HomeMy WebLinkAboutBuilding Permit #482 - 295 MASSACHUSETTS AVENUE 3/16/2009Permit N0: 3-161,10
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Date Issued: 61, ` 0
PROF
MAP NO: PARCEL: ZONING DISTRICT:`,Historic District
Machine Shop
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received 3 - 13 -61
610 �t�eo •e�'~O
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IMPORTANT: Applicant must complete all items on this page �
yes
no
no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One famil
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
f air, replacement
Assessory Bldg
Others:
Demolition
Other
Septic Well x
Floodplain Wetlands
Watershed District
1Nater/Sewer .
DESCRIPTION OF WORK TO
ED:
Rf:
W.o..,
Identification Please Type or Print Clearly)
OWNER: Name:_ Le.ng r• d S (o S.t_ k Phone:
Address: 'a 5 S
1W.70 ".0
ARCHITECT/ENGINEER /VA Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 S.F.
Total Project Cost: $ 1 5t06c� '--'� FEE: $_ 4 ,, 1 f�
Check No.: j� Receipt No.:
NOTE: Persons contracting with unregisteriwcontractors do not have access the guaranty fund
of
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 Qf H.I.C. And/Or C.S.L. Licenses
❑ CoPY of Controf-�'"
❑ 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
a 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)
o 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: Building Permit Application
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
a
THE FOLLOWING SECTIONS FOR OFFICE.U.SE ONLY
INTERDEPARTMENTAL• SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
"HEALTH t Reviewed on Signature
COMMENTS
. ' ' x'" w >
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board becision,
Conservation Decision:
Comments
• .t
Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
' Locat6d 384 Osgood Street
FIRE DEPARTMENT Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
t
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
❑ Notified for pickup - Date
Doe.Building Permit Revised 2008
Locatioti)D— Plow 19v -
No. Date /
TOWN OF NORTH ANDOVER
}
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # I_
21867
Building Inspector
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KITCHEN INSTALLATION ESTIMATE WORKSHEET - USA
Fnil!AX FINAL HE INSTALLER. ATCOPY O>K FINAL
NA KITCHLN ESTIMATE WORKSHEET MUST ALSO Hp IVENTOI1 B CUSTOMER B� MANUALLY
FAXED TO TH
`JSO in Job Site 4uate
reler to the lnstall&tlon speci(lcatlons Irl the spedid sOrvlees ._ystem for any related lnsratletlon programs 8 pdeing (flooring,
millworks, eta)
job will he scheduled once an materials ars at the job slte
Vote: The Hotter Depot does rat provide the following ae, vices (ai; port df kitchan Instaltptlon program).
Remove, alter or build toad bearing walls (other than stud wail traming)
;truetural altaratlons or repairs
ivAC watk
Niterations to oxtarlor of home
4emova1 of vinyl flooring or countertops unless in Installeto picifesslonal a inlan that the job {?leets industry standards fled norms and is manageable urxlor o
aorne Depot Hazardous Materials SOP
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customer Signature. KX/� pate:
i� _ rac i•• stn{-�r e, Date: -
Associate Signature:
page 3 of 3
4DS-27130 (013104)
£2 9-d £00/800-d 026-1 1lti£-V96-£09+ U0JdweH ON 90ti£ }odea ewoH-AOad MR: 1 0 8001-60-0
You c nary KITCHEN INSTALLATION ESTIMATE WORKSHEET - USA
a. riomove CA4,nets, li
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J-80 HCIi�MOVALiDNOLITION IJ- BOR (4pb $1111 g
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SUSTOTALI
atilt
75
15
2) DEBRIS REMOVAL
tr QTY u0mx
par unit
POINTOUVIML
a, Haul awa ca lasts an or Install debIiuot
rls from install 0b site e)
qX
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b. aui away cafdgoard only
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c, haul away appliances except rafrigarators)
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Haul riway raEngerators
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JSQ DEBRIS REMOVAL LABOR (Job alto QuN_
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I=ethical 02211ance preparation. pigialls, etc. Ina Ilex providi,s cam onan
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SUEFI CAL a
j) ELECTRICAL WORK
QTY UOM X.
