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HomeMy WebLinkAboutBuilding Permit #785-13 - 398 MAIN STREET 5/17/2013TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: Date Received Date Issued:. ' I - r IMPORTANT: Applicant must complete all items on this page LOCAT10Ni � Mq w b r N f�y arPt' Met` _ PRQPERTY�OWNER St Pav�� t%J2 iS C d"XI 1 '1 ' V Prmt 1 owear, Old Structure yes: no • MAP'NO: PARCEL: _ ZONIN0 DISTRICT Historic District yes Machine,Shop-Village yes, o TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family El Addition 11 Two or more family 11 Industrial ❑ AI ration No. of units: El Commercial epair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other #-_ ❑ Septic: ❑ Well3 p Wetlands ❑ Flo,od lain [I ❑ Watershed Districf� . NV -.-Ower, _ DESCRIPTION OF WUKK I U tst rtKr FrdA f CU: Identification Please Type or Print Clearly) OWNER: Name: S -r Paul -s t: pk5co (a �- Phone: 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: $ (9 i 30 FEE: $ Check No.: '��� , Receipt No.:� NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund rSignature ofAgent/Owner Signature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Sta ans ❑ 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 PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS DATE REJECTED El DATE APPROVED Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes . Planning Board Decision: Comme Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Towp. Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Tem_ p Dumpster on site yes no Located at 124.Main Street Fire Depai-tmdnt.signaturb/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 NU I Lb and UA 1 A — wor department use EJ Notified for pickup - Date Doe.Building Permit Revised 2010 Building Department The fohowing 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 app, al 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: Doc.Building Permit Revised 2012 Location < ?� No. 17 Date Check #�5 26414 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Building Inspector m m m m y m CA 151 v N 0 CD 0- Z CD O �r Q �. n cQ O 00 CD CLc CD O. .WJ N O O N n� 0 u M CD y� CD I O 0 CD O CD O O 9 Z m cn O N C 0 V+ CU Z • z fn 0 O m x 22 X N z z 2 cn <0 O -a —Z5 o —� -, O = -q 2 �• 5D O n z c �� ) p, vs a; CD C -n 0 0 .-• CL m W0 c1n) m c N C <D 'O CD S 3 FL a) N D O cQ. 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'iIL)VUIJ,:I ::ilr,rrlJUtAMUE 001l001 AL—L•AL�61C:3UU\G=uU�P C Darr trip d€R5'i�It r�IL� lv i��►Rl�S A ��l3ii�Ij��9RtLI�II�Iii ONLY Atk9 G@111h�RS t>!� I�GI�FiI� IJPL�� �! ;i ItO�T� D��'v tGT �c�Flr�if�(ii�TlV€b`1` OR PdE�Tilp�l.Y Rf•.REidQ, tl"I EI1Q OR ALTER a TI ifS CC -R T IFICA E 69 I[i;�UR {l6E ®C�9 II lV C6AM ND, l ��PU! f �Ci TR TH of FOR it 15 II E;OLQ�R, T�I� of;PESE€J51tiYlS�� 8R �R®6UC�l, �1fli[i i i°lie C�il�lC i t�P, Tf�i= dHeeisE f I�F�RI�@ Q 5 NII THE ISSUIIL F F , pC2RI,FE- lA�P��iAt�S': If fila e9r��rc�t9 HDIsrls era •n_, 't�O�D€ IIVmU,:EF;(�), �Uil;Or�ii;p the €&rifle and eondI.Ions Of qt& Ola c;818" tl. ih1M.