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HomeMy WebLinkAboutBuilding Permit #683-14 - 17 EDMANDS ROAD 4/7/2014TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATIO Permit NO: / JI : Date Received -4t* Date Issued: I PORTANT: "ppic ant must complete all items on this pag, LOCATION I _l1 C S �fYI T _ i, LivPri rim t PROPERTY OWNER .� 1'"�i S C Print ': • 1 o Year Old Structure yes no MAP NO:6 PARCEL. ZONING DISTRICT: Historic District yes no Machine Shop Village yes Cno TYPE OF IMPROVEMENT. ❑ New Building ❑ Addition ❑ Alteration epair, replacement ❑ Demolition ❑ Septic ❑ Well ❑ Water/Sewer PROPOSED USE Residential 210ne family ❑ Two or more family No. of units: ❑ Assessory Bldg ❑ Other ❑ Floodplain ❑ Wetlands Non- Residential ❑ Industrial ❑ Commercial ❑ Others: ❑ Watershed District DESCRIPTION OF WORK TO' BE PERFORMED: C/ 6 � 10 Identification Please Type or Print Clearly) I t OWNER: Name: %,.� �(1 C'XV' 1-� �—^ Phone: � Address: �1� 5 CONTRACTOR NameAl '� ✓'t �-�` � Address: h Supervisor's Construction License'. II Home Improvement License: N l. UA -'1 Q U VZA- I r r Y.;,4_ Phone'. Exp. Date: Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED OONN $125.00 PER S.F. Total Project Cost: $ FEE: $ -- Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owne �t1Z ature of contractor Plans Submitted Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Location t -1 L b vv1 No. (A 3 1 Date 411 Check #� ,27411 TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee, Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Building Inspector - Plans Submitted ❑ ..'Plans -Waived -EL: -.Certified Plot Plan ❑ . Stamped Plans ❑ TItPE O -S1 WERAGEDISPOSAL ` ... : . Public Sewer ❑ Tanning/Massage/Body Art ❑ ....Swimming Pools ❑ Well ElTobacco.Sales ❑ -Food Packaging/Sales ❑ Private (septic tank, etc._ ❑. --• _ =Permanent Wumpster on -Site ❑ THE.FO.LLOWING SECTIONS FOR OFFICE.USE ONLY INTERDEPARTMENTAL SIGN .OFF - U FORM .._,DATE REJECTED: DATE:APPROVED PLANNING & DEVELOPMENTS ❑ ❑ COMMENTS .,CONSERVATION COMMENTS, HEALTH COMMENTS Reviewed on Signature Reviewed on Signature . Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes . Planning Board Decision: 11 . Comments Conservation Decision: :Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Tow;: Engineer: Signa Located 384 Osgood Street FIREDIEPARTI1 .EN1T ' Temp Dump'ster on .site yes no L•ocated'bt'124eMai r Street.---- Fire"Departme►'it*.sigriature/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, rust -or service drop requires approval of Electrical Inspector Yes No DANGERZONE LITERATURE: -Yes No MGL Chapter 466. Section 21A =F and G min.$100=$1000.fine NOTES and DATA — (For department use ® Notified for pickup - Date Doc.Building Permit Revised 2010 } Building Department TFie foil awing is'A list of the required forms to be filled out-for.:the appropriate -permit to' be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application o Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application o Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) Engineering_Affidavlts for Engineered_pro -uc s__ __- _----- -_- --" NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apwal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Doc.Bui!ding Permit Revised 2012 04 Wtn° d'1y To 0Fi'qO$.T'ff.NDOvFR OFFICE OF BUILDING DEPARTMENT • cR,� :' ] 600 i0s900d Street Building 20 -Suite 24-36 North.An-dovex, Massachusetts 01845 acKU5 Gerald A. Brown Telephone (978) 688-945 TnspectorofBuildings - Fax (978) 688-9542 HQVM— WNER LICENSE EXEMPTION BEMD►ING PERMT APPLICATTON please �rini ' j DATE: ` I ' JOB LOCATION: • �"1 `l d Number SfreetA:ddress rYV Ck-f) dc) • _ . . oMEo NER ah a . � - , ®� 63 t _ G, av�.ap�,Lot Name Home phone Q • Work Phone PRESENT MAILING ADDRESSe CA ` n� C -6 �t?t� 7ipv Gods The current exemption for `$omeow_ners" was extended to inGlUde owner -occupied dwellings to i�vo units ox Tess and to allow subh homeoy Bels to engage ail; idividual.for hire .,rho does aotpossess a -lice nse, provided That the owner acts as supervisor). State lidding (Code 8eofion.108.3.5. i) DBFINITION 0F11011dE0WNER I'erson(s) who awns a parcel of land on which. he/she resides or intends to reside, on which there is, or is intended to be, one or two family structures. A person who considered a homeowner. constructs more that-One:home in a twoyearperiod shall not be , The undersigned `°homeowner" assumes responsibilityf Applicable codesorcompliances with the State Building Code and other , by-laws, rules and regulations, c The undersigned "homeowner" cerci cies that he/she understands the Town of North Andover.Building Department mi imam. inspection procedures and requirements and that he/she will com requirements, ply with,said proceduresrequirements, and TIOMEOWINPRS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Pon- Homeowners Ex&mpfion 'BOARI) OF APP.EAM 688-954] CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 0 Enter construction cost for fee cal - North Andover Fee Cakulatlon Construction Cost $ 10,000.00 m $ - $ 120.00 Plumbing Fee $ 15.