HomeMy WebLinkAboutBuilding Permit #017 - 316 JOHNSON STREET 7/9/2008 tAORTh
BUILDING PERMIT OF�ttao ,bgti
3?
All.
TOWN OF NORTH ANDOVER F L . A
APPLICATION FOR PLAN EXAMINATION
Permit NOP Date Received
�.9 p�RATeo•TP�.(y
a SSACH►15�
Date Issued: ' /` d
IMPORTANT: Applicant must complete all items on this page
LOCATION t,
Print
PROPERTY OWNERr, � - 1 Pe-ill(4
Print
MAP NO ,� . �PARGEL/e7 ONING 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
Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
f
/il
entification Please Type or Print Clearly)
OWNER: Name: Phone:
Address:
CONTRACTOR Name:_ t ffl_ �r'.�> -, Phone:
Address:
Supervisor's Construction License: Exp. Date:
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: 13►2-- FEE: $ J
Check No.:
1 Receipt No.. Q O
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
signature of Agent/Owner � Signature -of-f 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
Privatese tic tank etc.
� P � Permanent Dumpster on Site
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
r PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on 0 Signature
COMMENTS UEP
1
*IEALTH Reviewed on Signature
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
DPW Town Engineer: Signature:
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.
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
4❑ Workers Comp Affidavit f�'� �" �d YP fa J S4�0,e� 5 t
,--a— Photo Copy Of H.I.C. And/Or C.S.L. Licenses ell
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
o 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
o 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 DEPARTMENT:BPFORM07
Revised 2.2008
I�
Location ]0�1 vtS or, ST
No. G Date �� a
NORTh TOWN OF NORTH ANDOVER
O?O:t � o
• : ; Certificate of Occupancy $
! ;,sACN- � Building/Frame Permit Fee $
1
r
Foundation Permit Fee $
Other Permit Fee $ �
TOTAL $
Check #
2 , J G f Building Inspector
NORTH
0 of over
O 4.•
C,o LAKE o over, Mass.,
COC KICMEWICK
ORATED
`s E BOARD OF HEALTH
PE RM -IT T D Food/Kitchen
Septic System
..
THIS CERTIFIES THAT..........04.%4t......... e.x�.....
...................................................................I.. " BUILDING INSPECTOR
Foundation
has permission to erect........................................ buildings on ...............311. ......... .... .4 4.11.160............ ....• Rough
to be occupied as......... ...•....... .. . ......or ......................... Chimney
provided that the person acce tin this permit shall in eve respect coffl6rm to the terms of the application on file in
P P P g P every P PP 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 b MONTHS ELECTRICAL INSPECTOR
UNLESS CONS TR STARTS Rough
...................... Service
OR
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.
00wrp TOWN OF NORTH ANDOVER
::•.':'`� • °off OFFICE OF
BUILDING DEPARTMENT
. r 1600 Osgood Street Building 20, Suite 2-36
�►.�s�,,..��� North Andover, Massachusetts 01845
s�cNus
Gerald A.Brown Telephone(978)688-9545
Inspector of Buildings Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
� p_lease print
DATE:
3 �
JOB LOCATION:
�d
Number Street Address ` Map/Lot
HOMEOWNER
Name Home Phone work Phone
PRESENT MAILING ADDRESS 3A."? TC)h h s m S
�j 6I( A-at)
City Town State Zip Code
The current exemption for"homeowners"was odended to include owner-occupied dwellings to two units or less
and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the
owner acts as supervisor). State Building (Code Section 108.3.5.1)
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which helshe resides or intends to reside,on which there is,or is intended
to be,a one or two family structures. A person who constructs more that one home in a two-year period shall not
be considered a homeowner.
The undersigned"homeownc'assumes responsibility for compliances with the State Building Code and other
Applicable codes,by-laws,rules and regulations.
