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HomeMy WebLinkAboutBuilding Permit #588 - 24 MILLPOND 5/6/2009 14ORTH BUILDING PERMIT cfttL�o "ti � TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION * ,� Permit NO: Sd' Date Received �'°o "�y* D S �ssgc►+us�� Date Issues G ' IMPORTANT: Applicant must complete all items on this page :LOCATION y /1'1 Pena N©r4k AtJorcf". �� 1 Print PROPERTY OWNER Chr%5+1h-6 -Print MAP NO: PARCEL:- ZONING DISTRICT: Historic'District yes Machine Shop Village yes 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 DESCRIPTION OF WORK TO BE PREFORMED: 377 s-fa 11, ne-w ea6it)eEs i n fhe. k ; +cMA— . Identification Please Type or Print Clearly) OWNER: Name: Sc,s E ;n. B a 1<<e- Phone: (a03) &Y3- 306Y Address: I It st i l l P*4 Nor+h Andoir cr M A o ! 5 CONTRACTOR Name: Phone: Address: I Supervisor's Construction License Exp. Dater Home Improvement License: Exp. Date: 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. �I o Total Project Cost: $ 6 d . 0 1%� FEE: $ 5( Check No.: 1 �3 ReceiptN .: o NOTE: Persons contracting wit unregister d contractors do not have access to the guaranty fund gnature of Agent/Owner �� Signature of contractor t Building Department The following 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 ❑ 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 ❑ 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 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) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses j ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract l ❑ 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 appeal 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:INSPECTIONAL SERVICES DEPARTMENTMITORM07 Revised 2.2008 Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer 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 I CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS U Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located -384`Os ood Street FIRE DEPARTMENT Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/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, 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-$1000 fine NOTES and DATA— For department use i ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 Location No. .� Date ,.aR•� TOWN OF NORTH ANDOVER f �,y f y Certificate of Occupancy $ '+SJCN�SBuilding/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ ' TOTAL $ Check # 22 � � �? Building Inspector J f pORTM TOWN OF NORTH ANDOVER OFFICE OF a BUILDING DEPARTMENT * 1600 Osgood Street Building• + i q 8 ding 20, Suite 2-36 �.,s�•..•�'�� North Andover,Massachusetts 01845 •T'ACMU`�t . Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION lig DATE: �l��aooQ JOB LOCATION: P o n of Number Street Address p/ HOMEOWNE (jo3) g�13-3ooy (M) q 8$l- gi7s ° Name Home Phone. Work Phone R, PRESENT MAILING ADDRESS__A q /q, 11 POAJ- No r+L An doycr A AO1 S city own State zip Code The current exemption for"homeowners"was extended to include owner-o=Tied dwellings to two units or less and to allow such homeowners to an individual for edge hire who does not possess a license,provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) DEFINITION OF HOMEOWNER Person(s)who owns 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 structures, A who fatuity person constructs more that one home in a two-year period 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— The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Department minimmn inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNERS SIGNATURE _)od— APPROVAL OF BUILDING OFFICIAL RevisM 10.2005 Form Homo wun Ennqy ion TIOAR.DOF \PPE.\I.S(,S9')541 CONSERV.\TION 688-9530 HE.U..TH688-95-10 PL.INN[NG6R8-9535 NORT#q Town of 4Andover , 0 - : No. Q"38 4 �_= dover, Mass., " O - LAKE COCMICMEwICK 7,9 ADRATED PPS\ �5 S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THISCERTIFIES THAT............. .......6-1.. .................................................................................... Foundation has permission to erect........................................ buildings on.. ..... 1., . ...0�. ..... Rough Chimney to be occupied as................OK.L..., ..........�G. 1.r,� ......... ....z.✓p.....L7:vkf. . ................ provided that the person accepting this permit shall in every respect conform to terms of the application on file in Final 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 CONS STARTS Rough ...........................................................::....... Service BUILDING CTOR Final Occupancy Permit Required to Occupy 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. NORTH Tovm of 4Andover G .` No. QT .8 T . A K E = dover, Mass., ` � COCMICKEWICK y1. 7�ADRATED PPa` �y `s E BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THISCERTIFIES THAT.............z.'U.(&.... .n......l6 cj.. .................................................................................... ;Foundation has permission to erect........................................ buildings on ..c1s/......... IZ, ...0�. ................. Rough to be occupied as................ p L.., L.............�G.�1..r�?W� ........ ....�.✓.....1E-7. �•r,�.- ).............. Chimney provided that the person accepting this permit shall in every respect conform to terms of the application on file in Final. 