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HomeMy WebLinkAboutBuilding Permit #620 - 16 FAULKNER ROAD 3/16/2011 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: ✓ IMP RTANT:Applicant must complete all items on this page LOCATION - Print� PROPERTY OWNER D p L �W� Lv� )n /�i��� Pte, Print MAP NO: J� a PARCEL: Od/� ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family [I Addition El Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition El Other t .. u�- -� W ct afershed}pistr . z�'Septc `Well ❑iFloodplaiii . Wetlarids ' DESCRIPTION OF WORK TO BE PERFORMED: 2 ba,41i auv v5 rA ur d rLrt)•w\ , Lam;6e 1 1L. ®��Y�Ar�S i n h V lr w 5 Identification Please Type or Print Clearly) OWNER: Name: 1 6U�I GAS L u A W n Phone: Address: F m L,16 er CONTRACTOR Name: Phone: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ U TJ FEE: $�?��D� Check No.: _ � Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of_Agent/Owner : ignature of contractor Location �l 4,_ No. Q Date !&ORTN TOWN OF NORTH HANDOVER f �,Y F A A s Certificate of Occupancy $ cMus etas Building/Frame Permit Fee $ L ` s� Foundation Permit Fee $ *— Other Permit Fee $ �r TOTAL $ Check # 23965 Building Inspector Date.... ....... r f pORT1� ° s"`° '•�"° TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ,SSACMUS� This certifies that ...............1..!I�� .... /............. has permission to perform ........ ...1��! lL�/K�f........................... wiring in the building of...............1.!�D 9 rL..............�............................... at ................... ..... .North Andover,Mass. o0 2 Fee.4� .q.`" Lic.No.1....1..x..16......... . � ELECTRICALINSP�CTOR Check # 3cs'aiog.y Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody 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 f COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water &c 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.$10041000 fine NOTES and DATA— For department use (AAS 1 bo'AU'o , r,vovak � exi6 bAVln a� 1 laUr'AVV/ ruor^ v tti/i►�e syn . U 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 ❑ 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 peals that the appeal period is over. The pplicant mut then get his recorded at the Rewn Clerks office s ist stamp of Deeds. One co m andthe proof of roard of ecording rnust be submitted with the building application g copy p g Doe: Doe.Building Permit Revised 2008mi Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No.-- BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked V. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: City or Town of. NORTH ANDOVER e AIn 4eo&r�cqffWi r e_s: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) Owner or Tenant 000a L_uA,,i n Telephone No. 11,61-1?409 Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building_Du_y_na Utility Authorization No. Existing Service LIZ Amps 'Ca-0 /aS a Volts Overhead Und rd g ❑ No.of Meters New Service aW Amps I a0 /,qb Volts Overhead❑ Und rd g ❑ No.of Meters N Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: otY� Completion of the followin table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- .o mergency Lighting . rnd. Md. ElBaotte Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and I itia ing Devices No.of Ranges No.of Air Cond. Tonsl No.of Alerting Devices No.of Waste Disposers Heat Pump -Number...Tons KW No.of Self-Contained Totals: Detection/Alertin o,Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal El Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Water , No.of No.of Devices or Equivalent Heaters Ballasts Data Wiring: ` Si ns BBalNo.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of El ctrical Work: L400o,O(7 (When required by municipal policy.) Work to Start: I Inspections to be requested in accordance with NEC Rule 10,and upon completion. INSURANCE C VE GE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coy age is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE M BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties ofperjury,that the information on this application is true and complete. FIRM NAME: — e 1(_1,a LIC.NO.: ` X403-. Licensee: a t1'�t r' Signature LIC.NO.: (If applicable, enter " empt"in the licens numb r Ire.,) f la�o _ Address: I/� �� �- , /A Bus.Tel.No., )971?a0QS9a *Per M.G.L c. 147,s.57-61,security work requ es Department of Public Safety"S"License: Alt. c.No.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one Owner/Agent )❑owner ❑owner's agent. Signature Telephone No. r PERMIT FEE: $as ELECTRICAL PERMIT NO. IlNSPECTTOri REPORT: ELECTRICAL INSPECTOR 4 DOUG SMALL Y.ROUGH SPECTION: Passed Failed-[ Re-inspection requirecl($50.00)-[ ] Inspectors'comments: • �... (Inspectors Signature-no in(ials) Date 2.FINAL INSPECTION: Passed- Failed-[ .] Re-inspection required($50.00) Inspectors'comments: -/•2 -C (Inspectors'Signature-no* itials) Date 3•UNDERGROUND INSPECTION: Passed-[ I Failed-[ i Re-inspection required($50.00) [ ] Inspectors'comments: (Inspectors}Signature-no inifials) Date 4.INSPECTION-SERVICE: - DATE CALLED NATIONAL GRID: Passed-[ ] Failed Re-inspection required($50.00)-[ Iaaspec$ors'comments: (Iuspectors'Signature-no initials) ' £ � Date 5.INSPECTION-OTHER: Passed-[ ]- . iled-[ ] Re-inspection required($50.00)-[ Cuspectors' comments: Ospectors'Signature-no initials) • Date I)OOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE 7F THE AREA TO BE ECTED IS NOT ACCESSIBLE AND ARE-3WSPECTION OF S50.00 IS TO BE CHARGED. 