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Home My WebLink AboutBuilding Permit #72-15 - 162 PINE RIDGE ROAD 7/22/2014 t%ORTH BUILDING PERMIT aF��LEo TOWN OF NORTH ANDOVER fo2�h o-x APPLICATION FOR PLAN EXAMINATION * 4 -� Z . K; Permit No#: Date Received �qs0 TED Date Issued: -21 C( IMPORTANT:Applicant must complete all items on this page LOCATION i Print -PROPERTY OWNER �CCa a. (` - - Print* 100.Year Structure yes MAP .=PARCEL: _ . ZONING DISTRICT: __ Historic District yes no Machine Shop Village, yes q TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building Y One family ❑Addition El Two or more family 11 industrial ❑Alteration No. of units: ❑ Commercial ,q Repair, replacement ❑Assessory Bldg ❑ Others: Demolition ❑ Other ❑ Septic [Well ❑ Floodplain ❑Wetlantl,s ❑ Watershed District ❑Water/Sewer DESC PTION OF WORK TO TE PERFORM D: ani Az C? Identification- Please Type or Print Clearly OWNER: Name: PhongCR03 Address: Contractor Name GM O o Phone: _ - - Address: JA00 Supervisor's Construction License:�Z2-1p—t2-2! _rExp. Rated Home Improvement License:- __ Z _ _ Exp. 'Date- ARCH ITECT/ENGI NEER DateARCHITECT/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: $ h� �� FEE: $ Check No.: 4;� D Receipt No.: Q'�tL� NOTE: Persons contracting with unregistered contractors do not have access t ra :nd +Signature A Agent/O _ Si wner - gnature of contract _ r _ v 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 Li Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Cross Section/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) o 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 Doc:Building Permit Revised 2014 Plans Submitted ❑ Plans Waived 0 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 PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS 3 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 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 Call Email Date Time Contact Name Doc.Building Permit Revised 2014 Location/ Z- No. _ Date C o - TOWN OF NORTH ANDOVER .-•- Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ fry's4 TOTAL $ Check# 4780 ® Building Inspector Enter construction cost for fee cal- North Andover Fee Calculation Construction Cost $ 1905.00 m $ - $ 235.26 Plumbing Fee $ 29.41 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 29.41 Total fees collected $ 394.08 162 Pine Ridge Road 072-15 on 7/22/14 Close in 3 Story Foyer, . The CommonweaM ofMassaich.usetts , • Office of fftvestigafions 640 Washington Street .Boston,.MA 02111 wvrP i asv gov1d1a workew compensation Insurance Afdayff:13uiZders/Cont°actorstElectrxclans/?IiPixber$ Ap rznation Please Print Le 'bl Name(Business10rgaui'zationlindividual}: ' Address: City/State/zip: u 4', Phono .Are pout an employer?Cheekthe appropriate box: Type of project(recluixed): 1.❑ I am a employer with______ 4• ❑I am a general contractor and I 6. ❑New c6nstraction f � p ees y emp to full and/or axe time)* have hire dthe sub-contractors listed on the attached sheet:� `7• �Remodeling 2.Q I am a sole proprietor or partner Ship and`haveno.employees These sub-conixactoxshave 8. Demolition worldng form.@ in.any capacity. workers'comp.insurance. �. ❑B• ilding addition V90 workers'comp.insurance 5.�We are a corporation anlits 10[]Electrical repairs or additions officers have exerelsed.their required.] :right of exemption or MGL 11..Q 1'lumbingr@pairs or additions e do" .all w ork g p p 3.Q S am a homeowner, ,mg c.152 §1(4),andwehaveno 12, Roofre airs r a ❑ p myself �'o work@ s comp inswancaregaired.] employ@es.[l�lo workers' 13.Q Other comp.insurance requ red.] a limatthatcheeksbox#1mustalsofMduttheseofionbel6wshowingtheirworkerecompensat[onpolicyinfounafion. ' pp u t.submit a nevi affida it indicatin such. i submitthis affidavit indicafingthey 2re doing aLlworlc and then hire outside canfracfors m s`s V g Homeowners w$o a � atontContractors that ahekthis bx must attachednadditionalsheetshowingthenmeofthesub-confracforsandtherworkers comp,poticyform . cananernployerthaiis.providingwosykefs'compMSationinsuFan Ofo�ryernployees Berot�istliep0 yr�ncij0 site infarmadon. Insurance Company Name:. Policy#or Selz ins.UG.#: Expiration Date: I&Site Address: City/Sate/Zip: Attach a copy of tl e workers,compensatiowpollcy declaration page(showhig-Me policy number and expirationt date). Failure to secure=coverage as xecluix@dun.der Section 25A.ofMCrL o.152 can lead to the imposition of eriminalpenalties of a .fine up to$1,500.00 and/or one-Year imprisonment,as well.as civil penalties in the form of a STOP WORD ORDER,and a tine of-up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office o£ Investigations ofthe DIA.for insurance coverage verif cation. X do lie�eby uri epai allies of v,-r by tliattlie information,provideclaboye is true ancieo reef; - Si atur Date• / Phone#: Official use o ily. .Do not vxife in this area,to be completed by city or town official City or Town: Permlt/License# Issuing.Authority(circle one): 1.