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HomeMy WebLinkAboutBuilding Permit #675-12 - 50 MAIN STREET 5/1/2018 NORTH BUILDING PERMIT °��t,Eo 16 o o TOWN OF NORTH ANDOVER R _ - n APPLICATION FOR PLAN EXAMINATION , Permit NO: —/2 Date Received sgcHus���y Date Issued IMPORTANT Applicant must complete all items on this page CATI OiN' L _ d s t > A �Ksvw�� ; :"w .,mks ,- �rJftf` -'t S T •d'' ^ •tw � Y. '. PR��PERTX�OWNER F F���������f ���� ;3 k Pbrinf MAP NOPARCEL' ' ZONLN,G DISTRICT historic Distrtct yes> no� 4 z r e M s h y achtr�Sh � lage Yes .no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family El Addition V Two or more family 1 El Industrial El Alteration No. of units: �►r►.11 k Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: Demolition ❑ Other I Septic ❑1�7e1tL Flooplam 11(l/etlands `4Watershetl'Dtst �ct { ❑INaterSewr DESCRIPTION OF WORK TO BE PREFORMED: V i c � Identification Please Type or Print Clearly) OWNER: Name: C'61t16 tan&gorc.,� Phone: Address CONTRACTOR IVarrie Phone are, v x ?3 aN c N � Superuisos'onstrurtion Lcerise r g Exp$ Daus . s Horne Improvement Lacerise� ` . F Exp Daf01 ec' . 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: $ �6Od - 60' FEE: $ Check No.: Receipt No.: Vis'/2 S' NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund _. Signatureof Agent/Qwner Signature„o#contractor , r; . 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 DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes 0 Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit Located at 384 Osgood Street FIRE bEPARTMENT Temp Dumpster an sife` yes z no Located'at 124 Mam Street Frre ©epatrtment signature/da#e;y t , COMMENTS` 777777777777 Dimension me nsion Number of Stories: Total square feet of floor area, based on Exterior dimensions. i 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.s100-s1000 fine I NOTES and DATA— (For department use) ❑ Notified for pickup - Date Doc.Building Permit Revised 2007 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 3�, ❑ 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 liance 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 Location 7 Z/ — /-0 ��F74�� 1/ No. & 7 5---- 12— Date • TOWN OF NORTH ANDOVER • Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ tit 1 TOTAL $ Check# Z7/Z r 25125 B ilding Inspector V40RTH - 0 Of ' 0 . .� . :, No. o over, Mass., Q LAKE v COCKICKEWICK 1_1 5 RATED 5 -PERMIT T D U BOARD OF HEALTH Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT�..._,'�­hi'!e... ©�,.. ..p. ................................. .... .................................................... Foundation on has permission to erect........................................ buildings on... ....... .................... !j.......:.................................. Rough Chimney to be occupied as.................Pl%-Via.....-...... V.0 .:.. .. 'himn e provided that the person acting this permit shall in every respect c nform to the terms of the application 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 CONSTRUCTIONTARTS Rough ........ .................................. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on ` T the Premises — Do Not Remove Final No Lathing or Dry Wall 1 o Be Done FIRE-DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. t ?'he Commonwealth ofMassachusetts Department oflndustrialAccidents Office OfInvestigationg 600 Wash ingtonStreet Boston,MA 02II1 www.mas-vgov/d'ia Workers' Compensation lnswr4nceAffidavit:Buildelrs/Contlractors/Fiectlricians/Plumbers A licant Infolrmation �"lease Print Legib Name(Business/Organization/Individual): Address: •City/State/Zip:_ 47)oj'tr mA Phone#. . 9-7 3 �Z YT'� [� ha an employer?Check the appropriate box: _ a employer with 4. LML] project(required): ❑I am a general contractor and I loyees(full and/or part-time). have hired the sub-contractorsew construction a sole proprietor orpa tner listed on the attached shget. Remodeling andhaveno employees These sub-contra ctors have molition ing for me in any capacity. workers'comp,insurance. workers'comp.insurance 5. ❑ We aie a corporation and its dding addition red.] .officers have exercised their ectrical repairs or additions a homeowner doing all wont right of exemption per MOL mbing repairs or dditions lf.[No workers' comp. c.152, §1(4),and we have nonce required.]; em Io ees. ofrepairs employees.[No workers' comp,insurancerequired.] er •=Any applicant that checks box#1 must also fill out the section below showing their workers'compensation.policy information. 1 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew 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. 1,7M an employer that is providing workers'compensation insurancefor Iny employee's. Below is tliepolicy and jab site infomnation. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: rob Site Address: , City/State/Zip- Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). yailure to secure coverage as required under Section 25A ofMGL c.152 can lead to the imposition of crimivalpenalties of a Inc 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 Erne '-fu p to$250.00 a day against the violator. Be advised that a copy ofthis statement maybe forwarded to the Office of nvestigations of the DIA-for insurance coverage verification. fP J rY ` do Hereby cert�y under thepains anilpenalties o er'u tl2at the information provided above is true and correct. nature: 3 / !one#: Bate: Official use only. .Do not write in this area,to be completed,by city or town offcial. City or Town: PermitMeense# IssuingAuthority(circle one): , (.Board of health 2-Building Department 3.City/Town Clerk 4.Electrical Inspector 5,plumbing Inspector Other Information and'. I a . structions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to flus statute,an employee is defined as"...every person in the service of another uuder any contract of lyre, express or implied,ora'1 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 doemed to be an employer," MGL chapter 152, §25C(6)also states that"everystate 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 applicant who has not produced acceptable evidence of compliance with the ince coverage required:' Additionally,MGnsurafor any L chapter 152,§25C(7)states"Neither the commonwealth nor any rafts political subdivisions shall enter into any contract for the performance ofpublic 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),addresses)andphonenumber(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�dustrial Accidents for confirmation.ofinsurance 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 thattheaffidavitiscomplete and printed legibly. The Departmenthas provided aspace atthe 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 affidavitindicating current Policy information(ifnecessary)and under"Job Site Address"the applicant should write"all locations in town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the or 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 notrelated to any business or commercial venture (i.e.a dog license or permit to burn leaves etc)said person is NOTrequired to complete this affidavit. The Office of Investigations would like to thank you in advance for your c please do not hesitate to give us a call. ooperation and should you have any questions, ' The Department's address,telephone and fax number: The Col)-,=0I Vvc-alth,of M�ssachusetis Department of Xudustrial..A.ccideats Office of InvestigatIorRs 600 Washiugton S1iroet Bostaq M ,0211 X TO #617-727-4900 ext 406 ox 1-877-MASSME NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section I OA. The debris will be disposed of in: � i 14 n, (Location of Facility) gnature of Permit Ap lic t Date r 1pe D) hgs 74C 7� c� � e 4ye Massachusetts - Department of Public Safet, Board of Building Re�-ulations and Standards Construction Supervisor License License: CS 88368 JOHN W BEARDSLEY 9 LOWELL ST ANDOVER, MA 01810 Expiration: 3/17/2012 Commissioner Tr#.' 28618 -4114 office�t o me A airs iness egu atio License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration:;X-046678 Type: Office of Consumer Affairs and Business Regulation > Expiration: `5%19% 013 Individual 10 Park Plaza-Suite 5170 i Boston,MA 02116 J BEARDSLEY JOHN BEARDSLEY� =� 9 LOWELL T. ANDOVER,MA 01810 ^k,, �ture Undersecretary Not validithout sign