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HomeMy WebLinkAboutBuilding Permit #5 - 310 WINTER STREET 7/1/2009Permit NO: Date Issued: BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received I IMPORTANT: Applicant must complete all items on this pate LOCATION 3/652' LO Prin# PROPERTY OWNER DQ'gf G inn bo e-2, Print MAP NO: tJ st PARCEL: i� Z ZONING DISTRICT: Historic District yes no Machine Shop Villaqe ves 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: Demo i ion Other Septic Well Floodplain Wetlands Watershed District Water/Sewer SCRIPTIO,N OF VVORK TO PE PREFORM Please Type or Print Clearly) OWNER: Name: Address: CONTRACTOR Name: J C L Address: 34 /7;Z -4,4(n ' ' , mql Supervisor's Construction License: Exp. Date: 7—.3,) ` Home Improvement License: I , Exp. Date:_, N N �_ 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: $ � 00'- 0© X Z FEE: $-- Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor �6•'NO a 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 CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS t Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/Signature & Date Driveway_ Permit DPW Town Engineer: Signature: Locatea 664 usgooa wreet 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 2008 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 Doc: INSPECTIONAL SERVICES DEPARTMENTMITORM07 Revised 2.2008 Itzz Locations No. Date -p— O g TOWN OF NORTH ANDOVER ' Certificate of Occupancy $ Building/Frame Permit Fee $/ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check #� 22+ri1 Building Inspector m m m x m V/ v m v y C � � O CD MZ cn CD O 'O. = r- c � � C CL y CDCL O Q CD r� CD O CD C CD y. �. CD CL v y O co CD C O 0 Z s CD 0 to O ccC _ m m m S.0 N G e. N C41 m W?=0 ..N O Q w N = a z a� am O y C7 cn CD • m� mcl)d= NP?a m m ti ro o O h Irl G ocp ao cn 'n a CA d.d.•m a?m N = T_ m f ID co = � = CD 0 ti CD o.+0; 0. 0 2 CD :09ow CD a 'o o: o '!6 dm: = m O LA. c=9 m n co) _ = oto CL m cpm O eo i� CL CD 3 • O1 N . CLdd C7 ac ~ a ?v w CO O N O cn CD 7y G Cil "X w CCD = ti ro o n ;z G Irl G ocp ao cn 'n a CA -n o tz O d N O CD = � = CD 0 CD a� N 'o o: 0 dm: = m cn O d cn ~ o ac ~ d ?v w A z w cn CD 7y G Cil "X w 9z G ti ro z w n ;z G Irl G ocp d z cn 'n a CA -n o tz O d M • L omi 0 0 c North Andover Board of Assessors Public Access t ,10RTAI 1 O S•�to ° N X SSACNUSt Click Seal To Return Search for Parcels Search for Sales Summary Residence Detached Structure Condo Commercial 4 +►, , A.. 4 rs► 4 � �. 4 i`, 4 Page 1 of 1 Ak roperty Record Card D-1 m .11 nn nA A _nn69_Mnn n rv1nno f nmm„n;fi, - Nnr+6 A nAnvar in: 310 WINTER STREET Name: J C GEMMELL REALTY TRUST JOSEPHINE C GEMMELL, TRUSTEE Owner Address: 4 TAMYS LANE City: ANDOVER State: MA Zip: 01810 Neighborhood: 6 - 6 Land Area: 1.03 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 1234 sgft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 368,400 376,800 Building Value: 159,500 167,900 Land Value: 208,900 208,900 Market Land Value: 208,900 Chapter Land Value: ley http://csc-ma.us/PROPAPP/display.do?linkld=1464072&town=NandoverPubAcc 7/1/2009 Department of Public Health/Department of Labor & Workforce Development NOTIFICATION OF DELEADING WORK All sections of this form must be completed in order to comply With the notification requirements of M.G.L. c. l l l S 197, 454 CMR 22.00 and 105 CMR 460.000 as most recently amended Contractor performing project MAURO CICERONE License # DC000775 I Exp. Dau 01-19-2010 Lead Paint inspector Mel Blackman Date of Lnspection 05-20-09 License # Exp. Date ADDRESS OF PROJECT: Street Address: # 310 Winter St. Apt Number: # single City N.Andover MA Zip Code: 01845 Property Owner: Josephine Gammell Address# 310 Winter St. N. Andover MA 01845 Telephone Number: De Leading