HomeMy WebLinkAboutBuilding Permit #919-16 - 257 WINTER STREET 2/26/2016Permit No#: �,u—/�
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
Date Issued: Z ��/ c-,
I IMP , ORTANT: A-DDlicant must complete all items on this page
LOCATION �,C-7 �J I PJ —717�6 d� :!ST—
V Print
PROPERTYOWNER AN�,RfU) &
Print 100 Year Structure yes
MAP 164,CPARCEL: .3e ZONING DISTRICT: Historic District yes
Machine Shop Village yes
C
, 0
14,% r e D
no
no
no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
El New Building
0 One family
[I Addition
11 Two or more family
11 Industrial -
0 Alteration
No. of units:
D Commercial
El Repair, replacement
0 Assessory Bldg
El Others:
El Demolition
El Other
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DIESCRIPT _RFORIVILD:
A,I!PN OF WORK TO BE PF
-�--�A A7. 1 . - . — �
Identification - Please Type or Print Clearly
OWNER: Name:
ress:
Phone:
Contractor Name: --,6---&&w ae��- a0kPhone: :99
Email: -Tb 14 Py 0 cow, i2e-TIOW �416 -7-
C
Address: Ain., J6A1J),Q-IJ1-LJ0 Al
Supervisor's Construction License: C- S 1) Exp. Date:. /0/0/7
Home Improvement License:
. Date:
ARCH ITECT/ENGI NEER Phone:
Address: Reg. No.
FEE SCHEDULE. BULDING PERMIT. $1Z00 PER $1000.00 OF THE TOTAL ESTIMATED COSTBASED, ON $125.00 PER S.F.
Total Project Cost: $ 14 0 0 FEE:$ !&0
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contracOT3-4,q not have access to the guarantyfund
Plans Submitted [I Plans Waived 0 Certified Plot Plan [I Stamped Plans 11
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/Massage/Body Art r]
Swfinm'ng Pools
well
Tobacco Sales 11
Food Packaging/Sales El
Private (septic tank etc. El
Permanent Dumpster on Site El
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
",koning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
'Water & Sewer ConneGUOWSiignature & Date DrivewaV Permit
DPW Town Engineer: Signature:
LOcatea M4 USgOOa zjtreei
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
MGL Chapter 166 Section 21A —F and G rnin.$1 00-si 000 fine
NOTES and DATA — (For department use
U Notified for pickup Call Email
Date Time Contact Name
Doc.Building Permit Revised 2014
.No
M
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
4: 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
IOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
4a
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/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (if Applicable)
Mass check Energy Compliance Report (If Applicable)
.4. Engineering Affidavits for Engineered prodU-c-ts—
OTE: Ail 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
2012 IECC Energy code
Engineering Affidavits for Engineered products
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
Doe: Building Permit Revised 2014
Location
No.
Check #6-tl�4^"
300.511,
Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee
TOTAL
B ng inspector
I
Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
$ '75, 000.00
m
$
$
900.00
Plumbing Fee
$
112.50
Gas Fee 100 comm.
TOOM
Electrical Fee
$
112.50
Total fees collected
$
1,225.00
257 Winter Street
919-16 on 9/26/2016
Second Floor Addition
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The Commonwealth of assac useffs
Department ofindustrialAceidents
I Congress Street, Suite 100
Boston, Af_4 02114-2017
www.mass.gov1dia
Workers, Compensation)[nsurance Affidavit: Buuders/Contractors/ElqciTlclansfPl-umbers-
TO BE MEP WITH THE PEPMTT1NG AUT]'OFJTY Please Print LegLbly
Applicant Information
Name (B-Lisiaessforganization&divldiial): A J
Addxess:
City/Statc/Zip;
A an employer ee , Ve a
1 1 am a employer Vith—.L. _tImployees ftll and/or part-tiral-)-*
lam*a sole proprietor or partnership and have no employees Working for we in
any capacity. No workers' comp. insurance required.]
a.E] I am a homeowner doing all Work myselt [No workers, jcomp. insuranco required.]
4.E] I am a homeowner and -will be hiring contractors to conduct all work on my property. Pwill
ensure that all contractors ciffier have workers' compensation insurance or are sole
5. 1 am a general contractor and I haye hired the sub-coiAractors listed on the attached sheet.
'fheio s�ib- c ontractois &i� ei�ploye� s and have w�rkere cor�p. instiranc 04
6.FJ We are a corporation and i . ts offlqqrs have exercised their right of 'exemption per MGL 0.
152, § 1 (4). .4 'hay. ' ' * ' ' �s. p wor�ersl comp insurance required.]
