HomeMy WebLinkAboutBuilding Permit #269-13 - 1327 SALEM STREET 10/4/2012 { r
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: I' I Date Received I L?
Date Issued:
IMPORTANT:A licant must complete all items on this age
LOCATIQNr ��" L n't � .�✓� o ,6
PROPERTY OWNER
i
s % Prmt .:100 Year 01d;Structure yes' .
MAPNOi' PARCEL: ZON.ING'DISTRICT Historic District yes
I
Machine Sho ' Vill
_ ' . p
a ees o
TYPEOF
IMPROVEMENT T 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
❑ Septic ❑=well` ' ❑ Floodplain E Wetlands ❑ Watershed District
0 Vllater/Sewer
DE CRIPTION OF WOR .T BE PERFOR ED:
Y1� �- L�ti !L� /vta v A Z n
5&C
Av�,�, �� bvs 4 - � -_'x,3
Identif cation PI aTape or Print Clearly) _
OWNER: Name: /(`e,(+'iVn M� Phone. ydl�y
I
Address: Z /et� �✓�' !v lib Ua�--
CONTRACTOR Name !. !�'�; �. Phone
'
Address:
S.0 ervisor's Construction License a.� - f
i
I 'Ho'Mi§,:Improvemen't'License--,
ARCHITECT/ENGINEER 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: $ 9 CDUObFEE:
i�
Check No.: '! 1 (� Receipt.No.:
NOTE: Persons contracting with unregistered contra0tors do not have access to the guaranty fund
- [ Y �` JA � 11x1*a R - -'t
Signature of Agent/OwnerS A.° �`' "Signaiyre of contractor _.
- 't , -
Plans Submitted ❑ Plans Waived ❑ Certified Plot-P4 11 Stamped Plans
t
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
4
Water & Sewer Connection/Signature&Date Driveway Permit
DPW Town Engineer: Signature:
Lo ted 384 Osgood Street
FIRE DEPARTMENT =Temp Dumps r on site Y05 V1r no
Located at-124 Main Street
Fire Department-signatureldate b
COMMENTS
I. 0
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
Doc.Building Permit Revised 2010
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
o Building Permit Application
❑ Workers Comp Affidavit
o 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)
o Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
o 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
o 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: Doc.Building Permit Revised 2012
Location ' )7� IS�V-� w` ✓�
No. 2C09 - k3 Date
n
�a.
e • " TOWN OF NORTH ANDOVER
d_ o
.. Certificate of Occupancy $
Building/Frame Permit Fee $2' +'•00
" Foundation Permit Fee $
Other Permit Fee $
t TOTAL $
4
Check# 2 4 [o
25788 wilding Inspector F
a.
i y
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www-m
Workers' Compensation Insurance Affidavit Bu'ders/Contra
A licant Information ctors/EIectr><cians/Plumbers
Please Print Le ibl
Name(Business/Organization/Individual): �.���j1 C(Jy1 ; � �,�
Address: 96 F !�} tv /41 (f �fi[ 1� � V
City/State/Zip: 6 R, n CJ- 4- Ol g phone#: S3
Are you an employer?Check the appropriate box:
I•X I am a employer with ; 4. ❑ I am a general contractor and I r7.
of project(required):
employees(full and/or pa}t-time ,* have hired th New construction
esub-contractors
2.❑ I am a sole proprietor p p etor or partner- listed on the attached sheet.� Remodeling
ship and have no employees These sub-contractors have
working for mein any capacity. workers'comp.insurance. g' E]Demolition
[No workers'comp.insurance 5. ❑ We are a corporation and its 9• ❑Building addition
required.] officers have exercised 10•❑Electrical repairs their s or additions
3• _ P dations
❑ I am a homeowner doing all work right of exemption per MG
myself � P P P L 11.❑Plumbing repairs or additions
Y [No workers comp. C. 152, §1(4),and we have no
insurance required.]t employees. 12.[ Roof repairs
(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_
f Homeowners who submit this affidavit indicating Y are the doing
,all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showin the name of
g the sub-contractors and thew workers'com . olio information.
Cam an employer that is providing workers'compensation insurance or r policy bsite
'reformation. f my employees. Below is the policy and job site
hsurance Company Name: dL%r—,_0
?olicy#or Self-ins.Lic.#:_ j� (� -0
_ Expiration Date: /
_ 3
lob Site Address:
5/ . v�
City/State/Zip: 'V`�` /VA
"tach a copy of the worke �
rs'compensation policy declaration page(showing the policy number and expiration
Failure to secure coverage as required under Section 25A of MGL c..152 can lead to the imposition of criminal penalties of a
ine up to$1,500.00 and/or one-year imprisonment,as well as civil
lienaif up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwardedies in the form of a to th O�Ce o and a fine
nvestigations of the DIA for insurance coverage verification.
'do hereby certify under the pains and penalties ofperjury that the information provided above is
trite and correct
•i ature:
45" t
Date:
hone#: �-3 , l S 3
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 ector 5.Plumbing Inspector
6.
Contact Person:
Phone#:
ti
Informati®n and Instructs®ns
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-contractor(s)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 permittlicense 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 1-877-MASSAFE
Fax#617-727-7749
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Co �t? e_r _ s a�_c� s_ness Rea►aeon
10 aikPlaza- Smote i%Q
Boston,Massa, pse-Lts 02116
HomeLmprovemenq GydL�1 ;qCiOj'Regis2 U1?
@UI€LNS CONSTRUC t
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i-HOAAAS QUINN,
868 MAMMOTH RD-
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or registration valid for individul use only
iiOME IMPROVEMENT CONTRACTOR before,the expiration date. If found return to:
egistr2tian: 121604 Type: Office of Consumer Affairs and Business Regulation .
piration: 5/24/2014 DBA- 10 Park Plaza-Suite 5120
Boston,MA 02116
QUINN'S CONSTRUCTION
THOMAS QUINN
MAMMOTH RD.
DR
DRACUT,MA 01826 Undersecretary Nlot—valid without signature
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a aymt.IE IMPROVEM�_Ii.T C0N i'RAC TO R before the eegirsiiaa dais if found return to:
paisiration: 121604 Type: O_ffice of Consorter AL airs and Business Regulation
!4E.Piraaon: 5124120'4- DBA 10 ParkPlam-SulteS?i0
i. Boston,
QUINN'S CONST RUCT i0\
i NOMAS QUINN
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B im,„� � 6ur�ding Code is causefor revocation o._his license.
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NORTII
Town of EAndover
O `.'o.'•' �y IM
....
No.
0 � Z
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oh ver, Mass,
I� CO[Na�htwa[K �1'
U BOARD OF HEALTH
Food/Kitchen
P E R T L.D
Septic System
•
THIS CERTIFIES THAT BUILDING INSPECTOR
............... .. . ... ........................ . 1. . .! .. .... ..................
.... ..... ....
has permission to erect .......................... buildings on ..... .... . �M...,.�r�..:,..,,,,.....,,, Foundation
p' Re.RoofRough
t0be OCCU led as ............ ................ ...................................................................... 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
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTIO STARTS Rough
Service
................... . ................................. 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.
IFSEE REVERSE SIDE Smoke Det.