Loading...
HomeMy WebLinkAboutBuilding Permit #578-15 - 25 COMMERCE WAY 12/29/2014 BUILDING PERMIT of NOR%ORTH,bAti TOWN OF NORTH ANDOVER 3r h ''`' �_, o APPLICATION FOR PLAN EXAMINATION M Permit No#: /-7 �� Date Received A7eo�Pay(5 LSSA CH USSR Date Issued: IMPORTANT: Applicant must complete all items on this page J ni-erg ILOCP�TRONk -- ' �nnt- EP.R®PERtTYf`C®1NNER 'Pent 1001'ear Struc ur" yes no0 ;LMAP�l PARCEL x_ _ ZON;ING DISTfZ_ICT;��hgwit Ristfic� �ye�s� rnos - �_ . A Ma-eft, Sh°opUllagYe TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial D-Alteration No. of units: U-e6mmercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 3 "� _' O.Se�tic� ❑1Welld °® Floodpl ntWetlands 77t- F rshedN Dist t '� °:-_ DESCRIPTION OF WORK TO e,E PERFORMED:oor C>yld w jDwr. Ji' Ci �d1-1 Y�{� Q0 �l`Y" /YI)1P r/a A WO afoh M✓4 , j9aY 0 f 144J-,rh ploy M Identificatio Please Type or Print Clearly OWNER: Name: Vt � --2- YIy►�et / hone: �� `a-7�U✓�S R � D Address: �� D» L'Cl' ✓� >F=f9 f Vvt ri, d 17 3U `C no tar ctortNarme x (�Lo�Phone, -y-- -.:a � .� �.. / ,� { s/Aldress Su<ervrsor's�tConstru et, i®rgLrcense. 10 � r � T � � - _ .4_. E? Homelrn t r©vement+License w� ec" . p �_. ExpR, ®ate 4 a� 1_ .. - NA ARCHITECT/ENGINEER Phone: ,_ f Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COSrRASED ON$125.00 PER S.F. r � Total Project Cost: $ , y�fl r/" FEE: /30,64 Check No.: Receipt No;- ,-.?, NOTE: Persons contracting with unregistered contractors do not have access;to the aharantyfund OF Signatureof°Agent/Owner �� `` ° �. `"#3< reof � t Signatucoiitractar . &x#. Location ��-� � date No. • - TOWN OF NORTH ANDOVER . o'r ' .' Certificate of Occupancy $ Building/Frame Permit Fee $ ft :- Foundation Permit Fee $ Other Permit Fee $ �4TED X TOTAL $ Check# 283G7 17 Building Inspector Plans Submitted ❑ Plans Waived 0 Certified Plot Plan ❑ Stamped Plans ❑ TYPE 6F SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ 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 Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPAReTMENT Tempumpste�onsiteNryesb. snoa � �._ AFireDepartment�signatur`e/"date �COM°�MENTS 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 w. 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 Call Email Date Time Contact Name Doc.Building Permit Revised 2014 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 o Building Permit Application o Workers Comp Affidavit ❑ Photo Copy Of HJ.C. And/Or C.S.L. Licenses ❑ Copy of Contract o Floor Plan Or Proposed Interior Work o 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 o Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Ener Compliance Energy p 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 ConstructionSin le and Two Family) � g ❑ Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) a Copy of Contract ❑ Mass check Energy Compliance Report o 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:Building Permit Revised 2014 NORTH Town of E ', ndover o to No. soh ver, Mass, cocH�ctiew�cw �'► A0oA7r-ED HPa��S S U BOARD OF HEALTH Food/Kitchen PERMI T LD Septic System THIS CERTIFIES THAT ' � � BUILDING INSPECTOR ..................... ...... ................................. ............................. has.permission to erect .......................... buildings onjv�...... .'P��:�:g...�. .............. Foundation Rough to be occupied as ............. .-S:....70� . �6V-................................................................... 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 CONSTRUCTION STARTS Rough ............ Service ............... ... .y � 'tr:..�..r�............... 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. The commogwealth of9assachusetts , DepaptMifit offfidustrigl Accidents Q, lee of Investigations 600 Washington Sheet Boston,.MA 02111 -www massgovldia Worker ' Compen ationJfnsurance fxdav�it:BuilderslContrcactOrSLEZe�c�hic ease Print ��eb r �.ppixeant Wo r nation Name(Businessiorgauzatiouffi dividual): Cy c Q Address: City/State/Zip: f�Nd ci1/ ►�yjq d/��SPhone#: l 6 Y7�7 Axe your an employer?Check the appropriate box: Type of prof ect(require-0: 4. [{ I am a general contractor and I 6, Q New construction 1. am a employer with have liked the sub-contractors employees(full.and/or pax e}. r �. []Remodeling 2,[] I am a sole proprietor or partner listed on the attached sheet. ship an&liave no employees These sub-contractors have 8. [(Demolition working fox me im any capacity. workers'comp.insurance. y. Building addition [No workers'comp.Insurance 5. ❑We axe a corporation and its 10 p Blecfxical repairs or additions required.] offtcexs have exereisedtheir light of exemption per MOL 11.