HomeMy WebLinkAboutBuilding Permit #266-2012 - 35 CIDERPRESS WAY 9/28/2011 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: °2 2 Date Received
Date Issued: 910-tIll
IMPORTANT:Applicant must complete all items on this page
LOCATION 31 3 3 3 C(Jer S C�1 1C M mj)
Print 17 Mn
PROPERTY OWNER Unit#_V 33 3.r
Print
MAP NO: 1_ vYC PARCEL: ZONING DISTRICT: Historic District yes
Machine Shop Village yesPO
100 year-old structure yes
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
)<New Building ❑ One family
❑Addition ;K Two or more family ❑ Industrial
❑Alteration No. of units: 3 ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
o Septic 0 Well ❑ Floodplain `Wetlands I] Watershed'District
Int Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
( den ication Please Type or Print Clearly)
OWNER: Name: lV�W1 vt/�i Phone:CIA
Address Cae -, �� N• A f
CONTRACTOR Name:Zinz ^ Phone: QHS' 6E 7-Z 3J
Address:
Supervisor's Construction License: O S_S�l Exp. Date:
Home Improvement License: ISM Exp. Date:
ARCHITECT/ENGINEER 0 '1)()1fYih �� S Phone: ��
Address: S • Reg. No. 6O1y
FEE SCHEDULE.BOLDING PERMIT:$12.00 9R$9000.00 OF THE TOTAL ESTIMATg COST BASED ON$925.00 PER S.F.
Total Project Cost: $ FEE: $ l00 . (�09KW+r10 )
Check No.: y y ` Receipt No.:
NOTE: Persons contracting h unregistered ontractors do not h ccess to the ran ty fund
;Cinin�fiiro rif°Affiant nmar inri ii _ of nnnfirartnr. .
r -
Location
No. 2 66— /2 Date Z/
NORT►1 TOWN OF NORTH ANDOVER
0
F M
D
�o Certificate of Occupancy $
SACMUSEt� Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
2 46 J uilding Inspector
Plans Submitted 9 Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer U^ 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 N z�-A 4A UB ho l4 r n i
CONSERVATION Reviewed on 9 Signature
COMMENTS MA- ,D&P F"?qZ- 11 y i h d,CCoj n& LOOC aJ 1kX&j',d
HEALTH Reviewed on Siqnature
COMMENTS 'S(' be�y- ho �q4m kai.
Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: �' Comments
Conservation Decision: 2 YZ'1 Comments
Water& Sewer Connection/signature& Da;r11ZXd41Y14'-
Driveway Permit
DPW Town Engineer: Signature: Z7-/f
Located 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.047 s t-
Total land area, sq. ft.: 3O•��!C•
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector WA 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
FC)uNDATlot') 6 tT
Notified for pickup - Date
Doc:.Building Permit Revised 2011 June/mi
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
VOTE: 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: Doc.Building Permit Revised 2008mi
NORTH
Town of over
or'> 0%
No. ,,? %
o , dover, Mass.,LAKE
COCHICHEWICK
ADf?ATED P.?a�,�Gj
S ` BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
THIS CERTIFIES THATBUILDING INSPECTOR
�...........�. ..��. .. .. . . . . ....�f�.'?.�?.:�l.�f,�... �........................................ Foundarion
.... buildings on ........ ......3.. Ci. .. . �^....��-ss
has permission to erect................................. .. g ./�.....:......[rL/ . Rough
to be occupied as � .bb. ........a. Chimney
provided that the person accepting this permit shall in every respect c form to the terms of the application on file in
Final-
this
inalthis 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 ST 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.
MR REGISTRY USE '-' ' . 1 ,.'��'� / F f �•,,; ,'`1"' ,
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P °� J. r ASSOCIATES
VERNAL P OL I'I •'.' O ' , ia` WMAND nM
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O�.poRTM,+
TOWN OF NORTH ANDOVER
a s
PERMIT FOR WIRING
,SSACMUSE�
This certifies that .... '`. �C c r��G
............... .............. .........
has permission to perform ............S La.!. :-.........te. ...AI .g ..
wiring in the building of �'!.F✓ X`r
.... .6Us
..... ............................................
No �do�v , ass.
Fee....,�� .LiLic.No.l' ..... ........................... :,.. .. ..... <.....
r-- ? ELECTR CAL INSPECTOR
Check # J_as —3
'101, 60
-Commonwealth of Massachusetts Oficial Use Only
` Department of Fire Services [ERev.ernutNo. � On?
