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Home My WebLink AboutBuilding Permit #490 - 131 MAIN STREET 1/3/2007 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION o' "�STN H 9 Permit NO: Date Received G +� '+„ �: +► Date Issued: ` ��Ss,4CM� s IMPORTANT:Applicant must complete all items on this page LOCATION I -9 Print OWNER (?eu(,-� f v-) f Print MAP NO.: '�zoPARCEL: ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑New Building ❑One family ❑ Addition ❑Two or more'family ❑ Industrial OMIteration No. of units: b' C0 h°'"tyN( , "epair, replacement ❑Assessory Bldg ❑Commercial ❑ Demolition ❑ Moving relocation 0 Other ❑ Others: ❑ Foundation only DESCRIPTION OF WORK TO BE PREFORMED JCS Q(ac e 11�_ "J(r10 L _,,? W(\A v f`Kyi Ga u` u-�r`✓l c�o�ms's Identification Please Type or Print Clearly) OWNER: Name: �9 lea I`-r �Y,V9 Phone: 7a17941615- Address: ZI.�"¢��V" y y'1 ��U 1V1�'Jk94 Y2- W 'd CONTRACTOR Name: Q ( 61 k—cw Phone: 7 1ST 5 Address: C1 94 e(.P-q gtfl_ -j� # 4joveel dv1Q�i� Supervisor's Construction License:_c e7 00 l 0 a I Exp. Date: Home Improvement License: t ` Exp. Date: 1 ARCHITECT/ENGINEER Name: Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost :$ 21� D a FEE:$_ !// 2- -- Check No.:�7'7D Receipt No.: Page I of 4 TYPE OF SEWERAGE DISPOSAL Tanning/Massage/Body Art ❑ Swimming Pools ❑ Public Sewer ❑ Well ❑ `r Tobacco Sales Food Packaging/Sales. ❑ ❑ Permanent Dumpster on Site ❑ g" *--� Private(septic tank,etc. ❑ Electric M.eter 166,ation=to project NOTE: Persons con tr cling with unre ' ontractor do not have access to the guaranty and Signature of Agent/Owner Signature of contractor i Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF-U FORM DATE REJECTED DATE APPROVED z PLANNING & DEVELOPMENT ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED i CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ I COMMENTS FIRE DEPARTMENT -Temp Dumpster on site yes no Fire Department signature/date 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 Building Setback(ft.) Front Yard Side Yard Rear Yard Re uired Provided Required Provides Re uired Provided Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: NOTES and DATA— For department use Page 3 of 4 Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM05 Created JMC.Jan.2006 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 Addition Or Decks ❑ Building Permit Application ❑ 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) 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 of Contract ❑ Mass check Energy Compliance Report 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 DEPARTMENTMFORM05 Page 4 of 4 Location 3 baitY'tL' No. a Date NORTH TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ ; s�CHus Foundation Permit Fee $ Other Permit Fee $ " TOTAL $ Check # ? 9914 Building Inspector Ute" NORTH TO" Of t 19Andover No. y 9 oA = dover, Mass., COC MI C MEW ICK y�. A�RATEo P,' �y `s BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT I. � I,. ...... ............... ... ......... .. ... . ..... . ... ................. � I............... Foundation c has permission to4meet.ft. .1. !t........ buildings on.1�N.1...�!1.� .IN..�j...........t..3.1......YM.g1.14.....J. Rough to be.occupied as...1�..�...;A....... �.��....�/. �..li�............. 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. 3011 PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION TARTS Rough ..,�„�................ Service .... . . . .. . LDING INSPECTOR Final Occupancy Permit Required to Ocmpy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal 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. '�. ✓li6 -GO�Nf[vti lJ�vi7f#lltl'INAOQf(6�^. ,. BOARD Of p UILDlNG REG1s8.AT"S" YLicense- CONSTRUCTION SUPERVISOR '- Number. Cffi (S(t18Z4� 35 pp0 cf enclosed space { 5 BFrttideti: 401 1 1 A (MU Masonl .112 ony } +� E 4� 1: TE;nod-5396A ' 1 G_1&2 Family Homes '« " Failure to possess a tuaent edition of the a Re ,� , Massachusetts State Building Code C)A F fi u t is cause for revoc"m of this license. IID P GULW it �ANOO1/EJk M4 0104B 1 i DIG SAFE CALL CENTER: (88i)344-7233 r, a,+�°* r' t'1!dlartfl�vlsa�in �,a✓�,f ust�l�N�llli .�.._. -------- -•.�_-----�-... *' i1O11E1wAitl YEa C ICI M License or reesrtratiou valid for indFvldal use only. hrforc the expiration date, if found return to: . 4 '11Of9 ; ; Board of Bull dia R s / t Clue g egulations and StmWards a Ashburtoa'Plare RIt 1301 Boston, F. oscort,Ma.oaten Valid •. . witkent signature The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations d 600 Washington Street �rW Boston,MA 02111 M 5� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / Please Print Legibly Name(Business/Organization/Individual): C{U Address: 'Pu hurl� ,2 � City/State/Zip: IV 411u OV-f ( VV1 U`7 5 Phone Are you an employer?Check the appropriate box: Type of project(required): 1.D1—am a employer with 2 4. ❑ I am a general contractor and I employees(full and/or part-time). * have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. [ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' insurance.$ 9. ❑Building addition co [No workers'comp.insurance �• required.] 5. ❑ We are a corporation and its 10.El Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.El Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no 13.❑ Other employees. [No workers' comp. insurance required.] "Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and 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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. 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.#: (N G K6-56 S U Expiration Date: —7 W/0 Job Site Address: i- Moon V- /i' dOvP-- ft y� City/State/Zip: Ns Y 5— Attach 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 hereby certify under thus and penalties of perjury that the information provided above is true and correct. Signature: (� Date: ao Phone#: ( � 7 L f .� 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#: 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 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 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-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 carry workers' compensation 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 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. #617-727-4900 ext.406 or 1-$77-MASSAFE Fax#617-727-7749 Revised 11-22-06 www.mass.gov/dia