pui troll
POINT 8115TOTAL
v. Replete existing receptao g eW to - no u es uogracia to Q tr {installer erov1 eal
as X
7b
x
b. New switch on circuit (installer provides)
ea X
3
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c. Install new surface mount light, tolling tan, can Ilghl to existlp,l eeMoe,
same location (coo tomar •Qrovldes flxturc;,?_ . _
as X
9
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d. Install now under cabinet light to existing sarvloe�ansae localim (customer pmvidee nxlurg
on X
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o. Now outlet tied tb do existing, circuit (Installer provides companeniBZ
o¢ X
3
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I. Run a- now _circuit _for a dedicated microwave hood {Installa� ralovides components),_s
X 1
09
0
I=ethical 02211ance preparation. pigialls, etc. Ina Ilex providi,s cam onan
ISOX1
Install bar or Vanity slnic with aucet within 3' of existing ocatic in
(installer provides shut off, traps, valves, all materials as require
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JSO i.LICTM0AL WORK fjob SItB t;trrote
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laq IX IG
Jsq X
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S AU--���SgiO 01 11,rPel (14Alb.15111c
SUBTOTAL
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a) PLUMBINQ
qN UDM
X
par unit
POIN't $ij5Ta'rAL
a. InstalPhOOkUp temporary sink, taUdat: Ingludos 8° temporary top, Bink, faucet, Fm- n8r
baskets provided by Installer
0a
x
15
0
b- natal) cupf�sf gie bowl lopmount B nk w/fauoot, dispoanh w ihtn 3 al ax s n8
locatlon (installer provides shut off, traps and valvae as needs -d)
ea
X
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n. Connect to ondermount or Intrad bowl s roc w t t faucet, clisposal: within 3" of Mating location
. (Instnilar provides braided supply I1neo, shut off valves, piping and tra sits needed)
ea
Ix
11
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1, Install new reverse osmose fining® pmvided by Instal ar)
as JX1
4.6
a
a. install new Insta-hot - hot water dispenser 1tTi n s Providetlbv insle er)
09
Ix
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Install bar or Vanity slnic with aucet within 3' of existing ocatic in
(installer provides shut off, traps, valves, all materials as require
ea
IX
1 7
0
1. Gas ApplfanOe seAratlon; gas supply lines, etc. (installer provides components) '�
ISO PLUMBING WORK (JobXla Ouatc) — -�
CJS -2760 {116104)
page 1 of a
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WHITE -HOME® DEPOT CANARY- 4NSTALL9R PINK -CUSTOMER
£29-d £00/100'd 010-1 Ilks-b96-£09+ 1101dweH ON 9Oq£ }odea e111oH-H08:1 NdSZ:10 8002-60-d3S
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Wei em help:
tl1 4AIJIMT ALrEHpT10flS
a. Alteratlorls tb oabinetry rholea cut In beck or hnftaM lif slh
b. Build up base cabinet to offset floor thlcicnees (UR to 3W In
ASO CABIM AL,TSRAInONti (Jb, $1In Quottil
c,
d.
61 MOL13ING INSTALLATION
a. Molding for top or O tom of Wall Cilblnet& Eaoh Iger 2g asc
b. 3crlbe or cover molding includwd as part of cabltist Install,
c. Toe look -
JSQ MOLOINO INSTALLATION (Job Sho Quota)
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The Comn:onH,ealth of Massachusetts
l
p meat of Industrial .,4ccidentc
iw.
Office O
.J f Investigations
600 Wash
tngton Street
Bosto
n, 1124 02111
Workers Compensation I;asurance.A�fi��,.jt; gtWdersontractors/ElectriciaQs
Ac, iicant Iaforn Qi -;on /C/Piumbers
Please Print Leaibi,
Name (Busines/O
srganization/Individual):
Address:
c
City/State/Zip: (ten F FS i'own NH ole �! r
Phone
603— �•G 7, a 3 6
Are you an empioyer? Check th
e appropriate box:
l . ❑ I am a employer with 4. ❑ 1 am a a
2. ❑employees (frill and/or part-time).*
I am a sole
general contractor and I
have hired the sub -contractors
proprietor or partner-
ship and -have no employees
Iisted ori the attached sheet I
working forme in any capacity.