'We nQ.��qploy?
Type of project (Tqquired):
7. El Now consftuction
8. [1 Romodolitig
9. El Demolition
10 E] Builcyng addition
i i. Electrical repairs or additions
13. C] RoofiePairs
14. [J Other—
lm�taisoffl out the section below showing theirworkers' compensation Policy MOnuation_
*Any applicant that checks ' indicating they are doing all work andthea hire outside contractors must s�brnit anew affidavit indicating such.
110meowners who s6af k�ftr atdavit ached an additional sheet showing the name of the sub -contractors and state whet.her,or liot;1hos.a; entities hava
lContractors that check this box must-att
fi * ' emplo�ees, je� jimit pro-vido their workers, comp. policy number.
employees. if the sub-obArad6rg ave
don insurancefor my empl6yees.' Below 1S thepolicy andjob site
I am an eMployer that ispid-vid6ig worNrs' comPensa
information.
ThsuranceCompalrYNaR10- 7 ivi V I V F 11 r -
Policy # or Self -ins, MG. (4) i!: :S -3 -0/3Fxpiration Date:
Sob Site Address: A/ Cit�/State/Zip:
vk�& cbmpepsation policy declaration page (s1lowing the policy number and expiYa -Xon ate).
Attach a copy of the Wo
Failure to secure coverage as required under MUL o. 152, §25A is a criminal violation punishable by 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 flue ofup to $250-00 a
day against the violator. A copy of this statement may be forwarded to the office of Investigations ofthe DIA for insurance
coverage verification.
j:-d-0j,jereby ce '�er lat the inforinationprovided above is true and correct
,Kjfy�n Ifliepains,andpenalliesofpelitil.4,ltf
Official use only. Do not -write in this area, to be completed by city or town official
City or Town:
PermitlLicense
Issuing Authority (circle one): i
1. Board of Iffealth 2.13nildingDepartment 3. CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone M,
olsq__5�_
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for thei� e
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contractORAiro,
expres� or implied, oral or written." I
An employer is defined as "an ind&idu , pfttners1Vp, association, corpoxation or other legal entity, '
.0 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 tru�tea 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 ofthe
dwelling house of anotherwho 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 b6 deemed to be an employer."
MGL chapter 152, §25C(6) also states that "everystate 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 commouw�alth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 15.2. §25C(7) states "Neither the commonwealth nor any of its political Mbdivisions shall.
enter into any contract for the perfon-nance of public work until acceptable evidence, of compliance with the insurance
requirements ofthis chapter have been presented to the con -ft -acting authority."
Applicants
]?lease fill- out the workers, compensation affidavit completely, by cheeldng �ffie*boxes that apply to your situation and, if
necessary, supply sub'contractoi(s) name(s), address(es) and -phone number(s) along with their certificate(s) of
—Msumnc&—I,imt-ed-L-iablhty-eompame�—(L-L-eyor H
members or partners, are not required to cary workers, compensation insurance. If anLLC orLLP does have
employees, a policy is required. D o advised that this affidavit may be submitted to the Depattment of Ihdusfrial
Accidents fok con-fumationofinsurance coverage. Also be sure to sign and date the a-ifidavit. Theaffidavit'should
be returned to the city or town that the application for the permit or license is bein'g requi5sted, noi the De�artment of
ludustdalAccidenis. �hould you have any questions regarding the law or ifyou'are r6q�re� to obtain a workers'
compensatioA �oliej; please call the Department. at the, number Hsted below. Self-ib�ar6d companies sh.puld'entor-their
self-insurane'a license number on the appropriate Eno.
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 pormit/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 ormarked by the city or town may be providedto the
applicant as proof that a valid affidavit is on Me for future permits orlicenses. A now affidavit mustbe filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
0.a. a dog license or permit to bm-n leaves etc) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston, MA 02114-2017
ToL # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Re,vised 02-23-15 www.mass.gov/dia
(7�x
Office of Con sumer Affairs & Business Regulation
OME IMPROVEMENT CONTRACTOR
�;E,R gis
e tration: 113130 Type:
pi,
ation: 5/18/2017 Private Corporatioi;
GRASSO CONSTRUCTION CO., INC.
JOHN GRASSO
865 TURNPIKE ST
'v -
N. ANDOVER, MA 01845 Undersecretary
M ' assachusefts Department of Public Safety
Board of Building Regulations and Standards
License: CS -022988 F
Construction Supervisor
JOHN GRASSO
865 TURNPIKE S;rR
T
NORTH ANDOVEOR M4 Vt4,6
Expiration:
Commissioner 10/31/2017