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HomeMy WebLinkAboutBuilding Permit #10457 - 24 COBBLESTONE CIRCLE 3/28/2014 Code Start V84S OPOO 3 COBBLESTONE CIRCLE 210/059.0-0084-0000.0 I I I I i I i I 4 t Edward Kelle► serving the grea !serving ED THE PIUmRERttO , MerrimackValley and Southern New Hampshire since 1976 Ma Master 9429 � — cell:978.807.1044 s 978.470.0129 57 Marilyn Road EdPlumber@msn.com Andover, MA 01810 91W, www.askEdthePlumber.com 4aadxa .ialem 4oy pue 4eay anoA MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' CITY MA DATEPERMIT# 6 JOBSITE ADDRESSL`C`'4 OWNER'S NAME I POWNER ADDRESS TEL --� FAX TYPE OR OCCUPANCY TYPE COMMERCIAL © EDUCATIONAL ED RESIDENTIAL PRINT CLEARLY. NEW: 0 RENOVATION: REPLACEMENT: ®, PLANS SUBMITTED: YES® NOD FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 S 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM [ -_ _�J _ I _ _,._.- I —1. ___ [1 —1 DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN Ifi _--j ____jI_ i --J INTERCEPTOR INTERCEPTOR(INTERIOR) J T KITCHEN SINK 1 LAVATORY l F- 3 ROOF DRAIN I __f _ _I .I ___1 _.4 _-__f ._.__� ._ _I ____f .__.____ �_._4 ° SHOWER STALL SERVICE/MOP SINK TOILET I __ f ______i I URINALr..__�= WASHING MACHINE CONNECTION WATER HEATER ALL TYPES I I � I 1 ___ __ WATER PIPING - .. OTHER ff------_I _ _ _ ( ---•___l -I _. J INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO E1 • T IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY„' OTHER TYPE OF INDEMNITY © BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER F-] AGENT IE]I SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true a c rate to the best 11 ly knowledge and that all plumbing work and installations performed under the permit issued for this application will be in e ia en sion of th Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME C2 7 LICENSE# ® SIGNATUR 1 11 , MP JP]I CORPORATION Q# PARTNERSHIP0# ;LLC COMPANY NAME ( ADDRESS Z fir' CITY C%1�` _STATE ZIP ���!T^ii TELI2- 7 It FAX CELL TIL L--- --- _- • - - _ _....__{ ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ 36 1� FEE, $ PERMIT It PLAN REVIEW NOTES i L N The Commonwealth of Massachusetts - Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance.Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly i • Name(Business/Organization/Individual): Address: City/State/Zip: Phone 4: Are you an employer?Check the appropriate box: Type of project(required): 'Ln I 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. 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g, ❑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 11.❑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' 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 a-re 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and joh site information. Insurance Company Name:. i 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 DTA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Simature• Date: Phone#: I Official use only. Do not write in this area,to he completed by city or town official. City or.Town: Permit/License# Issuingl 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#: H � J 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-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 anLLC 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 permittlicense 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 anyuestions please do not hesitate to give us a call. ' The Department's address telephone p pone amid fax number: . The Commonwealth of Massachusetts - Department ofI dustrial Accidents Office of Investigatio_ns 600 Washington Street Boston,MA,02111 Tel,,#617-727-4900 ext 406 or 1-877:MASS.AFB Revised 5-26-05 Fax#617-727-7749 www.Mass.8ov/dia Date....... -���... ,. ..... �NORTN, TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION $8'�CHUg� This certifies that .....................................................................P ..`... ........................ has permission for gas installation ...Q!�A ...................... in the buildings of................ .......t�t4A...!�................................................................. at. ....... .....d ......f.......................... North Andover,Mass. � A Fee... Q.. .. Lic. No. ... �.... M.4"'..........................................:......... GAS INSPECTOR Check# 91 7 •` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I' CITY / O u 9 � _ MA DATE PERMIT# JOBSITE ADDRESS �OWNER'S NAME LCD G OWNER ADDRESS f;1na E ==j TELr— �FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES Q NO Q APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER _[ BOOSTER -,--�,. _... _ I _. �l _ I �� - 1::j- -- —F-7j- _. - - _ CONVERSION BURNER =_ -- COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE �1�I GENERATOR GRILLE L. INFRARED HEATER (, LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER _ UNVENTED ROOM HEATER i WATER HEATER ^( �'- OTHER INSURANCE COVERAGE khave a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ONO El I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY R11 OTHER TYPE INDEMNITY Ej BOND F OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER EI AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information 1 have submitted or entered regarding this application are true and accurate to he best of m wle ge and that all plumbing work and installations performed under