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 CONS ST TS Rough ..........................................................::::...... Service BUILDING R Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To BeDone FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. The Commonwealth of Massachusetts 1 Department o.f Industrial Accidents Office of Investigations 600 *-ashington Street ti 4,i Boston, MA 02111 fi www mass.gov/dia . Workers' Compensation 1witrance Affidavit: Builders/Contractors/Electricians/Plumbers Anolicant Information Please Print LeQibb Nanie (Business/Organization/individual); Address: City/State/Zip.-At-_,-Lk A4 t)�j�tr M O(�y Phone#: .o Dg13 Are you an employer?Check the appropriate box: Type of 1. prelect(required):❑ I am a employer with 4. ❑ 1 am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction . 2.❑ I am.a:sole proprietor or partner- listed on the attached sheet.i 7• ❑Remodeling ship and have no employees These su&r-ontractors have 8. ❑Demolition working for me.in any capacity. workers' comp.insurance. [No workers'comp.insurance 5. 9• ❑ Building addition p ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3. I am a homeowner doing all work right of exemption per MGL 1 l.❑ Plumbing repairs or additions myself.[No-workers,comp. c. 152, §1(4),and we have no 12. Roof insurance required-]t ❑ repairs re� ] employees. [No workers' 13-El Other comp, insurance required_] Any applicantthat checks bo)tll 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 con =Cotractors must submit a new affidavit indicating such. =Contractors that check this box must attached an additional sheer showing.t l'ie name of the sub-conttactons and their workers'camp.policy infomoation. I am an employer that is providing:workers' compensation u:surancejor nry.employees: Below is the information, policy and job site . Insurance Company Name: ' Policy#or Self-ins.Lie.#: 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$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. ]1do he_eby Pun 'r the nd penalties of perjury that the information provided above is trice am correct ttir � Date: Phone [6. ciat use only. Do not write in this area,to be completed by city or town official or Town: Permit/License# ing Authority(circle one): I. oard of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing inspector tbertact Person: Phone 4: 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 ortrustee of an individual,partnership,association or other legal entity,employing employees. *However the ownerof 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 coritracting 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,notthe 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 nuBnber.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 ofthe affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that 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 of Industrial Accidents Office of Lnvestiations 600 Washington Street Boston, MA 02111 TeL#617-727-4900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia Invoice Invoice # Invoice Date ,z 5210 5/6/2009 Due Date I` 5/6/2009 88' Job # Job Date StoneOne 2484 5/1/2009 75 Mystic Street Methuen MA - 01844 www.StoneOneCorp.com Phone: 978-681-7664 Fax: 978-681-1773 Sold To Install Address BAKER,JUSTIN 24 MILL POND ROAD 24 MILL POND ROAD N.ANDOVER MA N.ANDOVER MA Ph: 781-343-3804 I P.O. No Job Name Terms Rep Cust.Job# Reference# Kitchen Paid upon Completion Silvana Perrina Description Price Qty Extended Custom Kitchen (kitchen) _ 2,784.00 1.00 $2,784.00 Description Quantity Tropic Brown 3cm 48 SQFT. 3/8 Radius-Standard Inclusion _ 1 LINEAR FEET .......... ......... .................................. Faucet Hole-Standard Inclusion 1 EACH Soap Dispenser Hole-Standard Inclusion 1 EACH 1 Sink Cutout-Standard Inclusion 1 EACH ................. Template/Install 48 SQFT. Sub Total: $2,784.00 Tax: $103.20 TOTAL: $2,88.7.20 Payments: -$0.00 BALANCE: $2,887.20 StoneOne requires 50% Deposit due at time of order and 50% balance due upon installation or pick up from all customers unless otherwise expressly agreed. By signing below I am indicating my authority to sign for services and agree to pay for services in accordance with the specified terms. ***Square Footage Subject to change at time of template*** Cast Iron undermount sinks support by others. Stoneone will secure the Dishwasher if its undermounted and must be on site at the time of install. If side mounted secured by others. Countertop Removal and Disposal is not part of this estimate unless included in this estimate. At Stoneone we guarantee our labor for one year. A fee of$200 will be assessed if canceled within 48 hours of appointment. if a second trip is required for templating or installation a $200 fee is will be assessed. By signing this agreement I acknowledge that I have received the pre-template checklist and will comply with the required steps. The undersigned acknowledges that Natural stone varies in color, shine, sheen, pattern and texture. These patterns include but are not limited to grains, veins, pits, divots and blemishes. The patterns are in fact part of the stones nature and therefore cannot be claimed a defect subsequent to this agreement. The undersigned acknowledges due to the natural movement and or waves in stone, it is impossible to match stones exactly when seaming. StoneOne takes all necessary measures to ensure that the seam flows as best as possible. All seems are completed at the sole discretion of StoneOnes fabrication.