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HomeMy WebLinkAboutBuilding Permit #368-2017 - 36 & 38 Hepatica 10/6/2016 ?1bT_irw xla-&ScAnuve9 ✓ �arJA�T�oru1'lary SeP^"'Ev [e ��J �D NORTF� r��17 `r Je BUILDING PERMIT �`<��eD ;6 quo TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION tl yT Permit No#• "' Date Received Q°RAre° "" �'TS ACHUS�� Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER K y ��'� �°, -i Print 100 Year Structure yes o MAP PARCEL: ZONING DISTRICT. Vk Historic District yes Machine Shop Village yes j TYPE OF IMPROVEMENT PROPOSED USE Resid ntial Non- Residential ew Building One family [I Addition ❑Two or more family ❑ Industrial 0 Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 0 Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District 0 Water/Sewer 11 DESCRIPTION OF WORK TO BE PERFORMED: , 1 D�ST'Qyc � O-� mf= -t-mvti 0��•o� mob Orty �ek Uh c r Identification- Please Type or Print Clearly OWNER: Name: �rp�1 �.,c. Phone: "170- Address: lo e k914,011-01e, 61",6- Contractor /8 ,6Contractor Name: eyi'fhm;o C r G-yom Phone Email: Address: Ge 5 O L IL•'1 G r4 G-�r fin } /CJ o R f (��► yr •2_, Vh s4 o/Sys' Supervisor's Construction License: CS-O0 7,:!�30;t, _ Exp. Date: Home Improvement License: _ Exp. Date: ARCH ITEC ENGINEE L04ehc,el 0C iln Phone: Address: G roq Pt � OAA Reg. No. FEE SCHEDULE.BULDING PERMIT.$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. JT Total Project Cost: $ /8 000 FEE: $ Check No.: 0Receipt No.: NOTE: Person contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor Plans Submitted Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer I� 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 PLANNING & DEVELOPMENT Reviewed On 14 a.�� Signature_ COMMENTS U01-r 3b t 37 CONSERVATION Reviewed on co to Si nature COMMENTS 'G)-i(c3- - j l.� HEALTH-.Y � Reviewed on Signature COMMENTS F k r Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Con nection/si nature& Date Driveway Permit DPW Town Engineer: Signature: ' Located 384 Osgood Street FIRE DEPARTMENT - Temp. Dumpster on site yes no, Located at 1244 Main Street _ _ — w-- 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.$10o-$100o fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Pennit Revised 2014 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 o Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And p P 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 I 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 Doe:Building Permit Revised 2014 Location No. 3� 'Z� Date /0 • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ � Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# 1' I � Buildino spector / NORTH q Town of ? _ s ndover O - y.' ti 0 No. 010I1 h ver, Mass, / A�RATEo S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ..................... .. , /! �j..... ►................................................... BUILDING INSPECTOR AP �'�� V9 Foundation has permission to erect .......................... buildings on .._341.28 .. `dr 74, 79 Rough tobe occupied as .aa" 0 PeA .. ..... ............................................................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR. UNLESS CONST ION S Rough Service .. .. .. .. .... ....... Final' B LDING INSPE OR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. Smoke Det. Plans Submitted LJ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DI5b—S,ALL Public Sewer LI 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 PLANNING & DEVELOPMENT Reviewed Onsi 0 l gnature_ COMMENTS UV I 1 37 CONSERVATION Reviewed on (o to Si nature COMMENTS '��`-(`-— 51 " — �, �c� �. 'a✓\ HEALTH.. Reviewed on Si9 nature COMMENTS Zoning Board of Appeals: Variance Petition No: • Zoning onmg Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Si nature& Date btiveway Permit v DPW Town Engineer: Signature: ,A- oca a 84 Osgood Street F.IRE��DEPAR>TMENT T0tn Dumpster on,site" yes Located at 124;Mairn,Street Fire.Department signature/date r' COMM ENTS._ The Commonwealth of Massachusetts Department of jndustrialAceldents X Congress Street,Suite 100 F Boston,MA.02114-2017 7M SY'V �c www mass.gov/die Wo kers'Compensation insurance Affidavit:Builders/Contractors/Electricians/I'lumbers. TO BE FILED WITH TRE PEP2&TTING AUTHORA7 Z- „Please print Le 'bl A licant Information Name(Business/Organization/Individual): c w► C• Address: 10 Ile.e-4 k,c. ; 1�e. City/State/Zip: �o h d Phone#: 2 740 _60 93 -.316 3 PP P Type of project(required) Are you an employer?Checic thea ro riate box: m to ees(full and/or part-time)."' 7. ❑NeV d6nstruction 1.❑I am a employer with eP y 2.❑I am a sole proprietor or partnership and have no employees Working forme in $. Remodeling any capacity.[No workers'comp.insurance required] 9. ❑Demolition 3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 11.[]Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole . proprietors with no employees. 12T[]'Plumbing repairs or additions 5.�am a general contractor and T have hired the sub-contractors listed on the attached sheet. 11 Ej Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 14.0 Other 6.Q We are a corporation and its,officers have exercised their right of exemption per MGL c. Have no employees.[No workers'comp.insurance required.] 152,§1(4),and we *Any applicant that checks box#i must also fill out the section below showing their workers'compensation policy information fi 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 state whether or not those,entities,have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. lam an employer that is providingworkers'compensation insurance for my employees. Below is the policy and job site information. ( GAS � pG �j . t1C Insurance Company Name: �,S De e T e !� �'►t ^ 7115-117 Policy#or Self-ins.Lic. !50076a�� Expirationl)Om [ r • Job Site Address: ��/�J A,Le 'i .�Lilt�r �0. #,n jpk.,f t 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 MGL c.152,§25A is a criminal violation punishable by a foie 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.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 andpenaldes ofperjury that the information provided above is true and correct. ` r � Date: O /lv Si ature Phone Official use only. Do not write in this area,to he 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 Phone#: Contact Person- 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 enferprise,and including the legal representatives of a deceased employer,or the receiver'or trustee 6f 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 req'W`red." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter intp any contract for theperformance 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=contractors)name(s),address(es)and phone number(s)along with their certificates)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 Iudustrial 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 Iuvestigations 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 wwwmass.gov/dia M1�assachusetts €lepartrnent of Pubiic Safety Board of Building Regulations and Standards Construction superiisor License: CS-075302 BENJAMIN C OS 'BOO - ' �► 69 Old Village Ladel� North Andover WA 0 Si -ef0• Expiration Commissioner, 12/0412016 21'-2" 75'-6" 20'-10" 1 -0" 20'-10" 5'-6 _ _ 5'-0" ------ -------- Precast __ fD • d 'D �'d omn ..", ., d 'p v d v n vO 'b vd e � a d �D • O v "' ' v, > - ..�__ concrete -- -------------------------------------------------------------- -------------------_ - ------- ------------------------------ _U Bulkhead _-_-U P-_----_-..---- -_- -•____-- . ,.,.-.._ _-» ....___� D -o . d D • d ------ ----.o a 3r-Or. 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