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HomeMy WebLinkAboutBuilding Permit #722 - 151 SANDRA LANE 4/12/2012 BUILDING PERMIT r1ORTH TOWN OF NORTH ANDOVER o APPLICATION FOR PLAN EXAMINATION 1 u . �7 �? // Cafe o ,> Permit NO. Date Received ,� �'�s R^TED S/1CHUS Date Issued: 1 Z-I fl' �(01R_iTANT:Applicant must complete all items on this page ^mow ,Prmf PROPERT41(#�OWNER° — Tn Sho tVlla `e es. no i F.MAPIN® FARCEL ZONINGDISTRICT: _ x ' fHistoncl®istnct eyes o. A IMachine TYPE OF IMPROVEMENT PROPOSED USE Residential Non Residential ❑ New Building ❑ One family [I Addition El Two or more family El Industrial ❑Alteration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other a4S pfic l µ: _ `' ®f_loodplam Wetlands v 0 '+Watershed.D_ istrictj D Water/Sewer 1 - - - DESCRIPTION OF WORK TO BE PREFORMED: ,�e�ove G��S'%�•v Fix%GAPS '7'ife �` �,eylL r,4LL drew �IxT�vec.� ,ye w f<& �� Iwo SLio�vPrt .4d1P.¢ �Lorrst. /YPr� Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: tCONTRACTOR Name<. 9*14 Exp: f Date 7/G Lca� i .Supervisor� tConstrucfion License: - `Exp.. ARCHITECT/ENGINEER Phone: I k Address: Reg. No. FEE SCHEDULE.,BULDING PERF$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ / r1 -Soo, FEE: $ 2-0 Check No.: 1 `�, Receipt No.: 1 `� _ ._ -- _ NOTE: Persons con kacting with unregister,,�-ed cont`tors do not have access to the guaranty fund Signaturetof`A 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 �I 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--3M Osgood Street FIREIDEPARTMENT TbempDumpsterKoni ' eyes ino �Loca'tedtafi 124tMaiiiStreet jf C..OMMEN TS -- _- ---- 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 i Doc.Building Permit Revised 2008 J 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 ❑ Engineering Affidavits for Engineered products NOTE: Ali 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) E ❑ 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 a Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 i Revised 2.2008 P"e No. of Pages STEPHEN RQ. =SUNG 4 "Am& Remedeft 9 9th Steet West SAsbtsy,MASSACHUSETTS 01952 MA Ur 027489 Home tom. 201946 Pie(978) 682-2072 * (978)465-4712 POSALsuairruDio Prroeff IME U�/G �i� 2D/ sm�r .arra ?y, CRY.STATE ow ap CWE JW IACATM AFiGTQiEtr DATEOFR.ANS - _ MBPH(7NE We hQerftsubndt/specTicasom acrid Q four: GJ51 D X 2 '0' -ems �c�r�,. x-Lc�a - �� � ta_ ✓ ate.– fry, oD �i,7..- cu�z , ee��" ', ele_ All— P VLOPW hereby to furnish material ansa labor—complete in accordance with above specifications,for the sum of: L-10L-10f le 300, Payment be made as taltwvs !� 7 3 doh(S )- 10 Au rteaMM is WmuwftW W be as apex d M wmk to be caffoefed in a warto accm*Mtostandard Atryat mrtA�Ia§w*mnatmve� AtitltorEed h-MM ema costs"be e> 0*0 C*upon w ift orders,and%VM became an extM over and above the est Aff ee11 1 etppn _ decays beywrd au corNai O�to raey i p my be toys Our workers are taffy covered by wars Om�aam ktsur� vveStdra�m by res ff trot accepted wrfitm —The above prices,specil'ications and cxndetiwm are satisfactory and are taft accepbA You are autltor¢ed S'igrmhue tQ do tfie work as Pa�rtrnntt q� be made as outlined above_ NORTH ® Of over % . No Z2 _ I P71' 0 _ o , '� dover, Mass-,42 LAKE COCMICHEWICK y1. S RATED P �5 BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THISCERTIFIES THAT.................. .. ......... ............ ......1!1! ................................................................................ Foundation has permission to erect...... ...:............................ buildings on ...J.r.'.......... .�.....1.111060................. Rough to be occupied as............. .�► .....�....�...........� .. .. ...................... C imney provided that the person accepting this permd 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. PLUMBING INSPECTOR. VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ;L*� , CONS �' ELECTRICAL INSPECTOR UNLESS r LESS Rough *L ... r.Y................................ Service :: i BUILDING INSPECTOR Final IOccupancy 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 SIDE Smoke Det. P�� � 8 �1` �'��41 � F�� 9 � t j `�( gg �� � � �� �B►l� ��l� � � �g yf3 e �piF j Pij tsR�PS iIlkR OP ir Ir R ggp ( P i •" i E t � t �� � I FSE i Cont acturArbrtradaa The Home kPOVewd CW=dWUWMMdes bnnoowmers with tleright mimtiafie an arbbt 2flon action(as an aftmative to cant act)if 8hey have a&pne with a at>nhaetar. The salla tight is not altomdiealby affadad to a oo rt,however 71we coMmAorwcold have toresolnany dispfthd9whaswidhalm in court both parties agree to the optiond dam luovmed below lVa wodd*n*econm=mw&e=nefl&tD arbitration as is affmded to the homed wncrby the Home hgpwvemaA CaulmetwLaw The wand the homeowner hembymutuatlyagtee in advancer id in the event.the coonctorhma coIIc=fiDgthsCt►nU=C.the coa actormaysobmittledispn6etoapriie3tearbihationfiemwhiclhhasbeenagp+avedby Me Sezaryof&elixeumtiveOffice ofConnancrAffansandBAR andtheconsumer"besequned to submitto such arbitration as provided In MRSMIUMM Geral 'M 142A_ Homeownces sigaaime s NOTICE:She swudmes ofthe parties above apply only to the Weement of the patties to alternative dispute 1asoIU110n imtud ed by the ccubaitor-11chunuxomermw hhif altemnative resolution even where this sectionis notsVinWelysigned bythewitm / Homeowner'sRights A homeowne'sAghts undarthe Home lm l Contractor law(MGL chapter 142A)and other consumer PMocdw laws(ire.MM 93A)may not be waived in any waxy,eves by agteemeat. However;homeowners may be excluded from zighis ifft eon they dhoase is not ptopa fy registered as Eby lay. Homeoweaswho seiaue their own building permits we automatically excluded fm®all Gumady Fund the Home Improvement C Law. The comtrarxor is of timely andworhmnmabilz m� Hom wwnets to d to orb ter camzpletiog the vwu�as des acWr s a may be estitted to other specafific begah rigttfs ifihe orpwvides an express warranty forte ordain.ht additiontoguarantees orwa sties lxovidedby the all goods soldin ll cmry an implied vma, y of11 a , I and fitaetis for a paztwular lonpose-An emlmagrotion ofaffiff an whirl,the homeowner and conuactor hawdnlly agree may be added to the teles ofthe contract as long as they do sot reshict ahom cowmes bade comsomerdghts. Ifyon have questions about your consumedlomeowner rights,contact the Consumer hiffiamation,Hotfine(listed below). Execution of Contract The coutmct ilmstbe exealted in 4MR11glLe and should not be signed until a copy ofdl exhaft and refereuced dou>amlds have been anac ed. Parties are aim advised notto sip thedocamcat UnM an blank sections have been Mod in or ma&ad as void,deleted,ornot applicabin One original signed aWofthe contractwith its into bre given to the awRw wd the other kept by the conhutor-Any modification to the or4n t contact Abe in wti6ng and agreed to by bothparties.Contracted wo&may notbegin unM both patties have received a fully executed copy of the coating and the llnee day rescission pmiod has cWhed- AaAerated expired- APayments A conhac;W may notdemand paymeois in advance of&c dates spedfied on tate paymentschedale in cases whetethe hOmcownwdeemhm2&cmfftobefiamiewHymsecum i3ovuevay m mstanocs where a Jnr deems hnn&asdf to be financially insecure,the eanbacturmay mquim that the balance offinds notyetdue be phased is a jaintw account as a pmeqWSUD to continuing the conhacted wo& Vrdh avrl of finds fibom said accountwouldicqunotbe, siVnImes ofbothpaties. Additional Inf wmatiou Ifyou have gel gciestious orneedaddibaual information.about the Home ImpwVMcut Conhac for Law or other conslOM rights,or ifyou wish to obtain a free copy of"A Massac uaseits Consumer Guide to Home lmpraverocu" contact; r Constlmerinformation Hotline Office ofCausumaer Atfims and Business Regulation 10 Pa&Phma,Room 517%h3osta%MA 02116- 617-9738787,08-293-3757or visit the OCABRwebsite at -tiIr"rr.::-;c.macS-savioC bs' Ifyon wast to verify the reglshation of a contractor or ifyou have questions or need additional khmadon specificany about the contrHtarreglshation corms of the Ham lmptovement Canuactor Law,coutact Director of Home hWevement Coaractor Registration Office ofConstancrAffaits and Bumess Regulation 10 P9&Pba s.Room 5170,Boston,MA 02116 617X973-8787,8W283-3757 or visa the Hicvabsrteatl,L =_s,.,2fwitlCai, Go online to viewthe stahls of aHome bvwvemcnt Cis i elf;r.%ids.sf ate.ma.us:�7C5RiL'iTI`.ii)�L'i2lCilt�tSCC(I5.