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Home My WebLink AboutBuilding Permit #974-15 - 164 JOHNSON STREET 5/28/2015 BUILDING PERMIT oq"°DT.1 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION A Permit No#: Date Received AERATED I,PP. �J gSSACHU$ Date Issued: -1-PORTANT: Applicant must complete all items on this page LOCATION ,/G y -7614-15&,7 //0.. A��'W-e 1A � Print PROPERTY OWNER v c'r-�DO C) Print 100 Year Structure yes tn MAP � 7 PARCEL:ZONING DISTRICT: Historic District yesMachine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑AI ration No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ 'Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORM D: �e>P�hc� �� /fix/� Dcec ��gofr� o� bye e, o•� �'o.� � �e�r�-�. dent' cation- Please Type or Print Clearly OWNER: Name: v7 h "'Op Phone: Address: Ila q-,041140,n a Contractor Name: j u�9l;•7 �- &",On Phone: d -3 -t�(�e Email: Address: �5 !:'li �-�� A-ii a Supervisor's Construction License: e5 Exp.Exp. Date: 4 Home Improvement License ' Exp. Date: ARCHITECT/ENGINEER Phone: I, Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COS ASED ON$125. PER S.F. i Total Project Cost: $ f. !� FEE: $ Check No.: ?4_/ Receipt No.: V NOTE: P rsQns contract' with un gistered contractors do not have access to a guara fund 14 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 Packagi: gOaes l ., - ] Privatec tise t El� P �etc. Permanent Dump ster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF e U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS tHEALTH Reviewed on Signature COMMENTS Zoning Board of.Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes ~ Planning Board Decision: Comments Conservation Decision: Comments Wafter & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: ` _ Located 384 Osgood Street iF RED.EPARTMENT Teem ®urn �ster°onsite esu __ nod � sa IiLocated atFA-4 iFire(Depa_r�tmentsig►iature/dated C®MMEN�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 Call Email Date Time Contact Name Doc.Building Permit Revised 2014 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 OTE: 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/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 OTE: 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 P � C p lot 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 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: 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 Doe:Building Permit Revised 2014 Location No. Date . - TOWN OF NORTH ANDOVER • Certificate of Occupancy $ Building/Frame Permit Feet. / Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# / 2 Building Inspector i r 1 NORTH - 0. . :. .c . . ver O ~" No. ,� oh ver, Mass, 5 COCNICNl WICK �,9 ADR�TED PPa,`�� S t1 BOARD OF HEALTH PERMIT T L D Food/Kitchen Septic System THIS CERTIFIES THAT .......... .Q...... L Z?,Z?JBUILDING INSPECTOR has permission to erect ....... g (� q..&MbM...•,��. Foundation ................... buildings ....... . .�..... f � Rough .2-to be occupied as ... .��/..�.�c .....E...i� .� ... ....... .. ...-:........ .. lQ... .�� !� ... Chimney provided that the person accepting this permit sh every respect conform to terms of the applica Ion 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 JO. PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIONS RTS 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. The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations k1i 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/OrganizatiorAndividual): iey/ ��,►-yG -c Address: /9 / �i¢T•��' City/State/Zip: &D Phone#: 9 2 — OZ? 3 I G _:J; Are y9"n employer?Check the appropriate box: Type of project(required): 1.Erl 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.❑ I am a sole proprietor or partner- listed on the attached sheet.# E]Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. El 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 ILEI Plumbing repairs or additions myself.[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. i Homeowners who submit this affidavit indicating they aie 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. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:.A6/c,IJP �� eQS ..l_it UP dem' Policy#or Self-ins.Lic.#: ( C� Od..S^DD 73�l�o7Ol�/� Expiration Date: 7�// Job Site Address: Z&Y .(o 6.1.5,0,7 S 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 andvenalties ofperjury that the information provided abov is t ue pnd correct. Si ature. LI Date: A5 Phone#: 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"coo mainteuaance,con'st*uction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of sucD:.ginployrgent,.be,deemed to be an,employer." MGL chapter 152,§25C(6),-also states that"eyery state or local licensing agency shall withhold the issuance or renewal of a license or pe'rmif to operate a business or to construct buildingsin 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)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 hasyrovided a space at the bottom of the affidavit,for yan,to'Irll out in the event the O�0e,of Investiga'ti'ons has fo 6ontE' f ou 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 suliiinit nivltipie permit/license applications in any given year,need only-suliiniforie`affidavit`Iftating 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 aild fax number: The Commonwealth of Massachus0tq; Department o:f ludustriai Accidents Office of Investigations 600 Washington Street Boston.,MA.02111 Tei,#617-727-4900 exf 406 or 1-877-MASSAFB' Revised 5-26-05 Fax,#617-727.7749 www-mass,govfdia The limits of liability under Part Two are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ _ 1,000,000 policy limit Bodily Injury by Disease $ -.--1,{#00,000 each employee C. Other States insurance: Coverage Replaced by Endorsement WC 20 03 06 B 0. This Policy includes these Endorsements and Schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules.Classilications,Rates and Rating Plans. All Information required below is subject to verification and change by audit. Classifications-- _ Prerttlum 13asis gates Code Estimated Per$100 Estimated No. Total Annual Of ; Annual Remuneration Remuneration i Premium INTRA 285896 I INTER SEE,GLASsCODE SCHED E 1 l I Minimum Premium $575 Total Estimated Annual Premium $4,217 (3OV a{7V Deposit Premium $1,086 S. jCLASS MA Assessment Chg. MA ; 5845 $3,778.00 x 3.400096 $128 This alit including all endorsements,is hereby countersigned by "" � " � 07/31/2014 policy, 9 — -— Avihoaized signature ale Service Office: M P Roberts Insuranco Agency 54 Third Avenue 1060 Osgood Street Burlington MA 01803 North Andover,T",A 01845 WC 00 00 01 A(7-11) Includes copyrighted material W the National council on compensation insurance, used Wih lie permtaaian. I safety me�t ON8 U�jSandas�5 setts.DRc9u�Xat°01\s \\ Wass OV 'Pot ,aoatd o C°°``%v J.ion A15h_ nse 1.°r r 8E�369 �� EXP°�a2�16 AI G