the permit issued for this application will be in complianigii., i p i ' of Massachuse4ts State Plumbing Code and Chapter 142 of the General Laws. /✓ PLUMBER-GASFITTER NAME L /h / ;LLE LICENSE#= SIGNATURE MP CR MGF El JP[j JGF LPGI© CORPORATION©#=PARTNERSHIP 0#=LLC E]#= COMPANY NAME: ADDRESS _ _ I A � ��`71�f CITY11 STATE LZIP j / TEL Cf J0 GJ FAX CELL MAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES 6 The Commonwealth of Massachusetts - Department ofIndustdgl Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers , Auulicant Information Please Print Legibly } Name(Business/Organization/Individual): 1�� 1r rc � Address: City/State/Zip:--� Z_-6r_� Phone 7C Cl 2 i 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 employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction am a sole proprietor or partner- listed on the attached sheet.1 7. El Remodeling A ship and'have no employees These sub-contractors have 8. []Demolition working for me in any capacity. workers'comp.insurance. g, Building addition [No workers'comp.insurance 5. F1We 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.ElPlumbing repairs or additions 1 myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 13.0 Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. iHomeowners 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:- 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 certify under the pains and penalties of perjury that the information provided above is true and correct. _ Signature: 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#: i Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workerscompensation for their employees. Pursuant to this statute an employee is defined as"...eve person in the service of another under an contract of hire Y "...every P 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 aJoint 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 whb,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 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-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. AIso 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 bum 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 oflndustrial,A.ccidents Office of Investigations 600 WashiVon.Street Boston}MA 02111 TQJ,#617-7274900 ext 406 or 1-877 MA.SS.AFB Revised 5-26-05 Fax#617-727-7749 www.mass,gov1dia y a a ` WCOMMONWEALTH OF MASSACHt7SETTS`.` ..� PLUMBERS AND GASFITTERS , LICENSED AS A MASTER PLUMBER ISSUES+THE ABOVE LICENSE TO t EDWARD 'A :KELLEY 57 MARILiYN RD r r ANDOVER MA 018`10 293 9429 05/01/14 I8314G a: a I � i Location 5.7 C 0)ZZ L 5'1'Pn No. 2 t �"� Date . - TOWN OF NORTH ANDOVER . , n Certificate of Occupancy $ Building/Frame Permit Fee $ ti Foundation Permit Fee $ Other Permit Fee $ r TOTAL $ j Check# `f Building Inspector .. i TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: '� Date Received Date Issueq: IMP RTANT: Applicant must complete all items on this page LOCATION �- Prin . PROPERTY OWNER Print 100 Year Old Structure yes MAP NO: PARCEL: VZONING DISTRICT: Historic District yes Machine Shop Village yes o TYPE OF IMPROVEMENT, PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑A teration No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 0 Septic p Well ❑ Floodplain ❑Wetlands ❑ Watershed District Water/Sewer \/ DES RIPTION OF WORK TO BE PERFORMED: Identification lease Type or Print Clearly) Y) � OWNER: Name: Phone: Address: i CONTRACTOR Name: , + Phone: Address: Supervisor's Construction Licenser Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. r FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED�ON$125.00 PER S.F. Total Project Cost: $ �i�i��� FEE: $ 2 ` c) Check No.: �� �� Receipt No.: a--r3. 7� 2-, NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature�of Agent/Qwh �'� Sig ature of contractorM Plans Submitted PI ns Waived 101 Certified Plot Plan ❑ Stamped Plans ❑ I - . - Plans-Submitted ❑ -.,Plans -Waived ❑ ;,.Certified Plot Plan ❑ Stamped Plans ❑ TYPE:QFSEWERAGEDiSPDSAL Public Sewer ❑ Tanning/Massage/Body-Art ❑ Swimming pools ❑ Well ❑ Tobacco.Sales 0 _ToodPackaging/Sales ❑ Erivate: septic tank,etc._ permanent Diinpster ori-Site IT -THE_FOLLOWING 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 i Water & Sewer Connection'/Signature� Date Driveway Permit DPW Tow;! Engineer: Signature: Located 384 Osgood Street .FIRE DEPARTMr NT Temp Dumpster on site yes no Located r dW24jWt Street .. Fire- COMMENTS ire D •p�»� �:.,,.t �:• ,� e artinent signatureldate '�, ,ra s,. x _' �r.... A COMMENTS_ I I Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions._ _Totah 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.$10041000fine NOTES and DATA— (For department use i i i i I ® Notified for pickup - Date f � Doc.Building Permit'Revised 2010 L _-- - - f Building Department -'The following W4.11st of:the re4 uire&forms to be filled outfor 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 NOTE: All dumpster.permits require sign off from Fire Department prior to issuance of Bldg Permit i 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/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) i ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New ConstructionSin le and Two Family) ( 9 Y t. ❑ 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 apn•�al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.tted with the building application Doc: Doc.Builyding Permit Revised 2012 i i Enter construction cost for fee cal- North Andover Fee Cakulaf►on Construction Cost 20,000.00 m $ - $ 240.00 Plumbing Fee $ 30.