^. tiSl.:rS`? Regisftafimu- For assistance wghmfonnal mon ofdisputes orto regime formal complaints against abusums,call: ConsumerComplaint Section Officeefthe Attorney General 617 7274MM AND7OR Better Business Bateau 50"524M 508-755-2548 or 413-734-3114 Yasionzi-ltr=2010 i i I I Brockway-Smith Company i www.brosco.com _ ce { f zk-eA , r t � i ( i 4 1 a � i f F• V � t I i x 1 z t ff i _ F = Y i i 4 1f TI- 4- -4- - I j I ( E d , ' t( f ate..._... _......... f 5 } t t s' a ; ANDOVER, MA 01810 COXSACKIE, NY 12051 HATFIELD, MA 01038 PORTLAND, ME 04103 146 Dascomb Road Hudson Valley Commercial Park 125 Chestnut Street 203 Read Street 1-800-222-7981 1-800-222-7303 1-800-922-0191 1-800-442-6734 Fax: 1-800-242-4533 Fax: 1-800-222-7304 Fax: 1-800-922-0296 Fax: 1-800-443-0331 The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street s� Boston,MA 02I11 www.naa_ss govldia A licant Information - Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Please Print Le ibl Name(Business/Organization/Individual): Address: • I City/State/Zip: Phone#: 97 do' 3/?-- eYf 7 [[:] 1 an employer?Check the appropriate box: a employer with 4. Type of project(required): ❑I am a general contractor and I loyees(full and/or part-time).* have hired the sub-contractors 6 El New construction a sole proprietor or partner- listed on the attached sheaet. t 7• ❑Remodeling and have no employees These sub-contractors have 8. [❑Demblition ing for me in any capacity, workers'comp.insurance. workers comp.insurance 5. 9. ❑Building addition p ❑ We are a corporation and its red.] .officers have exercised their 10.❑Electrical repairs or additions a homeowner doing all work right of exemption per MGL 11.❑Plumbingrepairs or additions lf.[No workers' comp. c. 152, §1(4),and we have no 12. Roofreance required.]t employees. ❑ pairs [No workers comp,insurance required.] 13•❑Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation T Homeowners who P olio inf submit this affidavitindi indihirecating post licyubmit a ormation. G the are Join' then ing suc #Contractors that check this box must attached an additional sheet showing the name of the sub-contractoroutside s and their workers'oampapol cyavit infotrmat on. an employer that is providing workers'co information. mpensation insurance for•my employees Below is the policy and job site . Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: , City/State/Zip, Attach a copy of the workers'compensation policy declaration page(showing he 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 maybe forwarded to the Office of Investigations of the DIA,for insurance coverage verification. fP J , Ido hereby certify un t ze pa' s and enalties o er'u that the infornzationproviderl above is true and correct. Signature: Date: �—�/— 20/2. 'hone#: /�7 3/S�� ey-'5 7 FJ�ss:ulng only. Do not write in this area,to be completed by chy or Town official. n: Permit/License# ority(circle one): , I.Board of Health 2.Building Department 3.City/Town Clerk 4.EIectrical 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 apartinents 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 sha11'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 ofpublic 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 retained 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 n (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: xhe COM-nwearm, of jVj1assachi,�se-tts Department of h dustriEd Accidents Office Of InVestigattons 600 Washington Street Boston;NA,02111 W.#617-727,4900 ext 4406 ox 1.-877-MASSAFE Revised 5-26-05 Fay,#617-727-7749 www.mass.gav/dia �✓lze-Pan�no�uuea/,f/ o�,��.aaacccYaueelta . Of0e of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR t = Registration: p101846 Type: Expiration: 8/29%2012 Individual .STEPHEN M.KEISLING> Stephen Keisling -; 9 NINTH STREET SALISBURY,MA 01952`vim Undersecretary Nhis'sachusetts- Department of Public SafetN Board of Building ReguIations and Standards Construction Supervisor License License: CS 27489 STEPHEN M KEISLING 9 9TH STREET WEST SALISBURY, MA 01952 c— J"'`� Expiration: 7/16/2013 ('ununissi°ncr Tr#: 19624 Location�7, ��J/?l//�lI ���< No.--)'7'Z— Datelob * - TOWN OF NORTH ANDOVER e • ,. Certificate of Occupancy $ Building/Frame Permit Fee $ � Foundation Permit Fee $ Other Permit Fee $ "L xy TOTAL $ Check# 25174 Building Inspector