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Home My WebLink AboutBuilding Permit #112-13 - 255 HAY MEADOW ROAD 8/8/2012 i BUILDING PERMIT "° DTH qti TOWN OF NORTH ANDOVER �atyEy."_ r-•+6'6 O_ APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received U ��SSACHUS�� Date Issued: 0 • IMPORTANT:Applicant must complete all items on this page LOCATION Pri PROPERTY O NER not MAP NO;�6- E4QOdYOL, ZONING DISTRICT: Historic-District yes no 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 We'll Floodplain Wetlands_' Watershed District Water/Sewer �. DESC IPTION OF WORK TO BE PREFORMED: Identi kation Please Type or Print Clearly) ( � OWNER: Name: Phone: �( Address: CONTRACTOR Name:� Phone.,/22 -- Zfd-7-Cy6 Address: Supervisor's Construction:License: _ ` Exp. Date- Hopi e ate:Home Improvement License: . _ _ Exp. Date: ARCHITECT/ENGINEER Phone: i Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 P R S.F. Total Project Cost: $ FEE: $ I 2- Check No.: 2— ` t Receipt No.: NOTE: Persons contracting with unregistered contractors do not have acre s to t e guaranty fund Signature of Agent/OWner Signature of contractor i 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, I CONSERVATION eviewed on �� Signature 7 'NTS_COMM N S 1 U ('j HEALTHU Reviewed on Signature I COMMENTS A 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 DEPARTMENT = Temp Dumpster on site yes no . Located.at124 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) �XJa ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 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 ❑ 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 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 DEPARTMENT:BPFORM07 Revised 2.2008 Location �-66 M-ead�w No. ` Date D e • TOWN OF NORTH ANDOVER J,L • �, ` t;t1n Xr 1 /` '4st {0 _ s Certificate of Occupancy $ { Building/Frame Permit Fee $-21(o—�aU Foundation Permit Fee $ Other Permit Fee $ f�R iT I'll ti TOTAL $ Check#'2-) 'U 25595 Building Inspector NORTH own of E ndover O ti 0% No. s _ - h ver, Mass, ' A_ cocMic„lw.C� 7�p�R�tTE0 S U BOARD OF HEALTH Food/Kitchen T D Septic System THIS CERTIFIES THAT ...................PERML . °�........... ............ .. ..�`"* ......... BUILDING INSPECTOR Foundation has permission to ere ...............%......... buil ' on ... ,` ..��....... .....!!'�.Y.1!!!��e leo . Rough to be occupied as .. .....ipp N#A_ . ..........�. .... ...�P.......................................................... Chimney provided that the personting this permits 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 9QNTHS / ELECTRICAL INSPECTOR brr UNLESS CONSTRUCT1046TA Rough Service ................ ...... .......... ....... ............................... Final BUILDINGINSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildln 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 --NYLON I X17 - 17--- -- Ql _ -- ---- - -. - - - - - - g f _-+44+4+--- +44 _ - ___ - - ,- olf o�.�Q4a`rc�ruaeAb .1 - \ Board-of Building Regulations and Standards . HOME IMPROVEMENT CONTRACTOR i Registration: 161120 Expiration 9/25/2010 Tr# 275490 1 �� R.D.CARTER CONSTRUCTION RICHARD CARTERt-f t + 108 SOUTH RD. LONDONDERRY,NH 03053 Administrator' \1 �7 VV Office of Consumer Affairs and dusiness Regulation 1y1 ,. 10 Park PIaza- Suite 5170 Boston, Massachusetts 02116 Nome Improvement Contractor Registration Registration: 161120 Tvpe:' LLC Expiretion: 912512012 Tif 204205 R.D. CARTER CONSTRUCTION LLC. RICHARD CARTER 41 LEXINGTON AVE, ""- BRANEORD, MA 01835 Update Address and return card.Mark reason for than&- 0 Address f.I Renewal 0 Emplayntent L] Lost Card 3-CA1 0 50M-04 1-0101218 ,\_ OfriceoTs�oa�meF X�iln ` a on License or registration valid for individul too only i' HOME IMPROVEMENT CONTRACTOR before the expiration date if found return to: Rs91stratlon: 161120 Type, Oltica at Consumer Affairs and Business Regulation ration: 9125/2412 ExpilLC 18 Park Plaza-Snite 5170 � � Boston,MA 02116 R.