The undersigned"homeowner"certifies that helshe understands the Town of North Andover Building Department
minimum inspection procedures and requir+enments and that he/she will comply with said procedures and
requiTements•
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Revised 10.2005
Form Ho=*wnm Enwpdw
BOARD OF \.PPEALS 699-9541 CO SERl'_MON. 638-9530 HEALTH 688-9540 PLANNING bK3-9535
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POT+ Term CT,MA,W,N).NY,ki,VA 5500,444 Each Accident
Bodily Injury By Diw*ae
5540,000 Policy Limit
Workers CotoMmutiot+ Bodily bjury By Dium
$500,000 y aeb Person
to/15/2067/10/15/2008 TB2-11148M( ,377 General Aggregate-0tber than Prod/Conepieted Operetinns
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51404 000 OccurrCuct
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t3 $I404440 O aniatiael
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$1,000,000 Fire L t Liab. $10,000 Medicsrl rympU
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Ercb Person
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X 1'tvred .—.^
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Ofifim: WOMM MA rb om 800-762.5026 rr •r• xc .., —
ottiticslDeklaiiler M1E8. &"EYLFIS
Judy Reilly Au6oFtwd s«aientatFva
31.6 Johnson Street
North Andover, MA 01.845
Date bwc* 06/2312DOO PrcpxMd 2r-K5
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
-
+�•' 600 Washington Street
Boston, MA 02111
` ';w www.mass.g ov/dia
Workers' Compensation Insurance nsurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):
Address: �j (pc �Vyt SWl S 1'
City/State/Zip ��LC�+� AA U 6 tflPbone #: Cny —�n I --b
Are you an employer?Check the appropriate box: Type of project(required):
1.21 I am a employer with ? 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 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 10.0 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.
t Homeowners who subiiiit dhis af,idavit'nuicating 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.
1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins. Lie. #: Expiration 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.
/do hereby certify under the pains andpenalties of perjury that the information provided above is true and correct
Sip,nature: Date:
Phone#: OMX D�<
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 1
apte 52 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 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
Fax#617-727-7749
Revised 5-26-05 www.mass.gov/dia
YVALF'ULt�WVVUWVKRGti,, IIVtr. y_& mag "AneL ilf�Ru
MAKE ALL INQUIRIES TO ADDRESS CHECKED
E.Falmouth,MA 02636 0 Hyannis;MA 02601 Walpole,MA 02081 Ej Farminglon,CT 06092 [30reerwale,NV 11546 E]Morris Plains,NJ 079%
508-540-0300 5%-7753925 508-68&2800 880.677.9690 516621-9075 973-539.5555
Fram"am,MA 01701 [:]Mail Order 7 mtsmat: Wllmington,MA 01887 O Rfdgafiald,CT 06977 []Wale.Mie,NV 11976 0 WarWtek 8102886
5089756668 800-343.6948 978.658.3373 203.4.763134 631.126.2858 401.823.7091
Q Harwich,MA 02646 ❑Norwell,MA 02081 E Westport,CT 00880 aroat Fells,VA 220M
508482-0916 781-681.9099 203-265.9010 703-759.6901
CUSTOMER N0. DATE ORDER N0. BRANCH CLASS OTHER YES NUMBERS
ZZ' ORDERS NO
BILL TO NAME SHIP TO STRM
U L,7l til Q G x u_
STREET/P.O.BOX CrrY STATE ZIP CODE
CITY STATE ZIP CODE THIS AGREEMENT DELIVERED TO WALPOLE WOODWORKERS AT(ADDRESS)
J rFOH WALPOLE UISE ONi-v;
7U,t`� C_e V1'1fI UiXIS
c0 Home PMaa D PMM Sakapeha0n Name Sdea
a LT e
�.' •ChC.� 9C,�
9C 1 A&6ry �-cayxl )wpckz�
?CZr ISIAT 6S IA_
Lie S-- 1e_�''� —*---
--- RDFS scs_ �� --
�; J
51
DEPOSIT PAYMENT POLICY TOTAL SALE $ '�') 6 2 1 1 `
❑CA ❑CN ❑CC ONE HALF WITH ORDER,BALANCE C_O.D.UPON COMPLETION. a Y
BALANCE $ FINANCE CHARGES WILL BE ADDED TO ALL DELINQUENT TAX $ Q�s ZS
ACCOUNTS and will be computed at a perlo0lc rate of 1-1/2%PER
MONTH,WHICH IS AN ANNUAL RATE OF 187E The customer
CHANGES
$ agrees to pay all costs and expenses,Including,without limitation,an / _r
reasonable attorneys lees, cc*and expanses, which may be TOTAL
FINAL BALANCE
$ incurred in the Collection Ot any amount due tNlr .unftr,
1
r: :�• hI, ��a i t r
j 1Ur i .G I• I ! i J �__i_-; _ ADD'L DRAWINGS
f I
STAINED
J_v.