method: Wet/Dry Scraping Heat Gun Liquid Encapsulant Demolition Caustics Replacement (x) Covering (x) If "Other" selected, please explain. Replace all widows Check One: dwelling is multi -family other: Single Start Date: 06-30-2009 Completion Date: 07-3-2009 When will work be done: A.M.? 8, 00 P.M. 4,30 (Specify times on site) Weekends? Project Supervisor's name: Worker's Compensation Policy Number: License # Exp. Date Carrier: In case of emergency contact: MAURO CICERONE Tel. # (800) 559-0868 (contractor's representative) De Leadinz Contractor The undersigned hereby states, under the pains and penalties of perjury, that he/she has read and understood the Commonwealth of Massachusetts De Leading Regulations, 454 CMR 22.00 and Leading Poisoning Prevention and Control Regulations, 105 CMR 460.000, and that the information contained in this Notification is true and correct to the best of his/her knowledge and belief. Date 06-24-2009, r Sl2 Company Name Address Tetcphone Number (800)559-0868) OVER L'd 9£80 - 9L£ -81L euoAeoiC oinen d9£:l0 60 L0 Inf 2009-06-10 09:15 ACCURATE ENVIROMENTA 17813227479 >> 978 475 4575 J -H St L-awTence Swee _W amMA.UIW7 evil Fu 0 f178 694- 4040 June 8,2009 mks, odie Goffunlell -110 W -ice Viz. - Nofth Andam Ma Deur Mrs. �ejj' As, we fffiswu-,�w-d,, the, f b.flcnving ir, ow vmy site. invecticm— , I PMPO'W PMVMed StYottr Toquest, apd bas, INTERIOR: WIN- keM(We & MV12 "X -E Nkith. neW- Vinyl ret pjaC=eotOW& it A Wd, (stelms-Alhante Or fd-eatw'm- davkl�j. DOOMS t0l, GA4041 '. M-ove -Wfthen door vvh ute dom., Ddead b#mn=tdO'DT tO Mk- D-0-O&CASEMG5 00-m-lumm CowrvAth! alumintim entiveung for defewringst project. A.C. Del d. sarase doo, T to tie... P 1/3 2009-N-10 09-15 ACCURATE ENVIROMENTA 17813227479 >> 978 475 4575 P 2:`3 I,- - _'l EXTERIOR: C6Ver e,",KWim window casings widiahim�jum COVer-exterier, doer vat v*k Scrape th, to hate woold. Rep* 0"Vgyow, -0 simm door. " QVIREMIEVIIS: N)MkOl 1510he&lk j-, as fiDfjou- - the B . - ') () "_ third. art projea cost is due .halfway through PToject towLetim we &A one thw of the Wal PTo.jvt 004 is &e up ou t.he rfilets al. . the pTqjw .01.1d receipt of the, compriante jefter. M f a g and waB hwngings as ejaw be rmwvod, flo r m tit e site.rpld o ace, hi the Center of e36 morn for pria perconi ainment, 1, All food, itelm mul 616& be remove -d - . .0 sife.; or 1-4oft'd away fiv. mray anal all work - 4. Sh e must be vimant &Thw all deleadino activifies. 7, ve, Inellbonedd items and work re �� lima iml the abo Vedfirca only, Any ad4Wmal work, rNuests wig be• oansidemd as "ADD-ONS". ergx and Cogs assadaed with atob adld-o#s wiH k- detailed is a. separate propossal- e.,EaMroumm; tal is not .7 resp,anmsiblo for the 101121 arantee. that -this blou m4ve. 9'kftex lof full voWliavlm to tht kad oo"f will.parsaw alhil Inver of CT e03T OF PROM ... 'I'hank,vmi far jftv &-r thk- tj -itv w wfwk I we *Mpm-aate, the anot"tua 2009-06-10 09:16 ACCURATE ENVIROMENTA 17813227479 >> 978 475 4575 cmvwnimm. ShOufM 4ecidt 10 actept out proposal your.dgnaturt- is Pogwivd., Pie wsign. tin tile firie pro-viJed bdow.. Ke,vin? Wamt g C-0-0 I -, ,kcroted by w P 3/3 NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the .sion of MGL c 40 S 54, a condition of Building Permit at: ' provis that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 10A. The debris will be disposed of in: (Location of Facility) Signature of Permit Applicant 7-11 la � Date The Commonwealth of Massachusetts Department of industrial Accidents Office of Investigations 600 MashiR-jon Street Boston, MA 02111 c www_r».assgov/dia . Workers' _ orkrers'Compensationnsu Irance Affidavit: Builders/Contractors/Electricians/Plambers DDllc2nt nfarmai4w Name (Business/OWization/Individual):� Address: City/State/Zip: Phone #:-. KIL Are you an employer? Cheek.the appropriate box: l.