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HomeMy WebLinkAboutBuilding Permit #290 - 171 CORTLAND DRIVE 10/27/2008 yORTH BUILDING PERMIT i TOWN OF NORTH ANDOVER 3? I o L 'A APPLICATION FOR PLAN EXAMINATION Permit NO: 19go Date Received ISSACHUS� 9 Date Issued:_L A 0 IM ORTANT:Applicant must complete all items on this page LOCATION 1 -� Cd r2b n ' P t PROPERTY OWNER i ZS L Print MAP NO: ,O PARCEL:31 ZONING DISTRICT:'' �lHistoric District yes no Machine Shap Village yes I _ TYPE OF IMPROVEMENT PROPOSED USE j t Resid Non- Residential I uildi ne ami Addition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: I Demolition Other Se tic- WeII Floodplain Wetlands Watershed District I l 1Nater/ �Y i DESCRIPTION OF WORK TO E PREFORMED: 1 S� S�c1�- a� d `, t ' I entificatio Please Type or Print Clearly) Jr OWNER: Name: (,� Phone: 87 Address: 0�zu ' CONTRACTOR 'Name: -e k<k tMA Phone: 8 - 3 Address e . d I Date: 6 h", Supervisors Construction License: � S � �� Exp. Home Improvement License: Exp. Date: ~ ARCHITECT/ENGINEER Phone: irmit iAddress: Reg. No. )peals FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OFHE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. �� ording Z 1 0 nnrLL -.,a.,._, G. Total Project Cost: $ 4 .� E: $ rascy—r-�- –„�' Check No.: 30 O Receipt No.: , ' NOTE: Persons contracting with unregistered c n actors do not have access to the aranty c d gnature of Agent/Owner , ' Signature of contractor ------------ .tet.,......—_......... _ ..- _ _ --- -- - - -_-•-� Location ca No a Date 7 %ORT#1 TOWN OF NORTH ANDOVER s i Certificate of Occupancy $ qi' bene.r•.` CMUSEt�' Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ , /, v Check # Y10 , ` i i 2 1 6 ,j2 f Building Inspector it Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL <25Sewer 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 Sal - Ch CONSERVATION Reviewed on Signature /COMMENTS �- �� �� �Voff-- Ll HEALTH Reviewed on Si nature A/Za== COMMENTS (.-Y'\. Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: w I A Comments � i Conservation Decision: —Comments? Water & Sewer Connection/Signature&I at Driveway Permit DPW Town Engineer: Signature: jz� Located 384 Osgood Street FIRE DEPARTMENT -Temp Dumbster on site yes no Located at 124 Main Street Fire Department signature/date`', �c COMMENTS Dimension Number of Stories: l /2 Totalsquare feet of floor area based on Exterior dimensions. Total land area, sq. ft.: 30 .2 A C • ELECTRICAL: Movement of Meter location, mast or service d 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 - Date Doe.Building Permit Revised 2008 Plans Submitted Plans Waived rp'1 r �T:Y—PE—OF SEWERAC:F'nT"- artrnent Building Dep ermit to be obtained. � out for the appropriate p the required forms to be filled list of Pgr1Y11t5 -rhe following is a abilitat►on Siding, Interior R.l Roofings Application ° Building permit Af',davit Licenses L ° Workers Comp And/Or C.S., of H.I.C. A photo Copy Work Id Permit ❑ of Contract Products of Bldg❑ Copy n Or Proposed Interior prior to issuance Floor Plan ineer Fire Department P ° ering Affidavits for n off from ° En91s er permits requires g NOTE: All du p Addition or pecks permit Application ° Building Surveyed Plot Plan ❑ Certif Affidavit d C S L LicenSes orkers CompAn • h Sprinkler Plan And ° W of H.I.C.C Work Wlt ° photo Copy of proposed ° Copy Of Contract Of Plan rlCrosseCtionlEleva,j Appllca If Applicable) ° Floo Calculations of Bldg Permi, liance Rep°rr � Hydraulic nergy Comp Engineered products rior to issuance ° Mass check E Fire Department p Engineering Affidavits fsi n off from C ° Engin ermits require 9 NOTE: All dumpster p and Two Family) New construction (Single zonh Building permit Application ° proposed Plot Plan Certified prop d C.S.L. Licenses elude Sprinkler Plan AI Planni ° An to In ° photo of H.I.C. omp Affidavit one TO Be Returned) ° Worker is of Building