Loading...
HomeMy WebLinkAboutBuilding Permit #634 - 34 PRESCOTT STREET 4/20/2010BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION L Permit NO: Date Received Date Issued: Z0 Ild IMPORTANT: Applicant must complete all items on this page �_ r, LOCATION t . ,r r Print PROPERTY OWNER Q b h- Axo` YI'CkUe– L I Print MAP 210 PARCEL. ZONING DISTRICT: Historic District Machine Shop Villaae Vires no TYPE OF IMPROVEMENT of Residential Non- Residential New Building One family 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 �uASUKIPTiON OF WORK TO BE PREFORMED.. I — a /identification Please Type.or Print Clearly) is OWNER: Name: Q-©eT + 0-4 4 Phone:g7 F"6 F -d 6 G Address: CONTRACTOR "Name: P"T"CA U' J-2 - Phone: (t Address: Supervisor's Construction License: 7° �. Exp. Date: t, / 3 1 f I Home Improvement License: (b Exp. Date:_ 1 _ 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: [00. . cx-)FEE: $ JC–J X' °'L 362, Check No.: ��� Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to Me guaranty fund ,Signature of Agent/Owner Signature of contractor 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: Building Permit Revised 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 THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Siqnature COMMENTS '�iEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Commen Water & Sewer Connection/signature & Date Drivewav Permit DPW Town Engineer: Signature: FIRE DEPARTMENT -Temp Duml 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 Doc.Building Permit Revised 2010 Location 11, 44 S -T -- No. Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 0 22950 Building Inspector m m m m m m v C � CD CD n Z CO! a o -0 CL = CZ CO2 CD o p CD Cl CLQ "CCD CD w ov �. C CD CO) C. v y �C CDtp . CD CO) 1CD Z O CD O CCD V J y rn O cn W g'R g d � ao m '^11 w 'JC c° c -0 m y O � O. m C7 N m tz d N OG101's N -1 ...r R O ? a...r Q 0 T oil T o -1 = ma m Z:5.n O N C! Cn CD '^11 w 'JC c° oC= ^!7 D O m N o G C26 m m 0 a?� N tz d N x C a & CD m N a 1 N CD cc moo: CD CA o CD �: m: CD: cil N m: rL "% C') c) o CO) CD C O C2 O Cn B Cn al '^11 w 'JC c° o ^!7 D Cn f9 o G Crl tz 0 a?� o �. tz w x o c 4°S o 0 o ( n o o� oil z O • CA v O C PROPOSAL SUBMITTED TO dd11,,JJ\\ � -,, 6 STREET t'll. -3 y . f CITY, STATE and ZIP CODE i f ARCHITECT Proposal Page No. of'" Pages. oHST�U6't H.L.S. Remodeling Ll 7S_ y 6 Dexter Road SALEM, NEW HAMPSHIRE 03079 �VvIL {n,'�ts' {,t� gT4 898-3397 PHONE DATE JOB NAME JOB LOCATION 7n Cie 01FVS DATE OF PLANS I JOB PHONE I ICICUy �LU.l Uln1J11 Illd Mildl d— UUMPIele m aacoruance wnn sppey�citications Delow, Tor me sum or: Al1. h .+� ",Q t/ ''� oz. h Q c ollars {$ s Pay - ent to be made as follows: i 0 C-) y 00 V1 C CD rM D l -1, tC)- All material is guaranteed to be as specified. All work to be completed in a workmarilike V manner according to standard practices. Any alteration or deviation from specifications Authorized ��14 below involving extra costs will be executed only upon written orders, and will become an Signature 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 insur- Note: This proposal may be ance. Our workers are fully covered by.Workmen's Compensation Insurance. withdrawn by us if not accepted within days'. We hereby submit specifications and estimates for: t T� 41CCt'ptunre of Proposal — The above prices, specifications Signature and conditions are satisfactory and are hereby accepted. You are autho- rized to do the work as specified. Payment will be made as outlined above. v Date of Acceotance: V 4 i Fj Awal (n _0 > n ;o rm-, § K -44b Sm / / 13 2f 0 M 0 4 et (0 U) j 0 ( ` cn A . � m x S (D 7! Fj The Commonwealth of Massachusetts Department of Industrial Accidents Office ofInvestigations 600 Washington Street Boston, MA 02111 www mass govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): Address: , 1, .._0 _V -2 City/State/Zip: �4 /� 1 i OoPhone #: (6 67? t 7 7 LIN Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other g 1, Vt/L: y 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 isproviding workers' compensation insurance for my employees Below is the information. policy and job site Insurance Company Name: Policy # or Self -ins. Lic. #: E � E Expiration Date: Job Site Address: �. tii ` �—� S;J City/State/Zip:r/ 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. Ido hereby certify under thepains andpenalties oJperiury that the information provided above is true and correct 77 -60:z— Qq k= Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License # c® Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector 6. Other Contact Person: Phone #: Are /you an employer? Check the appropriate box: 1. L`3 I am a employer with .. 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ 1 am a sole proprietor or have hired the sub -contractors listed partner- on the attached sheet. I ship and have no employees These sub=contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No workers' comp. C. 152, § 1(4), and we have no insurance required.] t 5 employees. [No workers' comp. insurance required.] :Any applicant that checks box u1 must also fill out the section below their w,c 2 Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other g 1, Vt/L: y 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 isproviding workers' compensation insurance for my employees Below is the information. policy and job site Insurance Company Name: Policy # or Self -ins. Lic. #: E � E Expiration Date: Job Site Address: �. tii ` �—� S;J City/State/Zip:r/ 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. Ido hereby certify under thepains andpenalties oJperiury that the information provided above is true and correct 77 -60:z— Qq k= Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License # c® Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing 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 "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 permittlicense 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 600 Washington. Street Boston, MA 021.11 Tel. # 617-72.7-4900 ext 40.6 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-72.7-7749 www.mass._govddia 7oDp��7o� Zm-DimM0C: cnMmv�mm D ���0><: M m cO zO 0 c z c a �Omc=r m n n r- nCO m m H O mnmivM x MCI) m m Dr'm0D� O d v' im m� x�Amv Oo Dmm::Em m m n z vm C: CCOr,0 m o C) -, z �Z0KCt) F D m Z� C aoipyzm D D 03 Oz MM cKMMzm ZZK-jmv 0 m c z z m (nKOm D �Wy�v 0M-<zrD-� -1 m -I r0 -n m _ < 2 z r D M mcn_W "D0mG� O O m fpr-�m- n m n O — -u - z G) Mx C> m c o Z m m m m� O "D Y D Cl) - ,O--'cgz a mse �Z0�20 O z y v 0 D C C') m C) Sp z LA c D z n m 0=:c rtWr- mm r 3X;o V) z m :x =;o0-0 o;om� worm onH;o -4t7Z ,0 c) W n 0-0�r.] ;ID o;ID � CD ow rm-O 0 oom I rL4 N "I Iz OBD N cy, 00 N .Fa W m N O V 0 z rD c 0 r v m 0-01-4 Foams a • <a OOmC mx(m rw r w u"'+ OD:1:,0CD w N Ov,� w kn kn m C E O n m