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Home My WebLink AboutBuilding Permit #432 - 3 JOHNSON STREET 12/18/2007 BUILDING PERMIT pORTH TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION I ?, ea Permit NO: F� Date Received ,T.o �SSACHl1`'�( Date Issued: Y IMPORTANT: Applicant must complete all items on this page LOCATION \I l`'Q ki k. . Printy PROPERTY OWNER f C �`'1 ' c:.: 0 Prirk MAP NO: C 0 PARCEL: &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 Well Floodplain Wetlands Watershed District I Water/Sewer DESCRIPTION-OF Wpff TO PREFORMED: 0 ,Q\Qte Ideni'fication Please T e o Print.Clearly) �.,(� OWNER: Name: ' '� hone:� / , -Address: /5 'JJ " Z C� d Y CONTRACTOR Name: �� Phone: - f Address: t f_ Supervisor's Construction License: Exp. Date: I Home Improvement License: / `� `7 Exp. Date: r G " 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: $ ��, C.0 no FEE: $ �Check No.: Receipt No.: c�.�'(i NOTE: Persons contlactin with unregistered contractors do not have access to ran fund ^ it�� rr Signature of Agent/Owne 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 - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS DATE REJECTED DATE APPROVED CONSERVATION COMMENTS DATE REJECTED DATE APPROVED HEALTH 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 Located at 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 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 ❑ Notified for pickup - Date Doc.Building Permit Revised 2007 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 I Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 Location- No. ocation No. 3 Z- Date Z NORTH TOWN OF NORTH ANDOVER Certificate of Occupancy $ MU IL<� Building/Frame Permit Fee $ Foundation Permit Fee $ •r Other Permit Fee $ TOTAL $ Check # 20860 Building Inspector The Commonwealth of Massachusetts ,partme nt of Fire Services Office of the State Fir r e Marshal. _ P.0,Box.107�,State Road;Stow,MA 01775 PERMIT Date: North Andover Ter. iit No (City of Town) (If Applicable) Dig Safe Num er 7 In aceordaace with the-provisions of A GL 14&C-hap.terLL(L as provided in section 5 Z 7 ('MR 34 Start Date / This.Permit is grant Cd Full name ofpersou,Finn or Corporation Pennissionto locate dumps.ter for construction/renovation/demolition of building. Comments:. dumps,ter must be . 25 ` from structure if unable to lace with re uire.d Restrictions clearance dumps-ter musts :be covered with plywood or tarp end of 'work -day (Give Location by street and no.,.or c 6c in such a to r i tification of location) Fee Paid$ 50.00 Fire Chief This Permit will a pine� _ i `" (S ib azure of offical granting permit) offical grantingpermit (Tide) a ' I I �\ . Bard oLBuil�"rng.Regn�stf�dK5i�1rht�et.�. ., ,f H alt #MPIP�V;Kf A 'ice*UOPE& : kegist� rA Michael.RoadOKiI``�V , f� 4 Pegsc3t'Sitt `" r>,% s No AneiOh e41845 5°/ pq * -- tie �omrrzoiuue �/ � tu4elCb ►' Board of Building Regulations and Standards License Construction Superyisor License CS 28538 `' eirthdte 915/1948 y �![�xpiration9/612009 Tr# 2947 Reslilcti6n 6-1 MICHAEL V RO�D�N ` NORTH Town of And No. ~ ; C% _ o �` dover Mass. O LA COCMICKEWICK 0/?ATE D PPS\ BOARD OF HEALTH Food/Kitchen PERMIT T -D Septic System ,g L BUILDING INSPECTOR THIS CERTIFIES THAT.... �?�-/.�%/ +T� .tom...................! a ....................................................................... Foundation has permission to erect ...................................... buildings on ... ....To.)Nns.an.....5.r'................................... Rough / J1 `-C tobe occupied as........ ......... .. .................... .l..Q.....................................4... 1....... . Chimney provided that the person accepting this permit shall in every respect conform to the terms 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 UNLESS CONSTRUC S Rough Service ..................................................7 ....... BUILDING INS ECTOR 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. i • `. �1ze Ui oorr�rw�uuea./.