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Home My WebLink AboutBuilding Permit #666-14 - 15 STACY DRIVE 3/31/2014 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: A Date Received 3-51- a0/S/ Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION /S 4rr9c.y CK ,A)dr?.T4 4n b0Vf_A M 14 D18YS Print_ PROPERTY OWNELy— Print 100 Year Old Structure yes o MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT. PROPOSED USE Residential Non- Residential ❑ New Building KOne family ❑Addition ❑Two or more family ❑ Industrial RAlteration No. of units: ❑ Commercial "epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic ❑Well ❑ Floodplain ❑Wetlands 0 Watershed District VWater/Sewer DESCRIPTION OF WORK TO BE PERFORMED: ADD 3/V 6#41-1\ - geP%od-e L - 61,fSrC0- b,4*h kiACACAv C14gtn�. nook%-%q 4Z.e,9/4 c e GA rA.G ADS IC,,� (W �- - ��1� •��s Identification Please Type or Print Clearly) OWNER: Name: C 4-rw%( R Pv( l cl iks Phone: 9 78- X86- 3337 Address: Faewuw, 5f Nor?-+ )4apove,-L CONTRACTOR Name: 4 v I 'ns qac Phone: Address: e14ttew nit ST` Ala Supervisor's Construction License: C,5 osg /OS Exp. Date: Home Improvement License: Exp. Date;_ ARCHITECT/ENGINEER Phone: Ad rmss. - - - - - - - - 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: $ 3aoy . FEE: $ Y Check No.: �- Receipt No.: �� . y NOTE: Perso ontracting ith unregistered contractors do not have access to the gu anty fund Si nature of A ent/Owner Sig �afure of contractor - Plans Submitted Ej Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ - Plans-Submitted ❑ -.Plans-Waived-El- `_Certified Plot Plan ❑ Stamped Plans ❑ :TYPE OF::SEWER-AGE 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:APPR-OVED 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 Water & Sewer Connection lSignature& Da#e Driveway Permit DPW Tow,! Engineer: Signature: Located 384 Osgood Street FIRE-DfPARTM:.L-;NT.-:,Temp Dumpsteron site yes no Located7at!124,Mair Street Fire"Departure►if•signatureldate ' tr. - • _ - _ _ - - I COMMENTS ' : - - -Dimesion 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 DANGERZ®NE LITERATURE: =Yes No MGL-ChapterA66_ 21A-F and G min.$100=$1000.fine NOTES and DATA— (For department use do ff e At,�7iz-- ® Notified for pickup - Date Doc.Building Permit Revised 2010 Building Department :,,The fol-)wing is'a.list of=th6.requlred=forms to be filled out'-forAhe appropriate.permit to:-be obtained. Roofirg, Siding, Interior Rehabilitation Permits ❑ B,uilding Permit Application ❑ Workers Comp Affidavit a Photo Copy Of H.I.C. And/O•r G.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 o 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 Li 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 fo issuance ot-Bidg 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 apn•,al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subrn.tted with the building application Doc: Doc.Bui?ding Permit Revised 2012 Location No. — Date wl • - TOWN OF NORTH ANDOVER • n.�n r6�� . • r Certificate of Occupancy $ Building/Frame Permit Fee $� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check t t4 r • 4 `j ' i Building Inspector NORTFi Town of over p 0 No. ".Iq h ver, Mass,0 4"_ LAK 31 CO[NICNl WICK 1. � o RAreo ok S U BOARD OF HEALTH Food/Kitchen Septic System • THIS CERTIFIES THATPERMIT . Lr irs '(................ ...................... BUILDING INSPECTOR has permission to erect ........... buildings o .......... ...*l.w.....';t;�, ��,,,�,............... Foundation / � Rough to be occupied as ,.......C.0.11.10 �....�...10 ....... 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. F b+6 A. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR O • UNLESS CONSTRUC72N S S Rough Service ........... ......................... ................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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. Smoke Det. Bo assa�huse arty O f B tts_pe uitain part,�ent P 'cense.. -110ll �nOntations �S tic,,saf, PA CS-05 .r ta�'ar l 121 G. T,�,�usEr'r9105 ds NOnh AndAnd D ST,/- A Ando fi0184s 44 / ��ssioper'�n n a % 05/S�O1O� / 14 / The Commonwealth of Massachusetts , - Departmint of Industrigl Accidents Office of Investigations 600 Washington Street .Boston,MA 022111 www.