CLEAR FENCENE
U
It I j u ! TAffS/STUMPS IN
i ' i d„�i--T•y, �.._-�.. FENCE,}INE
FENCE ON WALL
I I I I j l i I i i CORE DRILLING
BRING COMPRESSOR
TAKE GOWN E7U$TOIG
.-... .-----i--!- ` -1- - i- —i--=--r-•--F--I'--+-�I---i-, -"�-- ---+ FENCF/SIACK
../ i ' I - --L _ 1-••-1-- I I .._1-. I I I -.i•-- DISPOSE OF FENCE
STEP SECTIONS
i I
--•T '-- ---i- ', ' r--I--;i---+-a---t----�-- ; � � J--•-�-..r ' ....i._...;_....;--- ExTRA LONG F'osTs
I Ii 1 �• I I 1 1 ; I I i i I I I I
�- i L�j,-J,M�(� ,• --Y.'_'-�_....A....__. �..{_.__I--.L.._�_..., -- - --�•-.;_"' RACK SECTIONS
- •E'-7- I .aF-+ ---I--ter- I l J'_- - ^I—a- --
__-�- _"'. I ' ' TOP OF FENCE
- r—,... -r----�
UNE STRAIGHT
-- ' .-*—^•-—1--�--'-�A r"',.� -- -.-1-"-"1"--*---- CURVED SECTIONS
PAVED AREAS
1 �J i I I 1 i —t... -_j._ WIRE ON FENCE
I— -�.-j /INSIDE OR OUTSIDE
I _ '
,(• ���}}}�...,,/�Ey(�Cl .�... .(_-.. r i 1-•--t--.. UNDERGROUND
- - I i.-.I"_. .i �'C`='C" I 1__� 1 i --T_.._v-.•-`•II--I..._1 � i i I PIPE OR CABLES
I 1
SITE AVAILABLE:
7 T1
A DIG SAFE N
.
The customer is responmble for establishing property lines and fence Bites,for clearly marking all underground and/or concealed objects,and tot conforming with local inning
0)-laws;the Customer i6 responsible for any damages resulting from failure to do so.This quotation is subject to conditions beyond our control and does not include costs arlsing
in extraordinary conditions;for example,striking ledge which may require the cementing of posts or the use of a compressor for drilling and pinning poets,or clearing trees,brush
or other Obstructions Irom the workiny area.This agreement,together with all documents and drawings incorporated herein by relerenw.Constitute the entire agreement between
Walpole Woodworkers,Inc.and the customer and there are no verbal agreements or representations in connection therewith.This agreement shall not W modified other than In
writing by an auNOrized representative Of each petty arrd neither party shag hate the authority to waive this Prohibition.
ALL SALE$WWCJ TO APPROVAL OF WALPOLE WOODWORKERS,INC. you.as the Customer,may cancel this agreement if it has FOREMAN
WAIPOI ,DATE J been signed by you at a place other then the main cillos
X any branch oKPe of Wagde Woodwodmw,Inc.provided
`1j7, D you notify WaIpo1B Woodworkers,Inc.in writing at ire mein E COMPLETED
BY$IBtaNG 1119 REEME E ER gCIWOWLEDUt$ nG AND uluoER °thbB or branch otflce by ordirrerymae posted,by telegram
STOOD THE TERMS STEO ON THE FROnY OF THI$AGREE ENL sent or bV delivery,not later than midnight Of the mlr0
ACCEPTED By pAT 0� agreement signed py u�r delivery to
you of atopy of this NAME TAG INSTALLED(-El
X [,nMINISTR TPJ.:,