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HomeMy WebLinkAboutBuilding Permit #092 - 28 STONEWEDGE CIRCLE 8/5/2008 NO1i BUILDING PERMIT Q* ft&ORTo ft TOWN OF NORTH ANDOVER 3� ° = °� APPLICATION FOR PLAN EXAMINATION ° � � 'A h Permit N0: Date Received °rap ��SSACHUS Date Issued: s O� IMPORTANT:Applicant must complete all items on this page LOCATION 28 SraJ9WD&*- C4cttl Print PROPERTY OWNER DV6alJ� PAM0.4 &4(,4u*Qr Print MAP NO: _tQkb PARCEL: ZONING DISTRICT: ZFS-Z Historic District yes �;noq�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 _ ater/Sewer F DESCRIPTION OF WORK TO BE PREFORMED: Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: ZS OI CONTRACTOR Name:. r ` arc Z�j� Phone: Address; a\2VtA. c� (Stoye_t�VtAG Supervisor's Construction License: Exp. Date: Z /6 d Home Improvement.License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $__ 2 ,0615 yO FEE: $ 31..2 Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access t the guaranty and L ,gnature of Agent/Owner Signature of contractor �� 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 s- U FORM' DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT - COMMENTS CONSERVATION Reviewed on Si nature 9W�,_ COMMENTS )Mdin.JVLA_ HEALTH- � ._ Reviewed on Signature COMMENTS Zorbi g 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�DEPyARTMENT Temp Dumpstecon site yes no _. :Located at 124Main-Street .Fire,Departrnent�signature/date. COMMENTS r i i Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: of Meter location, mast or service drop requires approval roval 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 j ❑ Notified for pickup - Date i 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. i Roofing;:Siding;-Interior Rehabilitation,- - - ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of'Contract i ❑ FloorPlan Or Proposed Interior Work ❑ Engineering.Affidavits for'Engineered products i 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 Com Affidavit i p ❑ Photo Copy of H.I..C. And C.S.L. Licenses _ o 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 Affida'vits.for Engineered products NOTE: All dumpster permits require sign off from.Fire Department prior to issuance of Bldg Permit New Construction (Sinlgle.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 4 - Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 i, Location �� Sr�►r�Gt/f�f � � f No. �ci� 'Date �aRT� TOWN OF NORTH ANDOVER ° - f n Certificate o occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ t Other Permit Fee $ TOTAL $ -€ Check # A� . B,&ding Inspector %,&O R H T0 0Andover . .w.w'•.... .�,V &. ...... C%0 - LAKE o dover, Mass., COCM IC KE WICK V RATED BOARD OF HEALTH PERM . IT T D Food/Kitchen Septic System BUILDING .INSPECTOR THIS CERTIFIES THAT.................4�.v��'.. ... ...... � ..........................................................................:.................................... Foundation ................ buildings old' ��r�:�.� ...F... ..> has permission to erect....................... gs on ................. . .. ..:w �r.....S,.�c:;11.1�........................ Rough t0 be occupied as �li P.JTra ....'0... ..... ./! � �.� .......................... Chimney Chim provided that the person accepting this p'brmit shall in every respect conform to tft rms 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 LESS CONSTRUCTION STARTS Rough .................................. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough-- Display -in ough-_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. The Commonwealth of Massachusetts Department of Industrial Accidents 0, i Office of Investigations 600 Washington Street Boston, MA 02111 t www.mass.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): t Address: �CSA e Inn S City/State/Zip: �O`l,Q\a k X tka (AZJ\\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 I 6. ❑New construction ^�mployees(full and/or part-time).* have hired the sub-contractors �,� 2.L� I am a sole proprietor or partner- listed on the attached sheet. 1 7• L?J Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised.their 10.0 Electrical repairs or additions 3.❑ 1 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' ❑ comp. insurance required.] 