucY infornration. P�3'� that is rovidinP workers compensation uisurarice for my employees Below is the policy and job site inforniafion. Insurance Company Name: Policy#or Self-ins.Lic.# Expiration Date: Sob Site Address: Attach a copy of the workers' City/State/Zip: compensation policy declaration as Failure to secure coverage as required under Section 2 Pae(showing the policy number,and expiration date). fine up to$1,500.00 and/or one-year imprisonment,aswall �MG�c. 152 can lead to the imposition of criminal penalties of a Of up to$250.00 a day against the violator. Be advised that a co penalties in the form this of a STOP WORK ORDER and a fine Investigations of the DIA for insurance coverage verification. Py of statement may be forwarded to the Office of I do hereby certify nder e P ' s enalties o er Si fP ury thzzt the information.Provided owe is true and correct �ature: Date Phone#: q_ Official use only. Do not write in this area to be completed by city or town official City or Town: Issuing Authority(circle one): I'ermitUcense# I.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector S.plumbing 6. Other b Inspector COn:aCL Person: Phone n: Information an- d Instructions Massachusetts General Laws chapter 152 requires all employs to provide workers'compensation for their employees. Pursuant to this statin;an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association o$other legal entity,employing employees. However the owner of a dwelling house having not more than three apartiui-ents and who resides therein,or the occupant of the dwelling house of another who employs persons to do mainte mmce,construction or repair work on such dwelling house or on the grounds or building appurtcnar+t thereto shall not be cause 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 c onstruct bindings in the commonwealth for any applicant who has not produced acceptable evidence of coxnpliance with the insurance coverage re4uired." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall =ter into any contract for the performance of public work ua-t:il 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 certificate(s)of insurance. Limited Liability Companies(LLC) or Limited Liabfiity partnerships W)with no employees other than the members or partners,.are not required to carry workers'comp ration 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 insurance coverage. Also be stare to sign and date the affidavit The affidavit should be ivt'umed to the city or town that,the application for the nerliait or License in being regztest.Pd,not t'.^.e Department.Of Industrial Accidents. Should von have any questions regardi bFy�-e w or if you ai v:,,^i:ired to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-incur-ance 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 officiaIly stamped or marked by the city or town may be provided to the applicant as proof that a valid af'-davit 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 ofinvestigations would I&e to than 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,tel phone and.fammumber:..... The Commonwealth Of Mamachusetts. I>TWtMMt Offndustrial Accidents Office of Investigatians 600 WashiRgbn Street Boston,hLA 02111 Tel # 617-72.7-4400 ext 406 or 1-977-NLgSS.A.FE Revised.5-26-05 Fa..): #617-72.7-7 749 vrvm,.mass..crov/dia. µORTM TOWN OF NORTH ANDOVER F t'°° OFFICE OF BUILDING DEPARTMENT 1600 Osgood Street Building 20, Suite 2-36 4 ceewr:s. +• "�ys^•no�PEt North Andover,Massachusetts 01845 SACHUS Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978) 688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE: z0 C JOB LOCATION: © S C �� V6 1 8 Number Street Address Map/Lot HOMEOWNER, W k 578-ZCg-)86 q7�- Name Home Phone Work Phone PRESENT MAILING ADDRESS_1260 S '� AA DIPAS City Toy�m ct, te Zip Code The current exemption for"homeowners"was extended to include owner-occupied dwellings to two units or less and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) 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 structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned"homeowner"assumes responsibility for compliances with the State Building Code and other Applicable codes,by-laws,rules and regulations. The undersigned"homeowner"certifies that he/she under ds the Town of North Andover Building Department minimum inspection procedures and r uireme is and t h /sh I c mply with said procedures and requirements. HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 ORTH ToOf Andover 0 rn 012 ---.1V0 . 1=== = o " dover, Mass. � ' •� C� T Q -- LAKE 1 COCF9ICMEWICK A�RATEO pP�,`�� SS BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT........ ' I Iq!!1� .............. .. �. �... !. �...l... P ..................... Foundation has permission to erect....... ................. ............ buildings on ..f.Z60........ ..1. ,.......... Rough .... ............ to be occupied as.... ... � �.... Chimney p T..........W 1 li!► ll�l............. . .. ...... provided that the a cce tin this ermit shall in eve respect con orm to the terms of th lication on file in P P P g P P PP 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 CONSTRUZ'T .TSRough Service .... ... .......................... ..... BUILDING IN R 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