� Board of Building Regulations and Standards I Construction Supervisor License L cense: CS 28538 B�rEhdate 9/511948 ,� Exp�rarort 51%2009 Tr# 2947 i Restriction _dU� MICHAEL V RODDENW v -----------� 47 PRESCOTT STS- N ANDOVER,MA 01'845 Cominissioner 1 FY'9curma"`waewin'*er. *` _. - I. _ _ �anw— <L,\ . Board oUg0iWng Reg# HOifiltr#AP� ` :<,A nc t M'jchael Rodd 47 �. Q:Ancto :: 1aa . NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: ` ,J is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 115 S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 10A. The debris will be disposed of in: L-t\,Q�om �� h f (Location of Facility) Signature of Permit Applicant Date The Commonwealth of Massachusetts Department of Industrial Accidents W Office of Investigations d 600 Washington Street .c Boston, MA 02111 ` M 5 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Tie ibl Name(Business/Organization/Individual): Address: - -e 1-� 'CA City/State/Zip:� �.r.�- � Phone.#: Are fou an employer?Check the appropriate box: Type of project(required):. 1.[�I am a employer with 'a 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.El am a sole proprietor or partner- listed on the attached sheet. 7. E Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in an capacity. employees and have workers' Y P n'• � . 9. ❑Building addition [No workers' comp.insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised.their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affeda:^:t indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. (Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance4or my employees. Below is the policy and job site information. , Insurance Company Name: A 1 ne K I CS'3\1 'k \1 A Q11A �l-e ll , Policy#or Self-ins. Lic.#: C_ e" I L Expiration Date: l 3 60 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 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 certify under.-the•pains andpenalties ofperjury that the information provided above is true and correct ��r� f� Si afore: Date: ' Phone k(V 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 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"ever 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, §25C0 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-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 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 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 permit/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 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 Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 6.00 Washington Street Boston,MA 02111 _ Tel.#6.17-7274900 ext.406 or 1-877-MASSAFE Revised 11,22-06 Fax# 617-727-7749 www.mass.gov/di-a 10 0 0 0 0 10 PRODUCT 218 Q To Reorder:1-80o-22"Wo or www.nebs-com r D p Q s tt l Page No. of Pages 47 Prescott Street NORTH ANDOVER, MASSACHUSETTS 01845 Phone (978) 687-2934 Lac. #028538 P A UBIVIFTEDTO PHONE - C DATE I c 1 1 K STREET ` \ ( JOB NAM �� f- r I CITY,STALE and ZIP COD ( JOB LOCATION ARCHITECT i DATE OF PLANS JOB PHONE l5 r proPOSC hereby to furnish material and labor—complete in accordance with specifications below,for the sum of: �- dollars($ + LCC L ). Payrrtent to be made as follows: i C• � I All material is guaranteed to be as sp cified. All work to be completed in a workmanlike + manner according to standard practices.Any alteration or deviation from specifications be- Authorized low involving extra costs will be executed only upon written orders, and will become an Signature 1k&, �— extra charge over and above the estimate. All agreements contingent upon strikes, acci- dents or delays beyond our control. Owner to carry fire, tornado and other necessary Note:This proposal may be insurance.Our workers are fully covered by Workman's Compensation Insurance. withdrawn by us if not accepted within I days. We hereby submit specifications and estimates for: \Ii,,L <<k��1� �< <� �`(L�z c1��.1 Z..��t�' z�` ��tet��• t1� zii MAI 1--t�'t1� ( Z� \fit lLt�` �tk� vcy eft �t11�l� C \: + L r� c�tLc�`� �+��kL_tt � J (ALQ� kjLk t�lctZ�tc c�� t� �tCc� Edi k, \\�c 1<e �LkiAw o,\v,IS,ca,` h1`� \�e��l �t'tcl-uKkkI L� } r ArPPptattrP of Proposal —The above prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized Signature to do the work as specified. Payment will be made as outlined above. Date of Acceptance: Signature