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Home My WebLink AboutBuilding Permit #154-14 - 39 HIGH STREET 8/16/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 7` Date Received Date Issued: E / h IMPORTANT:Applicant must comlete all items on this page LOCATION 1 ST 1�16C Nn��f�.rC Print PROPERTY OWNER RCS NdAv UL(- wckk U—C MAP NO: PARCEL.UU—CPrint 71,- - 100 Year Old Structure yes no 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: JCommercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identificatiop Please T e or Print Clearly) _ OWNER: Name: I CC N�,A,.A,.d�.1� - MT LLC Phone: ��1-(,�� 31J Address: S`C aR 5� tie VAX- CONTRACTOR Name-. LnzC lntsl Phone: Address: q�f ESQ e c zac 51- M AIO Imo:. Supervisor's Construction License: CS- � 5�, 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: $ � 6 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 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ tamped Plans 11 f I Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPEOF SEWERAGEDISPOSAL - l Public Sewer ❑ Tanning/MassageBodyArt ❑. . _Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ - I THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ El COMMENTS I CONSERVATION Reviewed onSignature COMMENTS HEALTH 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 r DPW To` 2 Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster on site yes no Located at 124 Mair Street- Fire Department-signature/date r. 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 El Notified for pickup - Date Doe.Building Permit Revised 2010 Building Department The folt,Bwing is a list of the required forms to be filled out for the appropriate.permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits u Building Permit Application u Workers Comp Affidavit u Photo Copy Of H.I.C. And/Or C.S.L. Licenses Li Copy of Contract Li Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks a Building Permit Application u Certified Surveyed Plot Plan u Workers Comp Affidavit u Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) L3 Mass check Energy Compliance Report (If Applicable) Li 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) u Building Permit Application u Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses u Workers Comp Affidavit Li Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o Mass check Energy Compliance Report Li 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 apw-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm-tted with the building application Doc: Doc.Builjing Peanit.Revised 2012 Location No. 5'y L/ Date /3 . - TOWN OF NORTH ANDOVER . Certificate of Occupancy $ Building/Frame Permit Fee $ cis= Foundation Permit Fee $ Other Permit Fee $ TOTAL $ r Check# �k� 26746 Buil mg Inspector Enter construction cost for fee cal- North Andover Fee Calculation Construction Cost $ 48,685.00 m $ - $ 584.22 Plumbing Fee $ 73.03 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 73.03 Total fees collected $ 830.28 39 High Street 154-14 on 8/15/2013 Kitchenette - The Commonwealth off Massachusetts Department of IndustriglAccadents 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/Organization/Individual): Address:!�`t City/State/Zip:U!� a, �GG . Phone#: c —p= Ar an employer?Check the appropriate box: Type of project(required): 1.M T am a employer with -'5-0 4. ❑ T am a general contractor and I 6. ❑New construction x have Hired the sub-contractors e v employees ees fulland/or art-time . p y ( p ) z 7. PRemodeling 2.❑ T am a sole proprietor or partner- listed on the attached sheet. 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. El We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.F1 Plumbing repairs or additions myself.[No workers.'comp. c.152,§1(4),and we have no 12. ]Roofrepairs insurance required.] employees.[No workers' comp.insurancerequired.] 13.❑Other 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T Homeowners who submit this affidavit indicating they tie 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 showingthe name of the sub-contractors and their workers'camp.policy information. lam an employer that is providing workers'compensation insurance for rnty employees. Below is the policy and job site information. Insurance Company Name:. k u5A Trn,5 V C6-C�- e< Co Policy 4 or Sol f-ins.Lic.4: ExpirationDate: I _64 4 Job Site Address: t&% �. City/State/Zip:-N��. 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 ofMGL o. 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 ofup to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Off-ice of Investigations of the DTA for insurance coverage verification. .bdo Izereb certi unlet•t/te ains a d It' o eY'u that the information Provided above is true and correct - Y /Y P P fP jury f P v . Si afore: Date: /3 Phone_# `�� jo Official use only. Do not write in this area,to be coYrtpleted by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of health 2.Building Department 3.CitylTown CIerk 4.EIectrical Inspector 5.PIumbing Inspector 6.Other - - - Contact Person: Phone#: 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 ofhire,• 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 j oint 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-contractore P (s)name(s),ad dr ss(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 notrequired 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-andprinted legibly: The Depai( erit 11as provided a space at the liotEom 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 submitmultiple 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. Anew 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 CQM. Monweali of MUSSa.'Ghuetts - Department Offadustdal.A..celdeats OfAce.of gmstigatio.m 600 Wasbiugtou Street Boston,SIA,021 x 1 `QL#61.7-72.7-4900 e7t 406 ox 1-8,77-MA.SSAFE Revised 5-26-05 BaY,#617-727-7749 r , NORTFj ve' 'o 0 No. 194. I * _T _ ,� i ' h ver, Mass � A- COCMIc"g WICK 7,4 AORATEO 0'*' �5 s V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ae�. . yrs:?'`........................................ BUILDING INSPECTOR .... ....................................................... Foundation has permission to erect .......................... buildings on ................. ........................................................... / Rough to be occupied as ........../.l P/�!F� ...................................... 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 CONSTRUCTION STARTS Rough Service ................ .. �,,.: ................................ Final BUILDING INSPECTOR 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. SEE EVERSE SI E