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 15.00 Total fees collected $ 250.00 17 Edmands Road 683-14 on 4/7/2014 Bath Remodel Division of Professional Licensure: License Search The Official Website of the Office of Consumer Affairs and Business Regulation (OCABR) Division of Professional Licensure Mass.Gov Home State Agencies A -Z Topics Home > Division of Professional Licensure > Check A Professional License By the Division of Professional Licensure LICENSEE Name:JAMES H. TIMMONS WAKEFIELD, MA Licensing Board: ELECTRICIANS License Type: JOURNEYMAN ELECTRICIAN TYPE CLASS: E License Number: 27468 Status: LAPSED Expiration Date: 7/31/2013 Issue Date: 8/1/1983 Exam Date: 6/4/1983 School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Monday, April 07, 2014 at 9:45:10 AM. © 2007-2011 Commonwealth of Massachusetts Page 1 of 1 Mass.Gov ONLINE SERVICES Check a License Locate a Licensed Professional Online Address Change Contact the Agency More... REFERENCES & RELATEDINFO Disclaimer Regarding Website License Searches Glossary of License Status Codes More... Site Policies Contact Us http://license.reg. state.ma.us/publiclpubLicenseQ.asp?board_code=EL&type class=_E&Iic... 4/7/2014 U) CD 0 Z CD O C r CL -a O 00 CDCLS cr CD O CD CL 0O CQ. CD Cn a n i a y 0 CD rF CD CD 3 Cn. 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C(n CD su CDCL W Aiwm r .a CD cn 0 0 co � 00 rt 0 = _ CD CD y CD � n N (D O h 3 D 'D n N S 0-0 a� 3 =" °: o rD C O 4 1 J Ln N WT .Z7 'T7 Vf 7J T A T r) S T N T 3 - O C 0 � O O O S O N0 j < 0 N N X- (D — 3 n N S 3 =" O- rD z M N y T O O < r O < y f1 rr � O ((D S M W 3 rD ' C C W O OH W z y z v M D H rC) O 'a M D O m m M z p _ M IaL 17 The Commonwealth of Massachusetts - Department oflndustrutlAccidents Office of Invesfigations 600 Washington. Street Boston, MA. 02111 www.massgov/clia Workers' Compensation Insurance Affidavit: Builders/Cont°actors/ElecfricianslPlumbers Anulicant Information Please Print Legibly Name (Business/Organization/in(Rvidual): Address: C� nYi a _X__) C � City/Slate/Zip• ()_y-Nc�Q \Ief, YY_YkPhone #: "(`i �0 C� I - lv4Vi�.t Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ 1 am a employer with 4. ❑ I am a general contractor and 1 6. ❑ New construction employees (frill and/or part-time).* 2. ❑ 1 am a sole proprietor or partner have ned the sub -contractors listed on the attached sheet. �• ['� Remodeling ship and'have no employees worldng for me in any capacity. These sub -contractors have workers' comp. insurance. 8. El Demolition 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 1011 Electrical repairs or additions q uired.] 3. 1 am a homeowner doing all work A officers have exercised their right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roofrepairs insurance re ed. ] employees. [No workers' emp 13.❑ Other comp. insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. f Homeowners who submit this affidavit indicating they 6doing 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 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 requiredunder Section 25A ofMGL o.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 STOR 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. .1 do liereby cert& under the pains and penalties ofperjury that the information provided above is true anti correct. Signature: �� ���} Date: J L Phone #• - 61 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. 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 ofhire,- express or implied, oral or written." An employes 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 notmore 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 -contractors) name(s), addresses) andphone 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 maybe 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 o£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. AA 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 OfMq Department of Jadwirial .Accidents Offtoe QUavestigaflons 60 Wasbi gtou Street Boston, MA 02111 TQJ, # 61.7-727-4900 ext 406 ox 1-8,77 MtASS.Ak`E Revised 5-26-05 Fax # 617-727-7749 Www aass,govldia