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HomeMy WebLinkAboutBuilding Permit #48 - 1475 GREAT POND ROAD 7/9/2010 BUILDING PERMIT o`.,,.•�tIORTIy .r 46:,,, ...a, •6 OO TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATIONoo Permit NO: Date Received ,"",RTEo'� cy Date Issued: ® �SSACHUS�� IMPORTANT:Applicant must complete all items on this page LOCATION I T C) kkFAT t`t61 _ Print PROPERTY OWNER, l� fl rh t D C`a 6 A H Print MAP 210 . . PARCEL:_ 7 ZONING DISTRICT- historic District yes no Machine Shop Village es no Y TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building ( One family Addition Two or more family Industrial Alteration No. of units: Commercial dRepair, replacement Assessory Bldg Others: emolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer _ DESCRIPTION OF WORK TO BE PREFORMED: -- KG ?LA-Cc TO I- L► M t-s row&5 S Tis eS I N FriolvT DT T-/4- j44w S& . 2L_j cM�� i�►'iorw� Tff� �o►�� Identification Please Type or Print Clearly) r F OWNER: Name: M 1 - 10 Phone: 7-?f 0 0 Address: LI C ►L�- {���. N . �3uc�t^-v\ - /lil/ CONTRACTOR Name: ( A 0Le t4a V9 go Phone: Address: t Supervisor's Construction License:=1 (4 Z Exp. Date: iO Home Improvement License: � 3 / � � Exp. � / C> 1 p f 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: $ 3 A op ,o"o FEE: $ f Ow I ,7j -71L � Check No.: I �- q- Receipt No.: 2 3 06(- S NOTE: Persons contracting with unregistered contractors do not have access to the ranty fun Signature of Agent/OwnerSignature R 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 r 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 o 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 a 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:Building Permit Revised 2008 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 � y ..............._......._.................._.__....._..._._...__........._........................_............................._..._.._ ....._...-__._.............................................i Doc.Building Permit Revised 2010 f 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 r 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 Location �TT—��� No. Date '~ v MOR,M TOWN OF NORTH ANDOVER 0�� �ao :•'�.y0 3? • OL I Certificate of Occupancy $ cMust< Building/Frame Permit Fee $ r7 FoundationPermit Fee $ Other Permit Fee $ TOTAL $ Check # 2 3 0 Building Inspector ORTH T0'" 0o And over No. � �O - LAKE -O '� dover, Mass., aCOc MIC ME WICK RATED SS BOARD OF HEALTH PERM IT T D Food/Kitchen Septic System BUILDING INSPECTOR ... .. THIS CERTIFIES THAT........ .. .........fd............�....s.... ..................... �..�. ........................................ Foundation has permission to erect........................................ bui rags on ..... .. . .. ........C��... 4 ........12 Rough v to be occupied as.......ss.4.n..... ....... .. crA...... .........��...���.....w.................................. C imn y h' eprovided that the person acceptis p�rmd,shall in every resplt conform to the terms of the application on file in Final this office, and to the provisions of the Codes arid'`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 S UNLESS CONSTRU ELECTRICAL INSPECTOR Rough :.........................................................................:........................:: ;; 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 Wall To Be Done FIRE DEPARTMENT' Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE S 1 D E Smoke Det. ! The Commonwealth of Massachusetts Department o f IndusV ial Accidents Office of investigations 600 Washineon street Boston, M,a 02111 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers Aonlicant Information Please Print Lega Name (Business/Orymization/Individual): Cy,(, 0/U/ Address: 2, City/State/Zip:_� �(�,(� Phone#: �'3 Are you an employer?Check the appropriate boa: 1•❑ I am a employer with 4. ❑ I am a general con7sheet F7. e of project(required): . ` employees(full and/or part-time).