- g>9� DOtic,J{I �jerlGet�a�. I? SU ROO TiJt�I to l(Lp p wT� D n �OIIE�, es 2lrt IJaIlel€s may r eRiPi; an ©r3' OL emOr3, sSafOr ;@I 0>3 4his �d ,�l17cbi� cam na@ co ,s' r rigraf6 I t ;a t certificate hetder In lieu ov-suFh erl�areerert s . fills ED, subleci Ya lPLaL1� Associate-.- A.M ,.�- 7-Iricla l'imam 6�OO��t� y FFIGME �La II t97e� spa —��G� FA= .r eta. (972) 601-017 ?�s�; Z����Tetnis�su��. aAn ?L10� til �fh't3'U'�a' � m IfdSUiKk a AAPOF,ISINO `uEVe'i,keo WAl01) INSUPSp Ii�6URE F J�Z9SP a l9b ZbOf3don 5 MIM -=I tOK0 SSL', Developmerit, INSURERa: C5f0 SaT!ftH Y=CF.0t5p INSURSRG7 -Do, Ptoad INSURER D: u6 -d ILS : 0 02 G'sURER 9: J � COVERAGES I14SUR6R F OERI1t=lQS� fllf�fcRE'"I�:��?r3OSa7iI YkIS IS TO CER?IFY ihlAr THE I'OLIGIES OF INSURANCE LISTED BELOW HAVE RI;y�IalCail j�i(J(tjje�P; IrdDICATEi7. N6TV� T HSTAN!?INC ANY REQUIREMENT, i �I��r 8R COWO(TIppJ 9ry ANY GOP1 SEEN ISSUED TO R OTHER D CUhrjEN ABOVE IRS THE POLICY PERIODH THIS OF-RTIFICATE MAY DE ISSUED OP. MAY PERTAIN, THE INSURANCE AFFORDED 6, THE POLICIES l)_S CONTRACT 9R OTHEF, 99GUh�ENT YigYH C�e5PECT TO (Ap�ilGf� THIS E9CLUSIOWS AND CONDITIONS OF SUCH POLICIES. LIMITS SWOW.,q MAY HAVE BEEN REDUCED By PAID CLAIIdtS. at: CRIBt;d H$giM IS SUBJECT TO RLI, THE TeP.AiS, L79 TYPEOF; INSURANCff Am d GGREP,ALIJABILITI NSa POU6YiQUplc�oR rt�l D EFP ! 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AUTNIQP,.I_C-Q �, the t6fIiL6 aflB cant33Liails ai'fha Nolic}', +:OF�in >vattelDS may ra(+l!!re Eta en�pPSorient, 1\ StCt8filentrEn�piG ep �Q��a aoE not eAlV�f�, Oct :g ..� cerUFfcaty holaor try IIDeI of `Uch vi9ioPDptfiant�gj, taaue (lE9U� • ddi nfltof rlsr7is to The f!! 20 tnsyPanee F�seectr:es d�C ����tisT -- North�gaot7 St td48 $ r •� E=LI: iD7S16-01 700 J; _._. .rtdaver, PtlAo�3a3 ;%5777 _ tw-uas��Cacv�C.cav�w.aar= �—I JA:skiSR•A- AJJeJ,Nu?dellnstlranCaga - �- ,?�Slr _ t:vfi1) P-n(10v0r 0al1dInn i;or7 n��ny 3;Sii 70 °Illon Roa12, d !N fiEMs� F'�111101'1, MIA MUG IN un. 0 • — cQV@(2&GES I • aua��- • _,� _—, _. _ C�RTIFtCR i E IJI UMSER: I DI is Pp CEA41q TyfaT TME POLICIES OF INCUP,ANCE LISTED BELOW MAH � "VISION NUMB R: INDICATED. p, NQ LoTI'rvTANDING ANY RGOUIReh1E4T, iERn4 OP, CONDITtt7i� OF ANYNCONT;AeTO TWE 7 OR fjTkl`URED IvAt3ep GErE FOP. 5=HE POLICY )�E,=,(gp CERTIFICATE n=:;Y 8E ISSUE OF MAY f�eFTaLti�, nI I auEo EXCLUSIONS S AK4 C6[dbRlt�NS (#F 4 I; NSURANC; „ I:R bOCyt7ENT L4i!N pESAoOp T®t LrAI°.H Tkl 0.( FVE EIE 8'l TME PbLICI$S @:SCRISED HEREI?J t5 SUBdt er i0 ALL TWU Tep,(;'g. �fga UCFI RCgpUCI>;e., LIMITS SgOtiLq+ MAY HAVE C+EcN REpU6ED Br RAID ALA I • t -- c TVVC O6INSUa.Atu�c 3aR POLICY N Fit: ea OEtt L CI4014ITY GENERAL LIA9LtTr MAC40CCURRENCE., g C]or (:;,r; tta Ac t x. .c;. `p t:Eo Erp 1%.nv .nt rzrvn( S Pltt•airy!¢ <AGry AL,iJAt• t .-^ -. • `�' L n•, C�iEI'-:.t;: UbnT ,taatlES `r;w ,TEYFI:AL;,C G�=C-qTc S -- %C G �yt.11r0?n0?It iv i f u I -W,21 -UU :•G�t:Li:T1.MZF' ALL OSawF'pRIM CeEDULED y 1.*gAL.