HomeMy WebLinkAboutBuilding Permit #746-14 - 214 SUTTON HILL ROAD 2/24/2014I LY
Permit N0: I I
Date Iss
=I LOCATI
,,- I Print.
PROPERTY OWNER 1#2�90e0aL f L( SIf )L'�
Print 100 Year Old Structure yes
MAP NO: PARCEL-�_, ZONING DISTRICT: Historic District yes
Machine Shop Village yes
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
/ ` IMPORTANT: Applicant must complete all items on this pa
s
Ab en
no
no
no
.TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
[I One family
❑ Addition
❑ Two or more family
❑ Industrial
Alteration
No. of units:
❑ Commercial
;Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
El Septic ❑ Well
❑ Floodplain ❑ Wetlands
❑ Watershed District
E]Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
. !2ii�Gl
44Z4,(xe A6 0 oGc2 4A_g4AZ_ 41V&4
Identification Please Type or Print Clearly)
OWNER: Name: pc22tp 9 &2 Phone: Ud 5_4 2
Address:
CONTRACTOR Name: Phone: f %c YrZ
Address:?✓�
Supervisor's Construction License: CS' /oS" O 69-" Exp. Date: .
Home Improvement Licenser
ARCHITECT/ENGINEER
Address:
Date:
Phone:
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: $ 3200 FEE: $
_ A(
Check No.: I C--)' p Receipt No.: oq-' `t: P�
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fu di
Signature of Agent/Owne Signature of contractor _
Plans Submitted Li Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans �
- Plans Submitted ❑ Plans Vl7aived-❑.. ".._Certified Plot Plan ❑ Stamped Plans ❑
J YFE0)=:SEWERAGE-DISPOSAL
Public Sewer ❑ Tanning/MassageBodyArt ❑ Swimming Pools ❑
Well ❑ -Tobacco Sales ❑
Food Packaging/Sales ❑
Private(septic tank, etc:_
Permanent DUmpster on_Site ❑
THE. FOLLOaIVING SECTIONS FOR -OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF'- U FORM
DATE REJECTED DATE:APPROVED
PLANNING & DEVELOPMENT ❑ = ❑
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No:
Zoning Decision/receipt submitted yes
Planning Board Decision: ` Comments
Conservation Decision: Comments
Water & Sewer ConnectionISianat�are & Date
- - Driveway Permit
D_PW Todva: Engineer: Signature:
Located 384 Os
FIRE L EPARTt Tern ''D umpster on site yes no
Located-at-.124iMair Street - - —
Fire De PdAm&it•signatu"re/date"
COMMENTS
ood Street
i
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area; sq. ft.:
ELECTRICAL: Movement of.MeterJocation, niast-or service drop requires approval of
.:Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes N®
7 -MGL -.Ch Pter 166.Section 21A -F and G min.$100=$1000:fine
Doc.Building Permit Revised 2010
F
Building Department
-- The folowing is'a list of;the required.forms to be -filled ouffor:the appropriate:permit to be obtained.
R.00firg, Siding, Interior Rehabilitation Permits
Lj 13,01ding Permit Application
a Workers Comp Affidavit
u Photo Copy Of H.I.C. And/Or C:S:L:.Licenses
u Copy of Contract
u Floor Plan Or Proposed Interior Work
u Engineering Affidavits for Engineered products
NOTE: All dumpster,permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
u Building Permit Application
u Certified Surveyed Plot Plan
a Workers Comp Affidavit
u Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
u Mass check Energy Compliance Report (If Applicable)
u 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)
Li Building Permit Application
u Certified Proposed Plot Plan
Li Photo of H.I.C. And C.S.L. Licenses
a Workers Comp Affidavit
u Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Copy of Contract
o Mass check Energy Compliance Report
u 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 apw-gal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submAted with the building application
Doc: Doc.Buiffing Permit Revised 2012
Location q <�✓ ►'` ! I r z /-
No. l ((% Date
Check # i2A--3
2%4`•U�
TOWN OF NORTH ANDOVER
I
Certificate of Occupancy $
Building/Frame Permit Fee "$
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
a
Building Inspector
ry The Commonwealth of Massachusetts , -
Department ofIndustriglAccMiks
Office ofluvestigations
600 Washington. Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Buftiers/Cont°actors/EIectriclans/Plumbers
.Applicant Information Please Print Lem ly
Name (Busyness/Organization/individual). �(� 0ee kl_*6 i 0
Address:
City/State/Zip: IV ?*VQ Ivy -1 Phone #: %� �� 91Z � eZ
Are you an. employer? Check the appropriate box:
Type of project (required):
1. [I I am a employer with
4. ❑ I am a general contractor and I
6. F1 Now constriction f
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet. T
7. [] Remodeling
ship and'have no employees
These sub -contractors have
S. ❑ Demolition
working forme in any capacity.
workers' comp. insurance.
9. Building addition
[No workers' comp. insurance
5. ❑ We are a corporation and its
10.[] Electrical repairs or additions
11 required.]