* have hired the sub eu'construction 2. I am a sole proprietor or partner_ listed on the attachRemodeling ship and have no employeesThese sub-contractors haveworking for me in any capacity. workers' coin . ' ❑Demolition p insurance. eq workers' comp. insurance 5. ❑ We are a corporation 9• ❑Building addition 4 required] rP ration and its 3•❑.I officers have exercised their 10•❑Electrical repairs or additions mysself [No workers'comp. a homeowner doing work right of exemption per MGL .11.❑Plumbing repairs or additions c.d 152 in��*�nce required-] ,§1(4),and we have no q ] t employees. [No workers' 12.[]Roof repairs POMP.insurance required,] 12.❑ Other )3omeowners'that��k box=? mut iso 1'iei cef the sectio^belay a,va +^ti Who submit this afi7davit indicating the~ _ n.�;^ �� m-a•QZ„� con's•-..�.•'-ti-Yv::CJ 'Contractors that cbenk this box must attached an additional sheet showing thea thin hire outside con+�ctorr�,ii ., itbmic a new aindavit indicating such. name of the sub-contractors and their warkets'co I am an employer that is providing workers'compensanon insurance or � Po�Y information inform¢iion, f my employee& Below is the policy and job site Insurance Company Name: UT �v(L,A M Ce- P� � � �--c�vv4 M Policy#or Self-ins.Lic.#: ( (�a�P o2 O (02 p ,o 1 7�-. Expiration Date: OJ Q� Q Job Site Address: r'J -fog/D 6 {� r l `5J City/State/Zip: �t/ ' AV to L,�tAN . Attach a copy of the workers' compensation policy declaration page(showing the poky numberand expiration date Failure to secure coverage as required under Section 25A ofMCiL c. 152 can lead to the imposition of criminal ) fine up to$1,500.00 and/or one-year imprisonment,as well as civil Of up to$250.00 a day against the violator. Be advised that a co Penalties e the form of a STOP WORK ORDER Penalties af�y Investigations of the DIA for insurance coverage verification. Py of statement may be forwarded to the Office of I do hereby certify under the Pa4andpen&jaes o er , 1 P %mJ that the in•formaiion provided above is true and correct Signature: Date. Phone#: �f � � �-� _ - Official use only. Do not write in this area, to be completed bJ,cam,)or town offccral City or Town: Issuing Authority(circle onePermitucense#): --------------- 1. Board of Health 2.Building Department 3. City/Town p 6. Other Clerk 4.Electrical Inspector 5.Plumbiab.Inspector Contact Person Phone.#: i Information an- d Instructions Massachusetts General Laws chapter 152 requires all employs to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every pt✓rson 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 tine legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership,association o>r-other legal entity,employing employees. However the owner of a dwelling house having not more than three apartazen�and who resides therein,or the occupant of the dwelling house of another who employs persons to do mainte 3nance,construction or repair work on such dwelling house or on the grounds or building appnrl-een thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or lo.c l licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to cn:enstruct buildings in the commonwealth for any applicant who has not produced acceptable evidence of co=mpliance 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=-til acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contr-a.cting 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'comp ensation 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 sig and date the affidavit The affidavit should be i.turned to the city or town that the application for the pertjrtt or liven-se rs being requested,not the of Industrial Accidents. Should you have any questions regarditxg the lav;or if you are—.�i:ired 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 stampesd 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 NOT required to complete this affidavit The Office of Investigations would Ince to thank you in ach-mce 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 Gf Massachusetfis. Department of Industrial Accidents Office of Im e�ations 600 Washington Street Boston,MA 02 111 Tel. # 617-727-4900 eft 406 or 1-8—/7-KkSSAFE Revised.5-26-05 Fax 4 617-72.7-7/749 ui''rW-IIlass-aov/dia Propool Page# of pages WPC Construction 124 Westford St Lowell,MA 01851 Proposal Submitted To: 19M D L=S A y Job Name Job# / C} i Address 9 , Job Location k/o n 1-14 Date 0 y ©!1 90 Date of Plans Phone# Fax If Architect r e hereby submit specifications and estimates for: ._..__......____._____._.—_.__..... ____.__.__.._..___. _ ___- --_ _ ,, ___ _�_ _.____._.._....._._____________......_.........__......____ v _....._-_......------__._____.___________ ____ __--------_..... __._.____ FRO-(, ---- ------ ___............----__-----________________ _._ ____________�____________ _----__ _ __ _............ ____ ------------- ffWe 7proposehereby to furnish material and labor—complete in accordance with the above specifications for the sum of: $ � �i�2C/S%/V.P 29/yd ©IVC lav N D let t Dollars with payments to be made as follows: - % 15�.�n 1 -���� TE-) Any alteration or deviation from above specifications involving extra costs will be Respectfully executed only upon written order, and will become an extra charge over and above the estimate.All agreements contingent upon strikes,accidents,or delays submitted beyond our control. Note—this proposal may be withdrawn by us if not accepted within days. Occeptance of J)ropool The above prices,specifications and conditions are satisfactory and are Signature hereby accepted.You are authorized to do the work as specified. Payments will be made as o`tli-d abovC . Date of Acceptance / " / _ 2-c> 1 (0 Signature 8z NC3819 MADE IN USA 580 Mvi ,dewo: I it✓11 , ..I ' 1� a tl� � l „ii. . .1. 1'1 ; .-1 .. \.J �' )1;• • ..i'i'. .- - ,. . �� i'•a ,'•7�.. +• +r ii: .'v 1'. .•��� 'l i1 i 1+.1. .. L't� i. 1 ., .it��+,. i�• + i 1 � .+1, ,..I � \ ... .,. ,t�- � ...t ��.\ ��.!��\ ' .� . 1, •i! ... � �r't /•• jl� \1�...il f.. �! i+. .Fi°T..{ +'. • �a,t i .i +�i�♦ T�..�nJL .:1 far...�� .-l'.i� t'. I'I+, }L....♦' ��.ri h.!`i:.�rl+. !1: *1•Ii. L i ..!i �� ;�E.l. .. i.i`l ii' ]'..i } .r. ..i v. '�•i'1 ...1S I .lr1, Il!, 111.1' LUC 10 iv�� ,.�.'l `..'.1.. !7i +�.'�' 'i t� - .!?+'...1 �_:L._. 11i Itl. All lli7rl7Unitt:r '11ali ht: rt2,,u1%Ld h� binding UTInU"allt►tl ill UC't:0TI.IUnC' V.il;l t.lr.: IWC!, ut il:lr werican Ar` `ra wn .k,%st,, ial'on. i C'txltra_t1+t "hal; nt►i ht' IlAhlt ft,r dna JC14a JUC [t► t:irt,U+llS(dnC':" burst d Its CI,r1t'MI thCttluittu iIt'ti, t<►��lalt t)r untl il:iE"ility l►f rnaic ri�tl.. 1? C ontractof v.ananls all wt►r', t()`u p}:rtod of day% folks"Ino eompl-Etitin- Now. T11\ thrill ;s not a substitute for the advice of an atmti%:, I.-gal Of try natUT Should he .ou ht from cumpacat. indvpcndvnt• lcgal counsel to the rJc,—int j6risdi"ion Absolut:ly no warrant rs are made regardink Ox suitability of this form for any particular purpose. Massachusetts_ Board of Department o ' Building,Rei t Public Sateh Construction S aulations.f License: C3 uPervisor L enseandards 4. Restricteq,to: 00 99244 WANOR DECgRVgLHO 124 W ESTFORD LOWELL, ST MA-01851 � tier i Expiration: 9/5/2011 99244 077 Ot�IL � 4 mei' arrs tsusmess a ,m iOW HOME IMPROVEMENT CONT g f �^ CONTRACTOR Registration 163989 Expiration .:10/2011 -_� Tr# 287684 Type {� 1 WANORDECAR� rc_=�4 WANOR DECAf,V, =.} 124 WESTFORD7 0 " Y v. LOWELL,MA 0185 j 9 Undersecretary