BOARD OF FIRE PREVENTION REGULATIONS ' ccupancy and Fee Checked
1/07] leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code C),527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: r—, I I
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number)--a 1 3
Owner or Tenant �r�rT, Y`�s�
/ Teleph eNo. _I3
Owner's Addressi IT(,_',,A-,L�_�� A;01
nwlk,
Is this permit in conjunction with a building permit? Yes [ri _ No
❑ (Check Appropriate Box)
Purpose of Building 0101S6��`� _ Utility Authorization No. g IX)Z
Existing Service Amps / Volts Overhead ❑ Und rd
g ❑ No.of Meters
New Service (20 Amps I 1p / 2.% QVolts Overhead❑ Undgrd No.of Meters 3
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
/"'a-
Completion
oCom letion of the ollowin table maybe waived by the Ins ector o Wires.
No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming PoolAbove E] in- o.o mergency ig ting
- rnd. rnd. ❑ Batter Units
No.of Receptacle Outlets No.of Oil BurnersFIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners No.of Detection and
Initiating Devices
No.of Ranges No.of Air Cond. Total
Tons No.of Alerting Devices
No.of Waste Disposers He Pump Number.•,Tons KW No.of Self-Contained
Totals: Detection/Alertin cy Devices
No.of Dishwashers Space/Area Heating KWMunicip
Local❑ al
Connection El Other
No.of Dryers Heating Appliances KW Security systems:*
No.of Water �, No,of No.of Devices or E uivalent
Bal
Si ns Ballasts as Data Wiring: `
ts No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
OTHER:
No.of Devices or E uivalent
Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of Elec ical Work: -3 ppn# (When required by municipal policy.)
Work to Start: 1 Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE C E GE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The
undersigned certifies that such cove e is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE W BOND ❑ OTHER ❑ (Specify:)
I certify,under the pains and penalties of perjury,that the information on this application is true anti complete.
FIRM NAME:
LTC.NO.—,j
Licensee: M,"„4� p„y„�,� ignature
(If applicable, enter "exempt"in the license number line.) LIC.NO.: Z?ftX
5—
Address: �. Bus. el.No.:ko� �4Z. ?_&%c�
*Per M.G.L c. 147,s.57-61,s curity work requires Department of Public Safety' "License: Alt.L c.No.l. � � Z—,
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below,I hereby waive this requirement. I am the(check one)
Owner/Agent []owner ❑owner's agent.
Signature Telephone No. PERMIT FEE. $
ELECTRICAL PERMIT NO.— INSPECTION
a•
ELECTRICAL INSPECTOR—DOUG SMALL PORT:
1.ROUGHINSPECTION:
Passed—j ] Failed—[ ] Re-inspection requfrecT($50.00)
Inspectors'comments:
(Inspectors'Signature-no initials) Date
2.FINAL INSPECTION;
Passed—j ] Failed— ] Re-inspection required($50.00)
Inspectors'comments:
(Inspectors'Signature-no initials)
Date
3•UNDERGROUND INSPECTION:
Passed—j ] Failed—[ j Re-inspection required($50.00)
Inspectors'comments:
(Inspectors'Signature.-no initials)
Date
PDAT;E
PECTION—SERVICE: -
CALLED NATIONAL GRID: NAME:
— Failed—j ] Re-inspection required($50.00)ectors'comments:
P�i
(Inspectors'Signature-no in! 'als)
Date
5.INSPECTION-OTHER:
Passed—[ ] Failed—j ] Re-inspection required($50.00)
Inspectors' comments:
(fuspectorsSignature-,no initials)
Date
D 0 O TAGS.ARE TO BE FILLED OUT AND LEFT ON SHE 7F TjgE AREA.TO BE INSPECTED IS NOT
ACCESSIBLE AND A.RE-INSPECTION OF$50.00 IS TO BE CHARGED.
r'
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):
Address: S P uk- 60_q
City/State/Zip: V(.,A)(g,,�`1v,J , ,,Vt f 03'�qk Phone #: l q ?-
Are you an employer?Check the appropriate box:
Type of
yp ject(required):
[2.
. I am a employer with 4. El am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ew construction
❑ I am a sole proprietor or partner- listed on the attached shget.1 7• ❑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.❑Electrical repairs or additions
3.❑ I 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.] 13.0 Other
Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
f Homeowners who submit this affidavit indicating 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 andjob site
information.
Insurance Company Name: VkA,,I Q t 0-v, _
policy#or Self-ins.Lic.#: 3 ( S 3 U_ �-1^ Plte -S 61/A4Expiration 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 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,certif under the pains and penalties of perjury that the information provided above is true and correct.
Si nature: Date: l
Phone
[[Contact
al use only. Do not write in this area,to be completed by city or town official.
r Town: Per #
g Authority(circle one):
rd of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
er
Person: Phone#:
L'
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 permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permittlicense 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 Comr-LiOnwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax#617-727-7749
www.mass.gov/dia