3 N am a homeowner doing all work
officers have exercised their
right of exemption per MGL
11. ❑ Plumbing repairs or additions
m elf. [No workers' comp.
c.152, §1(4), and we have no
12.❑ Roofrepairs
insuraucere ed. i
]
employees. [No workers'
1311 other
comp. insurance required.]
'Any applicant that checks box #1 must also fill out the section below showingtheir Workers' compensation policy information.
7 -Homeowners who sabmit this affidavit indicating they tie 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.
X
am an employer that is providing workers' compensation insurance for my employees l0w is die policy andlob site
information.
Insurance Company
Policy # or S elf ias. Lie. #:
Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensationpoliey 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 i a 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 maybe forwarded to the Office of
Investigations of the AIA. for insurance coverage verification.
X do Hereby cert der/tlae airs incl pens[ es of r u tat me informatton prowaea abov✓ejrstrue a%na correct.
Z
Official use ordy. 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 dhire,
express orimplied, 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, associatlon or other legal entity, employing employees. However tha
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 sub6ivisions shall
enter into any contract for the performance ofpublic 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) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other that 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 applicaiipm 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 tho 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 Ast submit multiple permit/Izcense 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 stamp ed 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. Anew 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 lice 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 aid fax number:
Tho CQmmoaw. eaith of MassachvsPits -
Dopaximent of Thfttdal .Accidents
Off oe of vesiiga 'ton
60Q Wuhhagto,a eet
Boston, 42111
Tel. # 617-7.2` -4.900 at 406 ox 1-877 MASSAFE
Revised 5-26-05 Fax# 617-727-7749
www.mass,gov/dia
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D a t c2 i -,// 7
.........................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that .............. /.
"I ....... ...... .............. 7 !.'� ...........
has permission to perform . L .. I...�. ; ......."................ .........................
wiring in the building of .......... &W, � .... ..............................................
I
at ................ ........... . North Andover, Mass.
Fe�4� .... ........... Li,c. No.
.. ............ ..........................
-,9-546- ✓
ELEC�MICArLECTOR
Check # 0
7490
y Commonwealth of Massachusetts Official Use Only T�\`
r r M {,
Permit No. %
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. ]/07] (leave blank)
%I I
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: -7 J 3) 0 %
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number)
Owner or Tenant G i) 1 e y Telephone No. 9 )j
Owner's Address
Is this permit in conjunc ion with a building permit? Yes ® No ❑ (Check Appropriate Box)
Purpose of Building �),- A v. t L Utility Authorization No.
Existing Service (goo Amps I ck) / ftyu Volts Overhead Q, Undgrd ❑
New Service Amps / Volts Overhead ❑ Undgrd ❑
Number of Feeders and Ampacity
No. of Meters
No. of Meters
Location and Nature of Proposed Electrical Work: Jia N� k` .77L- t^•
AG.,p.( Thst hoona --ujy,. 2� — /7�✓K f S c�-- /,rte .,, ��
Completion of the following table may be waived by the Inspector of Wires.
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑In- ❑
rnd. rnd.
o. o Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
No. of Detect*on and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
g
No. of Waste Disposers
Heat Pump I
Totals:
Number
Tons
KW
No. of elf -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:
No. of Devices or Equivalent
No. of Water KW
Heaters
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: app , co (When required by municipal policy.)
Work to Start: 78 /U -7 Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
/ certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: t ti. -TT e I ecCao LIC. NO.:,/'1t z "� 9
Licensee: Kivl-j t2. (; .J Me-rf— Signature A LIC. NO.: -7i7
(If applicable, rater "exempt" in the license number Cne.) Bus. Tel. No.: 9V '-6dp 2 9 7 70
Address: O 18o 9
l % y /tit -6" ✓q"l,- a / g y % Alt. Tel. No.: `t �d ' `�7�' (oo2
*Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, 1 hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent.
Owner/Agent
SignatureturaPERMIT FEE: Telephone No, ��
ki
,I, o --k 7- doa o7 [21�
aLt
0
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
''' "sl www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): t rtil ✓1n,e G ( e c- hat c °-C 1 «s
Address: pU 601,
City/State/Zip
(/Ma CX 9 `/ 9 Phone #: Cp d� % '3720
Are you an employer? Check the appropriate box:
1. Lv1 l am a employer with / 4. ❑ 1 am a general contractor and I
employees (full and/or part-time)".* have hired the sub -contractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. t
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] f
These sub -contractors have
workers' comp. insurance.
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.E24ectrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
*Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information.
f 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: I'" t.._
Policy # or Self -ins. Lic. #:
INC G� `f (a �_`i(o
Expiration Date:
l0/000 �-
Job Site Address: c4 "I S J kA-. City/State/Zip: /`'Gz VN
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 certi nde the w and penalties of perjury that the information provided above is true and correct.
Sianature: Date: `113V0 7
Phone #: q,? f " &,e 2 — 9,-) ?0
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 #:
