HomeMy WebLinkAboutBuilding Permit #701 - 136 OLD VILLAGE LANE 5/28/2008 BUILDING PERMITo�"°DT bq4.
TOWN OF NORTH ANDOVERoa '`:`''. o°
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
� �SSACHUS��
Date Issued: 5 d�
IMPORTANT::Applicant must complete all items on this page
LOCATION S„ v c L--/3h,A?
PROPERTY OWNER 2 / �} lG(e-PLn/
Print
MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
New Building One family
Addition Two or more family Industrial
Alteration No. of units: Commercial
_ epair, replacemeAssessory Bldg Others:
Demolition _�
on Other
Septic Well Floodplain Wetlands Watershed District
Water/Sewer
� f
Df SCRIPTI N OF WORK TO BE PREFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: �- 00.,ta-. gleLil Phone:
Address: D-6� 0 =tz
CONTRACTOR Name: c? -I ( ,2r n Phone: ?S1 -)06
Address:
Supervisor's Construction License: SSC t Exp. Date: 1/ '</d col
Home Improvement License: 3-6 7 Exp. Date:
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: $ �UU FEE: $
Check No.: 6 Receipt No.: 0?f
NOTE: Persons co tracting with r' e edcontractors 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/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
C:jMMENTS
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 Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
COMMENTS
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 2008
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 Lvc,) )Gs-y 30� y`05 60,
❑ 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)
❑ 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
Location�U -7,,
No. 20y Date
Com.
TOWN OF NORTH ANDOVER
� s
A
i Certificate of Occupancy $
CgUS CHU Building/Frame Permit Fee $
JA
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
C
Check #v/ w
1 Building Inspector
Board of Bu= mg e� onand� rd
Construction Supervisor License
Licgn"se�- CS 75111
BirthdateC,1/5/1965
Expiia�on 7/5/2009 Tr# 8364 j
Rtri ti DO
JAMES S BEAL ;` --7
27 JASPER ST
SAUbUS,MA 01906 _ __- Commissioner
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I
Bard of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registrafion:�130727
lug E�pJrat!om:,4/71/2010 Tri 265036
wTYpe DPA
BEALCARPENTR '-
JAMES BEAL V7,1 s -746c'-
27
$ ' i c'.27 JASPER ST
SAUGUS, MA 01906
Administrator '
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I
NORTH
Town of Andover
No. 1301 F
LAK 0 over, Mass., �5
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COCHICHEWICK
\- C
0"?ATE ?
BOARD OF HEALTH
Food/Kitchen
Septic System
PERMIT T D
BUILDING INSPECTOR
THISCERTIFIES THAT......................... ........................................................................................................... Foundation
el A. f
has permission to erect........................................ buildings on .CW.U.4..........0./ /..C..../. ...................... Rough
Chimney
to be occupied as.....Ot4 .Z.....sedic.....(3...... ............Fv!J. ...........................
P that the person achepting this permit shall in every respect conform to the terms o 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
tok - PERMIT EXPIRES IN 6 MONTHS
UNLESS CONS ELECTRICAL INSPECTOR
Rough
TM 0 TARTS
Service
........... ...................................................................................................
BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Rough
Display in a Conspicuous Place an 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.
Page# of_�pages
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Proposal Submitted To: Job Name Job#
+ ea-"
SIAN
Address Job Location
o rl_Q
Y Date Date of Plans
Phone# Fax If Architect
We hereby submit specifications and estimates for:
n S 'r� � (, �_�- / S►_fir vr. i3�9c L S, a_r_-.._ U' �i
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(ateG��-��_.....%
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___.. _ - _ .-_ . ......._.... _.__. _._ ......
... ..__ _ ........ _
We propose hereby to furnish material and labor—complete in accordance with the above specifications for the sum of:
"–G4 Dollars
with payments to be made as follows:`�3 0VO �� S ,z12 Q y�J [� ,rn /�,r�v S/ 4 p G/ZO C/1,N-11?
f � �' � v rya�y )e�n j
Any aiteYati or�atio�rom above specificatOns involving extra costs will be Respectfully
executed only upon written order, and will become an extra charge over and submitted
above the estimate.All agreements contingent upon strikes,accidents,or delays '
beyond our control. Note—this proposal may be wi dr by us if not accepted within _ days.
P- t 2cceptance of Vropogai
The /f/
" e-prices,specifications and conditions are satisfactory and are Signature
herebl �qqepted.You are authorized to do the work as specified.
Pagents yyill be made as outlined above.
l
Date 8f ddc6ptance Signature
NC3819
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
e
Boston,MA 02111
Y > www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: ,'Y-1
City/State/Zip: cJ 1�/� ��G b Phone
Are you an employer? Check the appropriate box: Type of ro ect re uired
' 4. m a general contractor and I p J ( q ).
"
1.l?✓ I am a employer with ❑ I ag 6. E]New construction
employees(full and/or part-time).* have hired the sub-contractors
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. E]Building addition
[No workers' comp. insurance comp.
required.] 5• ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑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
employees. [No workers' 13.❑ Other
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.
1Contractors that check this box lutist attached an additional sheet sho---g the narne 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 isproviding workers'compensation insurance for my employees. Below is thepolicy and job site
information. 1
Insurance Company Name: ` S /Z /AU
Policy#or Self-ins. Lic.#:'�/�t+'/ j� / VIVI,3 o-,7 Expiration Date:
Job Site Address: )10 to tJ (yr����L Z__61 ._ City/State/Zi &21 /
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 the pains and penalties of perjury that the information provided a ove is true and correct
Si afore: Date: i7 _
Phone#:
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-conttactor(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 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 bum leaves etc.)said person is i10T 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
D,-partment of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. # 617-727-4900 ext.446 or 1-877-MASSAFE
Revised 11-22-06
Fax# 617-727-7749
www.mass.govldia