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):,a�,(\ 1 1 l , gtKW Address: r I a Rio" �. City/State/Zip: �. n1 'ate phone#: 7g -7Q Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ 1 am a general contractor and I 6. ❑New construction mployees(full and/or part-time).* have hired the sub-contractors E] Remodeling 2121 am a sole proprietor or partner- listed on the attached shget.t ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp.insurance. 9. E]Building addition [No workers' comp.insurance 5. ElWe are a corporation and its required.] officers have exercised their 10.VElectrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. o workerscomp. c. 152, ,and we have no y � ' p §1(4) 12.0 Roof repairs insurance required.]t employees. [No workers' 13.0 Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new 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 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 pens es erjury that the information provided bov is true and correct. Signature: q Date: 19 O/ Phone#: 1 7, 1(?,9 d g 9 a 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#: .v 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 F 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 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 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 The Commonwealth of Massachusetts Department of Industrial'.Accidents Office of Investigations 600 Washington Street Boston,MA 02I11 www.mass:gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Flectriciansfplumbers Applicant Information Please Print I,egibl� Name(.Business/Organization/fndividual): DO U Address: k(o Fa�Alcyn l — Roo d- City/State/Zip: N 0A AN d OV t - Phone#: U 6 t` 4M_ 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. F1 New construction employees(full and/or part time).' have hired the sub-contractors 2.EJI am a sole proprietor or partner- listed on the attached sheet.s 7. E]Remodeling . ship and have no employees These sub-contractors have 8. ❑Demolition working for me in an capacity. workers'comp.insurance. g Y9. 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.KIam a homeowner doing all work right of exemption per MGL 11.❑Plumbing-repairs or additions yself: [No workers'comp. c.152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] 13.❑Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 7 Homeovmers 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.Lie.#: 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 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 ofup 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. I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct. Si ature: ]:�� Date: Phone#: ZS T M 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): X.Board of Health 2.Building Department 3.CitylTown CIerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: F µORTH TOWN OF NORTH ANDOVER 20t�T�eo h6'S4, oA OFFICE OF BUILDING DEPARTMENT 1600 Osgood Street Building 20, Suite 2-36 North Andover,Massachusetts 01845 SSgCHUs�� Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE: JOB LOCATION: �� �avlkrler �q�1 Number Street Address Map/Lot IJOMEOWNER D 0 U a5 W NamV HomePhone Work Phone PRESENT MAILING ADDRESS City Town S+w+w. Zip Cede The current exemption for"homeowners"was extended to include owner-occupied dwellings to two units or less and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is,or is intended to be,a one or two family structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned"homeowner"assumes responsibility for compliances with the State Building Code and other Applicable codes,by-laws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 ORTH ToVM 0 tA6And over O .T Yom- � .:.F.• "`;;.nt.:•k.. No. o = o '� dower, 1Vlass. �. COC MiC ME WICK � OrA P' BOARD '9S BOARD OF HEALTH PERMI.T T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT ................. 0................................................................. Foundation i I has permission to erect. ....... ........... buildings on .,.I ....... ....�..1rL..I,. N ..............:................... Rough to be occupied as...... r ...�1...4e)pec .' . ........ ............. Chimney provided that the pers n ceptmg t is permit shall in evet 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 UNLESS CONSTRUCTI S TS ELECTRICAL INSPECTOR Rough ................ .....9..................................... Service BUILDING INSPEC OR 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 SIDE Smoke Det.