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Home My WebLink AboutBuilding Permit #152-14 - 200 CANDLESTICK ROAD 8/15/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page ,LOCATION 4 . _ _. . ; • Print. PROPERTY OWNER Print 100 Year Old Structure yes no MAP NQ PARCEL: ZONING DISTRICT: Historic District yes no - Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE t Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑.Septic ❑Well D~Floodplain -•--0 Wetlands. ❑ Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: CONTRACTOR Name. 1. �•; 'Address: r lit, ~ .ur., -..,_ "4 . :. +...1iM a �•r 3. .-' •+ Y yL�° �` T Supervisor's Constructlon'Llcen"se Exp Date HomeImprovme enf License - x _ ARCHITECT/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: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner 8imnature.of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Q��4lD BUILDING PERMIT �? ,6,;,. • ^,. d Q� TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: Date Received '� "D, : 4.IV « �9SSACHUS Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER Mtedhf-L- MAyr(Z,E� Print ZONING DISTRICT: Historic District es no MAP N0: PARCEL. ll�� Y -i Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑ Water/Sewer Identification Please Type or Print Clearly) OWNER: Name: Rlel-WEL- Nleiyi2f Phone: 9�� 2y Address: CONTRACTOR Name: Phone: Address: Supervisor's Construction License: E p. Date: •� Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 7600 FEE: $ q1,96 Check No.: /7 Receipt No.: ?Cp-t1 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/O &,I,/Signature of contractor Location No. -1 Date r TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ CM Foundation Permit Fee $ Other Permit Fee $ TOTAL I { Check#175" 26744 l Buildin9 Inspector ector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE-OP SEWERAGE DISPOSAL Public Sewer ❑ Tannin Swimming Pools ❑ g/Massage/BodyArt ❑ g 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 �LANNING DATE REJECTED DATEAPPROVED & DEVELOPMENT ❑ ❑ as 1 COMMENTS I i CONSERVATION Reviewed on Signature N COMMENTS i HEALTH Reviewed on Signature I COMMENTS a C_. Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted=yes Planning Board Decision: Comments Conservation Decision: I Comments Water & Sewer Connection/Si nature& Date Driveway Permit DPW Tow2 Engineer: Signature: FIRE DEPARTM,�s NT - Temp Dumpster on site yes Located 384 Os ood Street Located at 124 Mair, Street n� Fire Depart merit signature/date 7 COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions._ i 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.$100-$l000.fine NOTES and DATA— (For department use I � , I I i ® Notified for pickup - Date i Doc.Building Permit Revised 2010 Department p j btained. is-la list of the requir ed forms to be filled out for the appropriate permit to be o ie following oof4"ag, 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 from All dumpster permits require sign oa Department prior to issuance of Bldg Permit off p Wdition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit I ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract Plan And ❑ F IoorlCrossection/Elevation Plan Of Proposed Work With SprinklerI 'c Calculations If Applicable) HydraullApplicable). ❑ Mass check Energy Compliance Report (If ❑ s for Engineered products prior to issuance of Bldg Permit Engineering Affidavit stet permits require sign off from Fire p All dump p New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposedplot PIaLicenses ❑ Photo of H.I.C. And ❑ Workers Comp Affidavit € Building Plans One To Be Returned) to Include Sprinkler Plan And ❑ Two Sets of Bu g licable -- Hydraulic Calculations (If App ) ❑ Copy of Contract Mass check Energy compliancelianc e Report rt , ❑ Engineering Affidavits for Engineered products require sign off from Fire Department prior to issuance of Bldg Permit TE: All dum permits req g pstet the decision from the Board of Appeals g all cases if a variance or special permit was required the Town clerks office must stamp 4 r. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording gat the apo,-al period ,s ove pp � lust be submAted with the building application e Doc: Doc-Building Permit Revised 2012 . d NORTH Town of 2 s E ndover ver, Mass, coc"IC"!WICK PILN*- �• ORATED N S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT .... �1....J.�.... 4 �E�� BUILDING INSPECTOR ......................//.��............................................................ '�� C��I/�/i� $� �................ Foundation has permission to erect .......................... buildings on .a................. .tib..... ....�. Rough to be occupied as ............ c� t> ... ....: .r. r::? ��=.. ......... .. r ..�:............ Chimney provided that the person accepting this permit shall in every respect conform to a 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 CONSTRUCTION TARTS Rough ........................... Service .................... ..,!:�5!� .... ...•�,_ 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. SEE REVERSE SIDE TOMW OF INTO RTH ANDOVER . OFFICE OF Td BUILDING DEPARTMENT � Osgood Street Building 20,-Suite 2436 9S Ac us c�5 North Andovor,Massachusetts 01845 Gerald A.Brown Inspector of Buildings Telephone(978)688_9545 H0ME0)0ER•L1QENSE EXENtpTION Fax (978)688-9542 BUIDING PERMIT.APPLICATION Please print DATE: JOB LOCATION: Soo e4lVb Number SlreetAddress Map/Lot �IOVMOWNER M ICh4 Et, su r2E T-'7g-97r-2 y.26Name, Home Phone Work Phone PRESENT MA MING ADDRESS o C144t,0.ZFd_r1Ck �0 � NO - 2T1� �iv�o1/ -K (''1 DI Vis C-iiV Tn•=n, Stats Zip Code The current exemption for`4homeowners"was extended to h-rclude owner-occupied dwellings to i�vo unit less to allow such horns.,nes to engage andividual.for hire who does not possess a license,brovided that the an 1 acts as supervisor). State Budding (Code Section,forhi e. p e owner i DERMTION OFROMEOWNER Persons ()who Qwns 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-yearperi ' shall not be considered a homeowner. The undersigned"homeowner"assumes responsibility for compliances with the State Building Code and Applicable codes,by-laws,rules andregulations. g other The undersigned"homeowner"certifies that he/she understands the Town of Borth Andover Buildin Department mmzmum inspection procedures and requirements and that he/she will comply with,said procedures and requirements, HOMEOWNP,RS SIGNATURE �J APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption 'BOARD OF APPEALS 688-9541CO7\SEr j r,: R1 ATION 688-9530 HEALTH 688-9540 PLANNING 688-953i The Commonwealth of Massachusetts Department of IndustrialAccWnts Office of Invesfigations 600 Washington Street Boston,MA 02111 U1 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: 10 0 C/�M D L E,51'lC),/ /2 64,b City/State/Zip: ff D aTV Phone#: g 7 8-q 7f 2 qo_Ur7 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. ❑New construction r-�employees(full and/or part-time).* have hired the sub-contractors 2.u I am a sole proprietor or partner- listed on the attached sheet. F1 Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working forme in any capacity. workers comp.insurance. 9. E]Building addition o workers'comp.insurance 5. ❑ We are a corporation and its p 10. Electrical repairs or additions officers have exercised their ❑ p required.] • • q ] 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions i g myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 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 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 requiredunder 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 cert!&under thee pains and penalties of perjury that the information provided above is true and correct~ Simature: t Q Date: l e1 1✓ 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 an contract of hire . Y , 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 shallnot 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),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 ca workers'compensation insurance q nY . If an LLC or LLP P 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 an questions regarding the law o ' Y Y q g g r if you are required to obtain a or Y q 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 permittlicense 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 futureermits or licenses. A new affidavit mus p v t 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 Jndustrial Accidents oface of Investigations 600 Wa.shingtoa Stxeet Boston,MA 02111 Tel,#617-7274900 ext 406 or 1-8777MASSAFE Revised 5-26-05 Fax#617-727-7749 www.11lass,gov/dja