$pard of Health 2.BuildinglDepaxtm.ent 3.City/Toym Clerk 4.Electrical Tuspector 5.Plumbing Inspector 6.Other - - - Information and Instr cction - Massachusetts General Laws chapter 152.requires all employers to provideworkers'compensation for t7zeir employees. Parsuant to this statute,an eraployee is defined as"...every person iii the service of another under any contract ofhire; express orimplied,oral oxwxitten" An.eMPlayWis defined as"an individual,partnership,association,C0:T0xat10n0X other legal entity,or any two oxmoxe ofthe Foregoing engaged in a joint enterprise,and includingthe legalxepxesentatives ofa'deceased employez,.or the xecWar or:trUstee of an individual,partnership,association or other legal entity,employing employees. PSowevex the owner of a dwelling house having notmow than three apartments and who xesides therein,or the occupant ofthe dwelling house of another who employs persons to do maintenance,construction ox repair work on,such dwelliug house or onthe grounds orbuilding appurtenant thereto shall not hecausobf such,employment be,deemed to bean employer." MGL chapter 152,§25C(6)also states that"every state or ideal Xicensing 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 pro duced.acceptable evidence of compliance with the insurancecoverage required:' Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall eutex into any contract for the performance ofpublic workuntil acceptable evidence of compliance with the insurance xequirements oftbis chapterhave beenpresentedto the contracting authority.." .Applicants Please ]]out the workers'compensailon affidavit completely,by checking the boxes that apply to your situation and,i,� 9iecessary,supply sub-contractox(s)name(s),address(es)and Phonenumber(s)along with their cermcate(s)of insurance. .LimitedLiability Companies(LLC)orLimitedUabilityPartnerships(LLP)withno employees otherthanthe members orpartners,are.notrequired to carry workers'compensation insurance. If an TIC or LLP does have BM ployees,apolicyis xequired. Be advised thatthis afddavitmay be submitted to the Department of industrial Accidents fox confirmation of insurance coverage. .Also be suxe to sign and date the affidavit. The affidavit should b e retumedto the city or town thatthe application for thepermit or license is being requested,;aot the D4attment of Industrial Accidents. Shouldyou have any questions regarding the law or it you axe required to obtain a workers' compensationpolioy,please call the Deparbnent at tha number listed below Self-insured companies should enter their self insurance license number on the appropriate line. City or Toym Mcials Please be sure,thattheaffidavit isComplete andpxiatedlegMy. TheDepartmenthaspxovidedas 'pace atthabottom ofthe aff7davitforyoutoM out in the event the Office oflnvestigationshas to contactyouregardingtheapplicant. Please be-sure to fiJ1 inthe permit/license number whichwill 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(ifnecessmy)and under"Job Site Address"the applicant shouldwxite"all locations in (city or towaa):'.A copy ofthe affidavit that has been officially stamped or marked by the city or town may be pxovided to the applicant as pzoofthat a valid affidavit 1d on filo:or"me,permits or licenses. Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a license ox peamit not related to any business or commercial venture (i.e.a dog license orpermit to burn leaves eta.)said person is NOT required to complete this affidavit. The Office of Investigations would liko to thank you in advance for your cooperation and should you have any questions, please do not;hesitafe to give us a call. The Department's address,telephone and faxnumber: The GQM-Monwtafth ormfawq ohv&Pttq .Depa X e. ut Qf Zxldu,�xzaj Arvjd0jjtg Moo 0:U)R `mRga7UQ)n�,% BQAQn, 021 It Revised 5-26-05 Fay,#617"727"7749 NORTH Town of s ndover O - .:;'. 0 No. _ h no h ver, Mass, Z Z COC NIG Nf WICN y1' 7q ADR4'rED PPP,`�(5 S V BOARD OF HEALTH Food/Kitchen P R L D E I T Septic System THIS CERTIFIES THAT ......... ... .................................. .. , BUILDING INSPECTOR ............. .........�.!!� ...1 � .. . . .. .. .. ..1.6 �...•..,. ...�. .. Foundation has permission to erect .......................... buildings on ..... ..��.... .. t / Rough to be occupied as .......... .�i�.`. iR........ . . . . .......�.�. .:Ik, tR......3.e�+ .."4.�Qal'� 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. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS . ELECTRICAL INSPECTOR 4) UNLESS CONSTRUCTI A Rough Service .................. ...... ................. ..................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. � NORTH Town of . : ndover No a115 `AN! h over, Mass, ZZ GOCNIC Nl WICN �� S U BOARD OF HEALTH Food/Kitchen ' PER IT L D Septic System THIS CERTIFIES THAT ......... �... .. BUILDING INSPECTOR . . .. .. .... .. has permission to erect buildings on .......1.6..�........8`..04..�+ .. + Foundation .......................... . .. ... • Rough ♦-t rr to be occupied as .......... .M`. Mt........Afkew.......�. R......3.e,1 .. .J.Q�1fChimney 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. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI A Rough Service .................. ..... .................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Occupancy Permit Required Occupy Bu 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. 1 i �: -!•�- �' ram tzXCl `��+� �a�s LI t L V � 1 /w��.J�\7 l I 7 f r I -Fl is CqT� „...---'--'•'” �/Le �Prnrzirrwazcu�a ulation &Business Re Office of Consumer AffairCONT.RACTOR 914nME IMPROVEMENT Type: .176523Individual x .ration:THOMA�,Vj'7eqi!stration-. F.MOSSON N THOMAS MOSSON IV 4 SECOND ST Undersecretary NH 03087 t WINDHAM, 1 1 Massachusetts -Department of Public Safety I Board of Building'Regulations'and Standards {� Construction Supervisor � { License: CS-079027 \\\ I r THOMAS F MOSSON W 4 SECOND STREET ' d i Windham NH 03087 �3 i Expiration Commissioner 01/24/2015 i