-._ Ar!Tci3 RO: :+DDtiY Id..LJkv •�—• `• •—• rnl�UJ rat roG0W,,iCn IPm LOOILYL' t,If:Ylpat•=farll $ HROER'rvDruJ.yE U?.t{aAEL A l?? f1 Orrttk r= -CESS LIAS r "Sg I J _ _ I CLA Mhic €AvN OCCUAtRGtCE Q t htL•NRC,N 1 st:Gk66nTC •. ^— -- I • -- ,. rtEfI�G�E'�11e�••.L�f'�'ft�isCUTt\•C " � ]i T`�� L�MIUI ^ � [{�t• -�- •_ .�_ L� ®_ r 114MIGIarylnh:pl�� fd Nta AWC7D2a267DgEd9? :L cnt:KACCt:Er. f , ! 41ri4f204� i4149rZ073 �!L �:�I ,il•f l�'t 17 f7P RATILC2=D,:Snw Li r^JLSFN:I`. FA ItMPL OVE(! i _ 400,660 �' l 5L ahEisb; r_aucYLti,IT s .— SOD.DDd 1 nlacr~,aitaN 8 aas+i'a°�i6hs ibaCAtiOMS i NExtC6eS IAL:u:O WC� ', — � -. C 705, A5`ulCcncl �:m:rc: 5:npLttic, Ifineto a:g�C: t_ rL-rtUlr.81 - __ , I dki6U6D ANY @P ?r;E AnQVE 52SCRISED viou au EE g :C(=6L0 5€F9t3E IFIL S;:PI€ATiou rii.:6 T„EPEgF;, tSriTIeE WILL, PE DEUIgEREta if, ACUQROARCE vurrT.7 7119 C OWL!Y t H,�Y121fiI�e. AUTkOR!Z.0f3ERREUCOTA77tc _ ACOR D =E iZd5 dtDSt T•nG ACQRt3 nams and logo aro realstored msr! s of&&SQP.p gC�12b gH�PQr.vSlo _ ir(! _Rt. res. 7416 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ni,,­ IDA"+ T .nfsihli Name (Business/Organization/Individual): �JQolr Address: Po 6CK � 5Z City/State/Zip.. AAJP0,,ea- K4C� Phone #: q -7b SU -� q4(! f A�re you an employer? Check the appropriate box: 1. L a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have Hired the sub -contractors listed on the attached sheet. 2. ❑ I am a sole proprietor or partner- These sub -contractors have ship and'have no employees working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its officers have exercised their required.] 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. t c. 152, §1(4), and we have no employees. [No workers' insurance required.] comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. El Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they aie 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 their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. ArAA 'A Lt- ructC_ Insurance Company Name:. Policy # or Self -ins. Lic. #: �W(,-%C�2� Z4iU1 10 1-b Expiration Date: Job Site Address: 3Q (� . �u + ^ ° City/State/Zip: %V /wUDr�2r Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a the form of a STOP. fine up to $1,500.00 and/or one. -year e violator. s Be advised that nt, as well a copy of this statcivil penalties ement may be forwardedOo theRK RfEe of d a fine of up to $250.00 a day against Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided awe is true— r f eYand correct. Gc1 elQ Official use only. Do not write in this area, to be completed by city or town offtcial. City or Town: Permit/License # Issuing Authority (circle one): wn Clerk 4. Electrical Inspector 5. Plumbing Inspector 1. Board of health 2. Building Department 3. City/To 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 -contractors) 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 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., M,A. 02111 Tel, # 617-7274900 ext 406 or 1-$77,7M'ASSAF'B Revised 5-26-05 Fax # 617-727-7749 vvw.rnass,govfdia