❑ I am a mployer with 4. ❑ I am a general contractor and I oyees (full and/or part-time).* 2. have hired the sub -contractors am .a.sole proprietor or partner- listed on the attached sheet i Ship and have no employees These suis -contractors have working for me in any capacity, [No workers' comp, iBsurance workers' comp, insurance. 5. ❑ We are a corporation and its required.] 3. ❑ I ain a homeowner doing officershave exercised their all work right of exemption per MGL myself. [No•workers' comp. c. 152, § 1(4), and we have no insurance required.] t .employees. [No workers' Comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11 .11 Plumbing repairs or additions 12.[] Roof repairs I3.❑.Other 'Any appiicam t that checks W#1 must also fill out the section below showing their workers' oompensation policy information. Homeowners who submit this affidavit indicting they art doing al) work and then hoe outside contractors must submit a new affidavit ZContnhctors that check this box must attached an additional shaetShowing • Ehe creme of the suis-conindicetiag such. tractors and their workers' rr i • irtnm�tior.. information. I am an employer that is providbtg:workers' compensation insurance for my employeeL Below is the Policy andjob site � Insurance Company Name:_ Policy # or / g®Q 3 ' 2. #: V Facilitation Date: /l -3Z Self-ins.Lie Job Site Address: ✓% . — e City/Swzzip;/� Attach a copy of the workerscompensation policy declaration page (showing the policy number and expiration daie� 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 $ I,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 andP 'es of perjury that the information provided obo is and rowed Si tore: Date. 4!! ��` 191 Ofj°Icial use only. Do not write in this area, to be conrplet ad by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Cierk 4. Electrical Inspector 5 6. Other . Plumbing Inspector Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all emp 3 oyers 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 truster of an individual, partnership, association or other legal entity, employing employees. 'However the owner.of a dwelling house having not more thin 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 m 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 shalt 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 untilacceptaiile evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workerscompensation• affidavit compte;tely, by checking the boxes that appiy to your situation and, if necessary, supply sub-contractor(s) name(s), addresses) and phone number(s) along with their cerrificate(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 cant' workers' compensation insurance. If an LLC or LLP does have empioyees, 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, notithe 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 nur2'rber. listed below, ^pelf-i»rtnrd cnm�s�rriPc aF�n�iin PntPr ti,P;r self insurane'e-license number on the appropriate dine. 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/Iicense number which %vilI 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. When 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 Investipations 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 Commonwcadth of MassachuseM Department of Industria( Accidents Office of Investigations 600 Washington Street Boston, MA 02111 TeL # 617-7274900 ext 406 or 1-8.77-MASSAF'E Fax # 617-727-7744 Revised 5-26-05 www.mass.gov/dia f�nRt_ ( MENT:oc�ns✓a�na iAtaTn OR Board of BudcoNTR HpMEi,,,ROVE Registration 131054 fir# 269462 ;_i EXp►rat►on: 5,12412010 FType' �BA .. i Enviromentai ' Accurate ard Michael How . 33 Administrator . 3a MAIN SST '35 MALDEN, MA 02148