��ARTER cotimuc-nON LLC. RICHARD CARTER ; f 108 SOUTH RD. LONDONDERRY,NM 08453 Uaderseewfirryy_ Not voiidw hout signature ' ' , !,,�. `la�.achu+ett•- i3�p;�rtmclti 11i Ptdtlic �a�vt�. Board tai Ridit ine Reaulalion%and Stan�larll. fi Construction Supervisor Ucenso License: 03 94814 a•. j r RICHARD CARTER j 1 41 LEXINGTON AVE �r i BRADFORD. MA 01835 1 Expiration: QM2012 1 t ouns..i••nrr Trd: $T9 • i I at►w\ Office of Consumer Affairs and Efusiness Regulation ' 10 Park Plaza- Suite 5170 z}= Boston, Massachusetts 02116 Home Improvement Contractor Registration Reslistratlon: 161120 Tom:. LLC Expiration: 912512012 TrO 204205 R.D. CARTER CONSTRUCTION LLC. _ RICHARD CARTER 41 LEXINGTON AVE. "— BRANFORD, MA 01535 -- - Update Address and return card.Mark reason for c6aage, C] Address (1 Renewal 0 Sniployment L] Lost Card s-CAI A SM-04M-010+216 \ Office oa Coa meF firs " `e8i�a a oe License or registration valid for individul use oniy r HOME IMPROVEMENT CONTRACTOR before the expiration date. Kfound return to: Office of Consumer Aaeirs and Badness Regulation Registration: 161120 -Type: Ni Expiration: 912512012 LLC 10 Park Plaza-Suite 5170 Boston,MA 02116 R.I .RTER CONSTRUCTION I. RICHARD CARTER 108 SOUTH RD. � _ LONDONDERRY,NH 03053a— I1ad�ecretury Not vatfd t hope sigltatarc 4Nw%%4Chu•wtt•- Ucgrartment tai Public Nilkq' lWa rd oaf Ritildine Rei-101ation%and Standard" Construction Supervisor License _ License: 08 94814 a•. RICHARD CARTER 41 LEXINGTON AVE {! aRADFORD,MA 01835 i Expiration: 91f12J2012 1 (uouni��i••nah TO: $73 • I I i d i I ,i M-Issuchusctts- Department of Public Safct% Board of Building„ Regulations and Standards C0n'structiort,Supervisor License License: CS 94814 RICHARD CARTER 41 LEXINGTON AVE - BRADFORD, MA 01835 Expiration:/9/12/2012 Commissioner Tr#: 873 i. r The Commonwealth of Massachusetts - Department of IndustriglAccidents Office oflnvestigations 600 Washington,Street Boston,MA 02111 www.massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Auplfcant Information Please Print Legibly Name(3usiness/0rganization4ndividual): Address:-44 - City/State/Zip: kz�k i J Phone#: 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 T 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.x �• E]Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working forme in any capacity. workers'comp.insurance. g, El Building addition [No workers'comp.insurance 5. El We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3111 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.E]Roof repairs insurance required.]► employees.[No workers' 13.❑Other comp,insurance required.) 'Any applicant that checks box#1 must also fill outthe section below showingtheir workers'compensation policy information. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew 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 pYoviding woYkers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name:_ Policy#or Self-ins.Mo.#: 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 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 in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Bo advised that a copy of this statement maybe forwarded to the Office of Investigations of the DTA for insurance coverage verification. Ido hereby cert and t1i ains andpenalties ofperjurythat the information provided abo a is tru and correct. - Si afore: V Date: `2 2 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 any contract ofhire,. 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 ofits political subdivfsions 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),address(es)and phone numbers)along with their certificate(s)of insurance. Limited Liability Companies(LLQ or Limited Liability Partnerships(LLP))with no employees other than themembers or partners,arenotrequirequired carry workers' insurance. Han LLC or LLP does have employees,aolio irequired. Be p Ys q advised that this affidavit maybe y 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 Pp the applicant. Please be sure to fill in the permit/license number whichwill be used as a reference number. In addition,an applicant that must submit multiple permiYlicense 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. Anew affidavit must be filled . out each year.Where a homeowner 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 Goz a Aonwoalth of M-assa.,ohUsetts Department of Industxiat Accidents Office ofInvesfigatio.m 600 Washin&a Street BastonMA02111 . Tel,#617-72.7-4900 ext 406 or 1-877,7MASS.RE Revised 5-26-05 Fax#617^727-7749 www ma$%govMa