Plans Conser ° Two Se lations (If Applicable) Water Hydraulic ont act ice Report e of Bldg PE ° Copy of C Complian products DPW Tt ss check Energy. for Engineered Department prior to issuance ° Ma Board of AI vets Engin sign decision from eering Affida off from ire the ust stamp the d e COPY and proof of re FIRE DEQ ° stet permits require office m Deeds. On Located ate NOTE: All dump the Town Clerks at the Registry of erinit was required et this recorded Fire Dep or special p must then g l variance over. The applicant In all cases if a application COMMEN, that the appeal period is° building pp must be submitted with the - _ DEPARTMENT. Doc.. Doc..IN 'CTIONAL SERVICES DEp� Revised 2.2008 tkORTH Town of over No. a90 _ C A O dover, Mass., - 0� COC Hi HE WICK y1. ADRATED `S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System ' BUILDING.INSPECTOR THIS CERTIFIES THAT 4v1 ��"��............. .�.'^-`:`.' �.......'.���� ���Jy2l ....... .. . Fou ` v � � .�............... Foundation �v has permission to erect........................................ buildings on/ ...� :... ...... ....... .................................... Rough to be occupied as.............................. ©CfI,I'G .C'L. l�'' ................. ................................................ Chimney provided that the person accepting this permit shall in every respect conform to the to s of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspectio , Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough 1 Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION S ARTS � ' " " 'x Rough .............................. Service BUILDING SPECTOR Final Occupancy Permit Required to Ocmpy 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. r 74e 1°anvnzorausea o�✓��zaaac�ivaeCiti Board of Building Regulations and Standards Construction Supervisor License License: CS 55417 Expiration:..`4J5/2010 Tr# 20721 ./ Restnction ,.00 THOMAS D ZAHORUIKO 115 CARTERFIELD RD N ANDOVER,MA 01845 Commissioner The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street ll if�l l . .�=; Boston, MA 02111 www.mass.g ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ,I Please Print Legibly Name (Business/Organization/Individual):— ,,4TJA2 &A 44$ iT6 tyQS nGY1a Address: 1 S' �4 r a-- �1 -q d ( Qay City/State/Zip: ,. u re. ,,kA,A O 19V Phone#: 7 9` 697-Z(3 Sv 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. D<New construction employees(full and/or part-time).* have hired the sub-contractors 2;A1 am a sole proprietor or partner- listed on the attached sheet. 1 7• ❑ 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. ❑ 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 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §](4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.❑ 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. #: 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$],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 covers rification. , I do hereby certify under the ins an alties f perjury that the information provided a ove i true and correct. � o �Z Si nature: Date: 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 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 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 Meetinghouse Commons at 15molak rarms rl � fir'-;-�;,---r•r' .._._.___._.__ _.� i-i El C! U L.0cj [.CI 9 rR(_) QT LL_?_VkT1ot,3 171 Cortland Drive, Unit#6 Meetinghouse Commons,North Andover, MA 01845 Scale: 1/4"= 2'0" October 21, 2008 oil aIJ LOFT 1 C3 WV-� 0 -�" LlLOk.5FlLL" 14 1 Lk o � t; e 1�-t-o 1a v 6 v 5-0 S 14 O St_CotvD FLnc��R � � F1�15�1�� t-�v1NG i ?6�, 1 - Meetinghouse Commons atjmolak rarms M 1:1 C-r _.___.. H.:f L-I l-10 011 l._..I I U .I2I r=R.® Q T tLr-v A-T A D V,3 171 Cortland Drive, Unit #6 Meetinghouse Commons, North Andover, MA 01845 Scale: '/4"= 2'0" October 21, 2008 i �d�t ZIcue)cl i 1 ,z 1 Sx R I