13. Other *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. Homeowners who submit ibis ar;idavit'ndicaiing they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors 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 job site information. Insurance Company Name: 1::Z) C Policy#or Self-ins. Lic.\#�:— CC � � z �,Z Expiration Date: Z 246)cj Job Site Address: 2 It �n� �r� eic r k-cC1 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. I do hereby certunder the pains nd penalties of perjury that the information provided�ab v is true and correct Si ature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town gfficial. 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 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-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. 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 pen-nit/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 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 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 Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-7274900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax# 617-727-7749 www.mass.gov/dia ��o�o�acr F,,�JtJlr::�BERUBIE CONSTRUCTION 771 Salem Street Fully Licensed & Insured ~ Groveland, MA 01834 . Phone: 978-521-2544 Remodeling • Additions • Custom Homes PRO PO SUBMITTED TEva, / �; PHONE# DATE yL� G a ( _A, FAX If STREET �` ' JOB NA ,• CITY,STATE f]ZIP JOB LOW IO WJ ESTIMATOR ` DATE OF.PLANS JOB PHONE We he submit specifications and estimates for: 1 !� /� / ,r ' P:ij t--ru-c firn: . . n.e vv d e"ck,. . . r.'�'.a. .uv!". d.e.a G3�f` a' ss �'�... . r c r .c� F t :c^► . . .f<t��r-. rc �1t`�`� r.S . v �.�. . . . . . . . . . . . . . .ow ertd. . vv, �: .e/1 e_1. .. . . . . . . t`a� 01.1.0.. -trI. In. .��A�. . . -�f�t 1 . .Vii t. e_ Us�'�Y. . ;ai-_r u_c b6n. d ebras. . .f. .I . .be_ . re-tY)'0.v.e_d . Vial. ; , r-) A �Q 3Pr0p0$e hereby to furnish material and labor — complete in accordance with above specifications, for the sum of: v� dollars ($ C Payment to be made as fo o s: 7t All work to be completed in a workmanlike manner according to standard practices.Arry alter- ation or deviation from above specifications involving extra costs will be executed only upon Respectfully written orders,and will become an extra charge over and above the estimate.This estimate is submitt=oteThis for completing the job as described above.It is based on our evaluation and does not include material price.increases or additional labor and materials which may be required should unfore- proposal may be seen problems or adverse weather conditions arise atter the work has started,or delays beyond withdrawn by us if not accepted within days. our control.Our workers are fully covered by Workmen's Compensation Insurance. Rcreptance Of Propogal—The above prices, specifications and conditions are satisfactory and are hereby accepted.You are authorized Signature 4wizen to do the work as specified.Payment will be made as outlined above. Signature Date of Acceptance: i Construction super-ovr--- License: CS 65246 Expirati n 12/16/2009 Tr# 10123 it r rRestpiation 00r All _7 SCOTT A BER.UB 4 771 SALEM ST t'r ' GROVELAND,MA 01834 r¢ Commissioner j f _.,1,l� �afrairncYruuea��, 4�_ r jte,.artryattte�6 Board.of Building Regulations and Standards# — ` HOME IMPROVEMENT CONTRACTOR Registration: 119555 _ Expiration: 7/26/2009 Trig 130084 . Type: DBA BERUBE CONSTRUCTION SCOTT BERUBE 771 SALEMST GROVELAND,MA 018M Administrator XAORT TO" Of Andover No. ;j LAKE O dower, Mass., COCKICMEwICK A. 7��'4ATED �P�,��� BOARD OF HEALTH M I T T.. Food/Kitchen Septic System / BUILDING INSPECTOR THIS CERTIFIES THAT..:............. % ... .....s .........0....'U°.................... .............................................................. Foundation � '����wFc .(.�e:: E..........::............ Rou has permission to erect...:::......:........................ .. buildings on . (......... ....... .. . gh to be occupied as...... ............... cr-mit �ir .1� ...!G ... ... -1�hf�?C P �.r.K. .......... ............ Chimney provided that the person accepting this pshall in every respect conform to th t rms of the appl'ocation 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 CONSTRUCTION STARTS Rough Service . ................... ... ...... ........... ..... BUILDING INSPECTOR 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.