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Prins;Leaffik Name(Business/Organization/Individual): `eO 4 V. Address: i 2• t F�0.wv w� S� City/State/Zip: Nott-rk 14N1b 0Ve1 N9 A- Phone#: 91 —(0 8'G — 3337 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and'have no employees These sub-contractors have 8. E]Demolition working for me in any capacity. workers'comp.insurance, g, ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10❑Electrical repairs or additions �, 9uired*1 officers have exercised their 3.I"Z am a homeowner doing all work right of exemption per MGL 11.[]Plumbing repairs or additions myself.[No workers' comp. c.152,§1(4),and we have no 12.❑Roofrepairs insurancere ed. employees.[No workers' comp.insurance required.] 13.[]Other xAny applicantthat checks box#1 must also fill outthe section below showingtheir Workers'compensation policy information. i-Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. TContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. 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.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation-policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A ofMGL o. 152 can lead to the imposition of criminal penalties of a :One 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 ofthe DIA.for insurance coverage verification. I do laereby cert&under the pains d penalties ofperjury that the information provided above is true anti correct. Signature: Date: 3 gar Phone# g 7 Y `y M — 3 337 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 Instrnctions 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 ofhire,• 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)andphone 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,apolicyis required. De advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. AIso 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 thatmust submitmultiple 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 Mid fax number: Tho Co oxlweajt� of ma achmetts - Depart mit ofludustxiialAccidents Qfrice of Investigatiom 600 Wasbiogton 8txeef; Boston}MA.4.21.11 Tel,#617-7.2.'-4900 OA 406 or 1-877-MASSA4FE Revised 5-26-05 Fax#617-727-7749 _wWvv_=s,gov1clia TO"OF NORTff AND OV p , as 1} 13LUDING DEPARTMENT -1600 Osgood Street Building 20,-Suite 2-36 7qS+�rrn "�i5 NOrthAMOVex,Massachusetts 01845 �Rcuus�•. , Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings . Fax (978)688-9542 HQMEOWNER•LICENSE EXEMPTION BUMINC,PERI4ffT APPLICATION Pleasoprinf , DATE: 3- 31 AM LOCATION: S S Tia- c Number SireetAddress Map/Lot ]JOMEO)IER Av I e r1l 9 7� � ��(� •33�7 Name Home shone Work Rhone -PRE-SENT MALM ADDRESS 101 y A-rl+ 4N7 1101/,, c . zip Code The current exemption for"homeowners"was extended to to allovV sUbh bomeo ttr - ' �GlLtde owner-occupied dtvel�ur gs to two units oz ass and ueas to engage au individual•forhire who does notpossess a 7 cense,provided that the owner acts as supervi or). SiafeBuilding (Code Section X08.3.5.7) DEFINITION OFHOMEOWNER 1'erson(s)who Awns aparcel of land on which helshe resides or intends to reside,on which there is,oris intended to + be,a one or two family structures. A person who constructs more that one home in atwo-yehe, i1 shall not be considered a homeowner. The undersigned"homedwner"assumes responsibility forcompliances with the State Building Code and other Applicable codes,by-laws,rules and regulations. The undersigned"homeowner"certfes that he/she understands the Town of North AudoverBuilding Deliartment mum inspection procedures and requirements and that he/s e will comply with,said procedures and requirements, / HOMEOWNERS SIGNATURE C. . APPROVAL OF BUILDING OFFICUL Revised 7.2009 Eonn$omeowners Exemption ,BOARD OFAPPRUS689-954IC01�5ER�r r ttTION 688-9530 HEALTH 688-9540 PLANNING 689-9535