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 30.00 Total fees collected $ 400.00 I 35 Cobblestone Circle 652-14 on 3/24/14 Kitchen Remodel I I i I i l NORTy- oWn o n--- O No. &5;— Iq h ver, Mass, C OC NIC Mt WICK ��A�R�lTEO u S BOARD OF HEALTH PERMIT T -D , Food/Kitchen Septic System THIS CERTIFIES THAT .....C.04'­d.. ..................................................... BUILDING INSPECTOR 1� f has permission to erect .......................... buildings on ....e6.1^...........�.'.�. ?.�??. . .7�?.! ?—.... Foundation ... Rough to be occupied as ........... ... .k- ...—.......( . ...........................................,............. Chimney provided that the person accepting this permit shall in every respect conform to the 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 CONSTRUT STARTS Rough Service ....... ........... ............................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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. 1 i The Commonwealth o Massachusetts - Department of Industrial AccWe is Office of Investigations 600 Washington Sheet Boston,MA 02111 www.mass govIdia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plbmbers Applicant Information Please Print LegM Name(Business/Organization/Xndividual): Address: City/State/Zip: ►Jc��,�,. ��� f �p Phone M 1 K(D 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 f employees(full and/or part-time).* have hiredthe sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑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 WTI officers have exercised their 3.►'L/I I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑Roofrepairs insurancerequired.] 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. 7 Homeowners who submit this affidavit indicating they a're doing all work and then hire outside contractors must submit a new affidavit indicating such. l'Contractors that check this box must attached as 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: V City/State/Zip: Attach a copy of the workers'compensationpoliey declaration page(showing the policy number and expiration date). Failure to secure coverage as requ*cclunder Section 25A ofMGL o.152 can lead to the imposition of criminal penalties of a fine up to$1,50 0.0 0 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine ofup 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 DIA for insurance coverage verification. I do hereby cert&under the pains andpenaltdes of perjury that the information provided above is true and correct. Si afore• ©1` � � Date: ��a S� •) �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.EIectrical Inspector S.Plumbing Inspector 6.Other - - Contact Person: Phone#: L Information and Instruction s 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 employd 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 employe." 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 ofcompliance 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 he. 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 theapplicant. 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 ci or town)."A co of the affidavit that ( ' PY has been officially stamped o y p x marked by the city or town maybe 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 Ile to thank you in advance for your cooperation and should you have any cluestions, please do not hesitate toin've us a call. The Department's address,telephone and fax number: Tho CQMMOAWOalth of Mo ssa h e"tts I)OPaxtMO.Ut ofXndustdal.Acddeuts Qfoe ofInvestigations 600 Wa$ iVon Street Boston,M-A 042111 `o ,# 1 � 27400 OA 406 -8. ASS Revised 5-26-05 Fay,#617-727-7749 'ww4v.x�ass,gov�c�ia. TOWN OF IOTORTH ANDOVER OFFICE OF BIUMDING DEPARTMENT • �oda `y°y,� 600 0sgood Street Building 20,-Suite 2-36 North Andover,Massachusetts 01845 Gerald A.Brown Telephone(978)688_9$45 Inspector of Bi it gs • - Fax (978)688-9542 ' HONIEQW- M- R•LICENSE EXEMPTION M DEC'PERM T APPLICATION Pleaseyrint DATE: JOB LOCATION: Number StreetAddress Map/Lot 150MEOWNER 0�`, TIV Name. _ Home Phone WorkPhone PRESENT MAMINGADDRESS C`t y TSfwtte Zip Code The current exemption,for"homeowners"was extended to include owner-occupied o to allow su,h homeo�Vners to engage an ndividual.for hire wao does notpossess a license,provided units-Q owner eand acts as supervisor). Slate Building (Code Section 108.3.5.1) that DEFINITION OFHOMEOVMR Persons)who Awns aparcel of land on which he/she resides or intends to reside,on which there is,oris intended to be,a one or two family structures. A person who constructs more that one home in a two yearpeniod shall not be considered a homeowner. The undersigned"homeowner"assumes responsibility for compliances with the State Building Code and other Applicable codes,by-laws,rules and regulations. c The undersigned"homeowner"certifies that he/she understands the Town of North.Andover minimum inspection procedures and requirements and that he/she will comply with,said proc duresnand apartment requirements, ' H011MOWNERS SIGNATURE O�• (d�,� APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption BOARD OF APPEALS 688-954] CONSERVAT70N 688-9530 < HEALTH 688-9540 PLANNING 688-9531