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HomeMy WebLinkAboutBuilding Permit #390-2011 - 158 MAIN STREET 11/5/2010 BUILDING PERMIT of Na pTk q TOWN OF NORTH ANDOVER c2 h��t_ ✓;3J 6�a~� APPLICATION FOR PLAN EXAMINATION 3 4 v / y Permit NO: Date ReceivedTED y a �gSSACHUs��� Date Issued: 5 .�� IMPORTANT: Applicant must complete all items on this page LOGATI©Na. PROPERTY MAP+NQ:�'`�, . PARCEL: ZQNING;DISTRICT:. Fiistonc'District ly 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 ;(Repair, replacement ❑Assessgq Bldg 9 Others: CkAV Fit` ❑ Demolition Other k-;4 C ti Septie ®tWell F f,Floodplaih M Wetlands p:'1%1/atersfiedipistricf ❑Water/Sewer+ - - DESCRIPTION OF WORK TO BE PREFORMED: dentificationl P ease Type or Print early) OWNER: Name: Phon - Address: �CONTIRAGTOR :Nam:e: Phon — Add cess �"�� __.JI.K�(�'C��:�\�I N.��: _ - •+c7 t�?,�`rn �`�� -- t�`�C��q- � k.,_.,., . - ' Supervisor's,.Construction;License: G � lg���.r - _ 1Exp: Da te:_ �_,; p,�w�Y Home Ir proypMenf.License: Exp. Date` i ARCHITECT/ENGINEER (V('Z14 t-tPhone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ M= FEE: © Check No.: � Receipt No.: aZ 3 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund ,Sig nature�offAgeht/Qwnerr _ n. -_ Signattare of_coritr_actor ._ 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 Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street �F_REBEPARTM- T Temp'Dumpsteron site eyes no ;Locafed�af 124�Main;St�eet Fire0epar'tmen 4sigi:;ature%date _ - I 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 C6A� ❑ Notified for pickup - Date ' I 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 ❑ 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 Construction and Two Family) Newonstru (Single le g ❑ 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 p p Compliance Report ❑ Engineering Affidavits for Engineered products MOTE: 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 i Revised 2.2008 //��yy�� X37. G,1 PCV.�ljs Ael,11PVA4,11 Location ///f1/4) iE'��'r CLjwtc! No. 2?,0--w// Date 11151-9010 �oRTM TOWN OF NORTH ANDOVER 9 Certificate of Occupancy $ Building/Frame/Frame Permit Fee $ s,KMust 9 Foundation Permit Fee $ Pio Ili OtherJPermit Fee $ TOTAL $ Check # �aJ 23666 Building Inspector The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print'Legibly Name (Business/Organization/Individual): Address: 4°,R no mown ar i City/State/Zip: Q},evf� yl� p7,p`t Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.[X I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction part-time).*employees full and/or . have hired the sub-contractors p Y ( P ) listed 2.❑ I am a sole proprietor or partner on the attached sheet. t 7. Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in an capacity. workers' comp. insurance. Y P ty• 9. E] Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL l 1.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.]i employees. [No workers' 131-1 Other comp. insurance required.] *Any applicant that checks box#I 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. #Contractors 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.#: � =7 � Expiration Date: Job Site Address: `aIm RT City/State/Zip:�p&WI MJ'_Y, )-4 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 ce Qunpr tlr in nd penalties of perjury that the information provided above is true and correct. Si nature. Date: Phone# 1(on) 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-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 pen-nit 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 sur&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 pen-nit/license number which will be used as a reference number. In addition,an applicant that must submit multiple pen-nit/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 pen-nits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or pen-nit 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 Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia uaaaasiapull 6LO£O HN'W31dS 1SNI`dIN H180N 6ZV SNI110013VHO1W §Iy17100 V 13VHOIW edA Zt0�t9C'1.r>: uoge�ldx3 nua 1p1 8056t►4`' mO-LOvu1NO01N3W3%1021dW13WO14 uo4x102ad ssaulsag V snxjjV iamnsuo0.lo aay;O 8OZL :#J1 �aunits�uuuq) ILOZQIL.:uol;el►dx3 £LOCO HN 'W3WS N ° M X08 Od/1S NIVW N 6Zi► K SN1 1'100 V 13VH01W h Yli:)uYU asweq ap yf wMn�.a JL :o;palolalsab L96W SO :asuaDl-1 asu031-1 aoSIAJadnS uol;onj;suoO sparpur.;S pur, suoi;rin.;ag ;uipl!ng jo parog U?;rs ailtlnd.;0 luaut;.tl:tiaa -slaasnyaltssr.W r` EverGreen Environmental Co.hducted b Health ft Safe Y Associated Gener ''Inc of Vernbnt al Contra' Certificate ,,Of Attendance Renovator Initial_ and Successful Corn English Per 40 CFR 745.225 Mike Collins P0• Box 281 N.Salem, NH 03073 Certificate • Number- R-1-19630-10-001 umber; R-1-19630-10-00288 �4 � i The Commonwealth of -Massachusetts icon' Department'of Fire Services : . "° aft Off-ice of the State Fire Marshal P.O.Box 1025 State'Rnad,-Stow,b1 k 01775 ' PERMIT ' Date: North Andover perzztiti�to i ' • •(City of Town) (If Applicable•) Dig Safe Nnun er In accordance.with the provisions of Ni-G.L,1 Lt.8 Ghndtcr 1 0 asprovided in section 7 7 C'Mg 34 Start Date This Permit is granted to:. Pull name cfpecsoa,Firm rperation pCm2issionto locate dumpster • for const ruction/renovation/demolition of building, Comments:' dumpster. must be. 25 t from structure if unable to Place with reciuired Rcstrictioas: ' clearance dump^s�ter must be covered withAl wood or tar end of 'work -day at �/�j r / ^iL. 6 �.. (Give location by street and no.,or describe' ch manner as to rovied adequate ideatificadon of rocatioa} FeePaidS 50.00 • ' Fire'. Chief This Penirit will expire O � _311 mature o c granting permit) Offical granting pcmut W (Title) 6. N° FD 7508 Date4.-�:..:<<�... NORT/y TOWN OF NORTH ANDOVER s�� ". ,, .�•: » RECEIPT e�+crtuae This certifies that !�t� ....�'l! ............................ haspaid.v�• .......'... ............................................................................... for. i!j'1.� ! ''� :... '' ,f���.�./... ............................. Received by..... D'xx.&o. D...................