[]Plumbhgrepairs or additions 3.[] I am a homeowner doing all work g p c.152,§1(4),and we have no 12.[l Roof repairs myself.[No workers comp. '.ees em to o workers insurau•cerequiredl employees.an 13-El Other comp.insurance required.] -Any applicanttfrat checks box if mustalso fdl outtha section bel6w showingtheir workers'compensationpoRoy information. i Homeowners who submit Ibis affidavit indicatamgtbey 2i a doing allworkand then hire outside contractors mustsubmit a new affidavit indicating such. TContractors that cheekthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.POlicy information. jam an employer that is providing workers'eompaisadon insurance for my employees: Below is the policy and joie site information. 0 0 q 7 7 / 0 -7 Insurance Company Name:. :5��NL5�0 QExpiration Date:I�alicy#or Self ins.Lic.l#: 1 job site Address: �� cc)rr��G� �� City/State/Zip: /Y tAe ✓�U 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 e.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 arab,one-year imprisonment,as wellas civil:penalties i u the foam.of a STOP-WORK ORDER.and a ane of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Ofbice o£ Investigations of the DSA for insurance coverage verification. ^ X 01 Iiereby Ce ti,fy u�lcle pains and penarties of'perjuTY Haat A in•formation provided aa600ve xs Ira an d correct Date: Si afore• (� � �, ��{ Phone# I �u—�_-�� �� • Oficial use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Xssuing.Authority(circle one): 1.Board of Health ,7.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing faspector 6,Outer 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 orimplied,oral or mitten." An employer is defined as"an individual,partnership,association,corporation or othex legal entity,or any two or more Of the foregoing engaged in a joint enterprise,and including the legalrepxesentatives of a•deceased employer,or the receiver or trastee`of a i divzd ial,partnership,association or other legal entity,employing employees. However the 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 Incensing 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 fbr 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),addresses)and phone numbers)along with their certificates)of insurance. Limited Liability Companies(GLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not regaired to carry workers'compensation.iusmance. If an LLC or LLP does have employees,apolicyis required. Be advised that this affidavitmay be submitted to the Department of htdustrial Accidents for confirmation of insurance coverage. ,also be sure to sign and date the affidavit. !'he affidavit should be retumed 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 n o ` the appropriate hie. , City or Town Ofdcials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit you o e y fill out m the vent the Office of Tnvesttgatxons has to contact you regarding the applicant. Please be sure to fill in the peimitTcense number whichwill be used as a reference number. Th addition,an applicant thatmust submitmultiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(ifnecessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."own . A copy of affidavit officially stamped ormarked the city or town may be provided to the applicant as proof that a valid affidavit i S on file for future permits or licenses. A new affidaviit must be filled out each year.Where a home owner or citizen is obtaining a license ox permit not related to any business or commercial venture (i.e.a dog license orpermit to burn leaves etc)said person is NOTrequired to complete this affidavit. The Of face of investigations would like to thank you in advance fox your cooperation and should you have any quesgons, please do not;hesitate to give us a call. The,Department's address,telephone and fax numb or: Tho Com.monw.Wth ofYbuaohus,tts Depaxtix int o. fadu5tdal Aaoldettst Off toe of7mstigaVan X04 Wa ' an.fort Bostoux MA.02111 TO, 617-7-27-4900 Qxt 406 9r x-$77:MASSAFE Revised 5-26-05 Fax#617-727-7m r I a CS-001821 ` DA VID P GULEZTAN 428 PLEASANT ST r N ANDOVER MA 01841 10102,7015