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Home My WebLink AboutBuilding Permit #465-14 - 351 WILLOW STREET 11/26/2013Permit NO:_ Date Issued: LOCATION, PROPERTY MAP NO: C BUILDING PERMIT TOWN OF NORTH ANDOVER l APPLICATION FOR PLAN EXAMINATION I Date Received CANT: scant Hurst all items on this runt I ZONING DISTRICT: Historic District Machine Shop yes yes 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 rs 1 % C' -f u Is Lncc�-er rn OWNER- Name: Address: ilk Identification Please Type or Print Clearly) Phone, CONTRACTOR Name:C(i1C. T_U6)Sn 3v# 1 d, -- ct Phone: , Address: - toMA y Supervisor's Construction License: Exp. Date:' Home Improvement License: Exp. Date:' t ARCHITECT/ENGINEER To _ _ Phone. (_ 01528 7qZ-7/ol Address: 1Z- �� qZe� r ; �, �mA C�� 1 t� to Reg. No. 3c) 70?3 FEE SCHEDULE: BULDING PERMIT. $13.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost, $ -7,_(,a I FEE: $ 33 Le . °G Check No.: e> 2 Receipt No.: NOTE: Persons conlrae6rewith unregistered contractors do not have access to t gu ra , f nd -41 .r Permit NO: Date Issued: TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER Print 100 Year Old Structure yes no MAP NO: 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 11 Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: Phone: Arlrlrccc- CONTRACTOR Name: 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: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund ,,,-i n, -we-of Agent/Owner Signature of contractor Plans Submitted Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Plans Submitted'[] Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYP1i_OF-W -:SEERAGEDISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ . - . Swimming Pools ❑ Well IT. 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 PLANNING & DEVELOPMENT ❑ COMMEN CONSERVATION Reviewed on_ l —,�— b ` 1 COMMENTS HEALTH DATE.APPROVED re Reviewed on Siqnature 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 Tow; ]Engineer: Signature: - Located 384 Osgood Street 'FIRE DEPART ENT -Temp Dumpster on site yes no Located -at 124 Mair Street Fire Departme►it signature/date _ - z 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.$100-$l000.fine NOTES and DATA — (For department use ® Notified for pickup - Date E Doc.Building Permit Revised 2010 Building Department -The following is`=a.%ftst of the retluired.forms to be filled out for the appropriate. permit to be obtained. Roofii-Ag, Siding, Interior Rehabilitation Permits u Building Permit Application o 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 Li 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 o Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract o 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 apnaal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.+.ted with the building application Doc: Doc.Bui?,ling permit Revised 2012 Locatio7, 7, � No. �" Date Check #s, 13) TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $� . 4 Foundation Permit Fee $ Other Permit Fee $ r TOTAL $ Building Inspector The Commonwealth of Massach usetis 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/Oreanization/Individual): CMC Design Build, Inc. Address: 1 Pine Hill Drive, Suite 400 City/State/Zip: Quincy, MA 02169 Phone #: 617.328.7899 Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with — 4. ❑ I am a general contractor and I b. ❑New construction employees {full and/or pari -time}. * have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub -contractors have g. Demolition working for me in any capacity. employees and have workers' comp. insurance.# 9. Building addition [No workers' comp, insurance required.] 5. 0 We are a corporation and its ME]Electrical repairs or additions 3. ❑ 1 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.E] Roof repairs insurance required.] t c. 152, § 1(4), and we have no 13.El Other employees. [No workers' comp. insurance required.] *Any applicant that checks box #t must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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 insurance for my employees. Below is the policy and job site information. Insurance Company Name: Continental Casualty Co. Policy # or Self -ins. Lic. #: WC 593672241 Expiration Date: 09/29/2014 Job Site Address: 351 Willow Street South City/State/Zip: North Andover, MA 01845 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 statemdnt may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido Hereby certify un r the pains allies ofperjury that the information provided above is true and correct. \\ Sivnafi re• I=it /� A/ ,0 \ n1 +a. 7 1 J__-, /l'? Phone #: 617.328.7899 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 #: CA m X m m CO) mm 5 U) cF z cD o CL r > o v CDC cr CD 0 CD . o cm (1) 0 VOL0 6�WA U) �G 0 U) c U) CD CD CD v z CD 0 CD 0 n o�%o 2) __ <r to CO) G O, CD n � C7 0 C2 n m o 3 mo y = N1 rO5-my, ' yT 0 0.� CL 0 m -� y 0 'a CA O -i CD CD 2 9: C11 NCD O O O C) CQ Q' . rt U) O O � C07 '+ C CD CD � c<� co O O to -�c-.0 0CDs E. n0 CL N 0 < CD > O CU < � CL ,N r� CD C.)cn d o FitCD 3 D. cn c� o v_CD • CD'o 0) -a :,�• o A) o sz . I =1 4 'I J (n O 0 ID *O Lon 0 O C �+ m m D T ZI 3 H z CA p �0 T N n ;O S z -v = 3 C z m 0 T m = S T :3 aj er n 7v T - 'r 7 rD ' w z v O m 2 N- o x z U) c� n � �z o O a) 0 � 0: z —, ,rz cn Z _ Z :r m 0 ;0. o�%o 2) __ <r to CO) G O, CD n � C7 0 C2 n m o 3 mo y = N1 rO5-my, ' yT 0 0.� CL 0 m -� y 0 'a CA O -i CD CD 2 9: C11 NCD O O O C) CQ Q' . rt U) O O � C07 '+ C CD CD � c<� co O O to -�c-.0 0CDs E. n0 CL N 0 < CD > O CU < � CL ,N r� CD C.)cn d o FitCD 3 D. cn c� o v_CD • CD'o 0) -a :,�• o A) o sz . I =1 4 'I J (n O 0 ID *O Lon 0 O co rDD �+ m m D T ZI 3 H z CA p �0 T N n ;O S m '° n r M T = 3 C z m 0 T r) 3 = S T :3 aj C G z 'o m A 0 N f1 K K CD 3 T - 'r 7 rD ' w z v O m 2 c c� Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 273621.00 m $ - $ 331.45 Plumbing Fee $ 41.43 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 41.43 Total fees collected $ 514.32 351 Willow Street 465-14 on 11/26/13 18x26 foundation permit