These sub -contractors have
workers'
[No workers' comp. insurance
comp. insurance.
5. We are a corporation
3. ❑required.]
I am a homeowner doing all
and its
officers have exercise-d.their
work
myself [No workers' comp.
insurance
right of exemption per MGL
c. 152
e 1(4)° and we have
required.] t
no
ern lo'
P Y s [No workers
comp, insiiran
Type of project (required):
.6• ❑ New construction
7• Remodeling .
8. ❑ Demolition
9• ❑ Building addition
.1 0-0 Electrical repairs or additions
11 -11 Piumbin'arepairs 'oradditions
12:❑ Roof repairs
ce required ] 13 ❑Other
*Any appfic rs wlat cheeks box # 1 .muse also fill out the seotian below showing th-ir workers' compensation oL
'
Homeowners why submit •flits fl¢davit indicating they ers dolt:..' t;c3r::
tCantractors that checf this bot 'muse ..t-Iu Ehe P mmrmat�on.
attached an additional sheet showite� th r hitt o¢tside conerru;iuM rnusi sub iii a new atiidavii indimnng such.
r _ , a name of the - w-00nmetom and their..
�.,W&V.yC, uiac a provcacn; workers' co etu&i0I1 i ----...". N„ 'nronnatton.
information• assurance for >T, employees. Belo N, is the oft
P cy and job site
Insurance Company Name:
Policy # or Self -.ins. Lic. #:
Expiration Date:
Job Site Address:
Attach a Copy of the workers' compensation tic tieCia city/state/Zip:p° y ration page (sbowing the poGry number and expiration date).
.Failure to secure coverage as required under Section 25A of
fine up to $1,500.00 and/or one-year imprisonment; as well MGL c. 152 can lead to the imposition of criminal penalties of a
of up to .S250.00 a day against the violator. Be advised that a Civil penalties in the form of a STOP WORK ORDER and a fine
Investigations of the DIA for insurance coverage verification. py of this statement may be forwarded to the Office of
-1 do hnrni.a
7-
penalties of per• jurJ, rhm the inform zaon Provided above is true and correct
Uffcctal use onlp. Das not write fn this area, to be completed by city or town 0Icia/
-v
City or Town:
Permit/License 4
issuiap Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Eiectri"l t.,�..,._ —
fi. 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 inclucii rr.g 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 ap tments and who resides therein, or the occupant of the
dwelling hoar
use of another who employs,persons to do mint- ance, construction or repair work on such dwelling house
or on the grounds'or building"appurte-nant thereto shall not because of such employment be deemed to,be an employer."
MGL chapter 152, §25C(6) also states that "every state o r local licensing agency shall withhold the issuance or
renewal of a iicense or permit to operate a business's or to construct buildings in the commonwealth for any
`ap�uiicant wh6 has not produced acceptable evidence o►f 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 worl< until acceptable evidence of compliance with the insurance
requirements of -this chapter have been presented to the cont=acting authority" .
Applicants
Please fill out the workers' compensation affidavit comps-etely, 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 otherthan the
members or partners, are not required to carryworkers' compensation insurance. If an LLC or LLP does have _.
employees, a policy is required Be advised that this affidavit may submitted to .the Department of. Industrial
Accidents for confirmation of insurance coverage. Aiso 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, anyquestions re_=—�rdirg the.law or if you are required to obtain a workers'
compensation policy, please call'the Department at the ntLanber,Iisted below- pelf -insured ccrnpanies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure That the'affrdavit is compiete and printed Iegibly. The. Department has provided a space at the bottom
of the affidavit foryou 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 pennit/iicense applications in arty given year, need. only submit one affidavit indicatincurrent
policy information (if necessary) and under ".lob Site Address -the applicant should write "all locations in d (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 Iicenses. 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:
j
The Commonwealth of Massachusetts
Department Of lmdustr-ial Accidents.
Office of Lavestigations
600 Wasl E gton Street
Boston, MA G2111
Tel, 4 617-727-4900 =1406 or 1 -877 -MASS AFE
Revised 5-26=05
Fax 4 617- 72 7-7749
Wlwl.IF ass.gov%dia