The URL can be used to link to this page

Home My WebLink AboutBuilding Permit #435 - 4 JOHNSON STREET 12/8/2009 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: 2 IMPORTANT:Applicant must complete all items on this page LOCATION 0-S,0 to PROPERTY OWNER_Ck ee ea4 Y 10- "Print 0-Print MAP NO. PARCEL _ZONING DISTRICT: Historic District 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: mercia epair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District a#erl�ewer DESCRIPTION OF WORK TO BE PERFORMED: / e f6 �Vay `oy 7`v ?:i/i 7 to 0,C Poe .7.47y JZYS14V t ?%`n m� Tt�i o !17►�7 D)/L!�/� ,�/SLTKS ��D cy .L s 'fir,S UGL Z'o.z j!L 7'6 Je l e4`o oc Idratification Please Type or Print Clearly) OWNER: Name: elet ;e ee*LfY Phone 3b8-3�$- 1o3� Address: ISO k0ef4 411do0ole-oz 00 R CONTRACTOR Name::gt!�U-dwft*c 4f' - a6'-000 Phone: ` -y ► Address: . 11�xl-sf- " ► ' rca - Supervisor's Construction License: 734.2 Exp. Date: , Home Improvement License: Exp. Date: ARCHITECT/ENGINEER ��& Phone: Address:,PO/ 56-,e DMZ I)A- F t 41W Reg. No. FEE SCHEDULE.BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ c:P(,V6�0 FEE: $ 4*' Check No.: /0<<-� Receipt No.: �22 6S NOTE: Persons contracting with unregistered contra rs do not have access to the guaranty fund Signature of Agq—ny-Q---wner 9 'gnature of contractor t 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 Signature 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 DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster on site es no Located at 124 Main Street Fire Department signature/date COMMENTS t 'fcte�. 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 ❑ Notified for pickup - Date Doc:.Building Permit Revised 2008 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: Doc.Building Permit Revised 2008 /r Location No. 41? J Date X-2 �'/> NOR,h TOWN OF NORTH ANDOVER O? • • Ow ' Certificate of Occupancy $ Building/Frame Permit Fee $ 4CMU5 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 226 � `i .� ^ilding Inspector i c x40 R TH Tovm of t RAndover No. * --1 A K E _- dover, Mass., COCMICNEWICK 7,9 A0RATE0 `S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System i THIS CERTIFIES THBUILDING INSPECTOR AT �� -CS�'� ............... .... ...... x........�'.............. ............................................................ Foundation has permission to erect........................................ buildings on ....- ..7..... . ...:... ...... �. -?.. ........................... Rough to be occupied as ........../ ate'' ,.. ..,.,., { /►' : rt, a Chimney p' .5. ..... .. ..... �.. ,�. �.. � ................ y provided that the person accepting this perm shall in every respect conform to tlfe terms of the applidation on file in Final 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough `"'" ............................................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. EEL::SEE REVERSE SIDE Smoke Det. i The COMM ealth of Mass*ach,c_ 3)efts Department of Fire Services =� Office of the State Fire-Marshal •.P.O.Box 1025 State Road,Stow,MA 01775 PERMIT Date: North Andover Permit No (City of Town) (if Applicable) :Dig Safe Num er In accordance with the provisions of lViG I 1 4 8.Chapter_as provided iu section—5-27 ('Mg 34 This Permit is granted to: �t .0 p ` Start Dace HCl// // f�i�/ f //�[�f'T Full name of person,Finn or Corporation Permission to locate dumpster for construction/renovation/demolition of building. COmn'e dumpster must be Restrictions: . 25 ' from structure if unable to olace with re uired clearance Idu/mpster must be covered with 1 wood or tar end of work day at 7 Vy�t ii fon I (Give location by street and no.,or describe in such manner as to Prov' dequate identification of location) Fee Paid S 50.00 Fire Chief This Permit trill expire — p v (Signa e o ica granting permit) Qfitcal granting permit (Title) Massachusetts- Department of Public Safet% Board of Building Regulations and Standards Construction Supervisor License License: CS 75302 Restricted to: 00 BENJAMIN C OSGOOD �,p`f 1 69 OLD VILLAGE LANE NO ANDOVER, MA 01845 Expiration: 12/4/2010 Tr#. 6955 --i . .... .. .... .... . WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Employers Insurance Company Burlington, Massachusetts (800)876-2765 NCCI NO 40959 POLICY NO. I WCC 5007581012009 ITEM PRIOR NO. I WCC 5007581 il 2008 1. The Insured Key Lime Inc Mailing Address: 10 Hepatica Drive North Andover MA 01845 (No. Street Town or City County State Zip Code ❑ Individual ❑ Partnership ® Corporation ❑ Other FEIN 04-3311218 Other workplaces not shown above: 2. The policy period is fron-p9/15/2009 t009/15/2010 12:01 a.m.standard time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here; MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident$ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 policy limit Bodily Injury by Disease $ 1,000,000 eachemployee C. Other States Insurance: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06 A D. This policy includes these endorsements and schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating plans. All information required below is subject to verification and change by audit. Classifications Premium Basis Rates Code Estimated Per$100 Estimated No. Total Annual of Annual Remuneration Remuneration Premium INTRA 285896 SEE EXTENSION OFINFORI IIATION PAGE Minimum premium$ 500.00 Total Estimated Annual Premium $ 2,846.00 As indicated,interim adjustments of premium shall be made: Deposit Premium $ 755.00 ❑ Annually ❑ Semi Annually ® Quarterly ❑ Monthly MA Assessment Chg. $2,419.86 x 7.2000% $174.00 This policy,including all endorsements,is hereby countersigned by 08/25/2009 Authorized Signature Date GOV GOV KIND PLACING CLAIM NAME SAFETY STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP The Fairway Agency Inc MA 5645 123 505 305 Forest Street WC 00 00 01 A(11-88) Bridgewater,MA 02324 Includes copyrighted material of the National Council on Compensation Insurance, used with its permission. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: /o -Pe, City/State/Zip: i{/aRl 4460-G2 Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. �am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet t 7. [remodeling 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. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 13.❑ Other 'Any applicant.that checks box rl 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. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: /¢ ,6- Policy#or Self-ins.Lic.#:_ u'G G J 0 0 L71j'$/Q/ .2 po? Expiration Date: /j O/U Job Site Address: cO _ / To 4aSa-or ST City/State/Zip: 4s / $W 6 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. I do hereby certify under the pains anted penalties of perjury that the information provided above is true and correct Simature: C Date: oL ,7�gp Phone#: ,78--G � --,j G — �� Op,� -3'+� 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): J1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: I 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 or 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 permittlicense 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 lndustrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-72.7-7749 www.mass.gov/dia