HomeMy WebLinkAboutBuilding Permit #216-2011 - 45 SECOND STREET 9/14/2010 BUILDING-PERMIT µORTH`
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: ' l� Date Received
_ °`+1reD`��R�
Date Issued: CJy /� �SSACHus��
IMPORTANT:Applicant must complete all items on this page
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TYPE OF IMPROVEMENT PROPOSED USE
Resi I Non- Residential
New Building One famil
Addition ' o or more family Industrial
Auer No. of units: Commercial
epair, replacement- Assessory Bldg Others:
Demolition Other
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DESCRIP 10I�OF WORK TO BE PREFORMED:
Identification PIease Type Print Clearly
OWNER: Name: f�
"Phone: f•7�zr7c?- Yy
Address: _5GeJI>17 � C� Dd5v /
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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: $ ;;t 'I�� FEE: $_
Check No.: / 2 / Receipt No. 2
NOTE: Persons contr-acting with unregistered contractors do not have access to the guaranty fund
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Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF EWERAGE DISPOSAL
Public Sewer Tanning/MassageBodyArt 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 Sigriature
HEALTH Reviewed on Signature
A
COMMENTS
r
Zoning Board of Appeals".'Variance, Petition No: Zoning Decision/receipt submitted yes
Planning- Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Si4rtature&Qate Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
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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 fne
NOTES and DATA— (For department use)
0 Notified for pickup - Date
t
Doc.Building Pernut Revised 2010
Building Department
The following is a fist of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
o 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
o 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)
❑ IVI
"'ass 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
❑ 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:Building Permit Revised 2008
Location �� G UN� J
No. Date
NORTIy TOWN OF NORTH ANDOVER '
3:0�,1`•D I•,MOOL
Certificate of Occupancy $
cHUS Building/Frame Permit Fee $ �
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # 2�
23 4v
Buidiri Inspector
r10RTM ,
O
0 over
No.
dower, Mass.,
T Q � LAKE
COCMICMEWICK V
%S RATED PP�,��C�
BOARD OF HEALTH
Food/Kitchen
PERM IT T D Septic System
L BUILDING INSPECTOR
THIS CERTIFIES THAT .!?... ..Ff"I:.iyt...,! �G. .�`.G
.......... Foundation
has permission to erect.... .................................. buildings on .. �i �GC�!! . ................................. Rough
to be occupied as................. ... - ?iI ?.....rf... �!r.l ...... tJ. "7L� .. � ...164".-... Chimney
c
provided that the person accepting this permit shall in every respect conform to the terms dthe 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 CONSTRUCTION STARTS Rough
Service
... ... . ................ ...
BUILDIN 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.
SEE REVERSE SIDE Smoke Det.
The Commonwealth of Massachusetts
Department of Industrial Accidents
.'� Office of Investigations
:►r !U 600 Washington Street
, X 1 ,t.,
Boston,MA 02111
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):Rty�OF—e-F L.LOCEVl N (�J-P6 4� RPMODE'uK)e"-
Address: T) ► -- S J
City/State/Zip: � � )n� d� % hone#: `� ?_K3 O-7
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
mpees(full and/or part-time).* have hired the sub-contractors
2.to,�IamluayEole proprietor or partner- listed on the attached sheet. t 8. emoliting
shi and have no employees These sub-contractors have 8. ❑ Demolition
r p
working for me in any capacity. workers'comp.insurance. 9. ❑ Building addition
[No workers'comp.insurance 5. ❑ 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 11.0 Plumbing repairs or additions
myself. [No workers'comp. c. 152, §1(4),and we have no 12.E] Roof repairs
insurance required.]t employees. [No workers' 13.0 Other
comp.insurance required.]
*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 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 andjob site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: 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 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 c y u er the pains an penalties of perjury that the information provided above is true and correct.'
Si ature: Date: I G
Phone#• / -�O 1� yr,� a 7
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):
1. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
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-contractor(s)name(s),address(es)and phone numbers)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 sur&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 pen-nit/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 pen-nits 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 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,MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727--7749
Revised 5-26-05
www.mass.govldia
" Massachusetts - Department of Public SafetN
Board of Building Re'ulations and Standards
Construction Supervisor License
License: CS 2685
Restricted to: 00
ROBERT M LANGEVIN
795 DALE ST
N ANDOVER, MA 01845 4 '
Jam- Expiration: 2/24/2012
('unmiissioner Tr#: 15366
- --✓�e -�0�.7��no�urra;/t o�._/�aaaac�ucae�
Board of Building Regulations and Standards
HOME.IMPROVEMENT CONTRACTOR
Registration*: 111990
Expiration: 2/11/2011 Tr# 280787
Type: LLC i
ROBERT LANGEVIN BLDG 8,REMOLDING LLC.
ROBERT LANGEVIN
795 DALE ST
N ANDOVER, MA 01845
Administrator !�
a
Proposal Page No. of Pages
7�5 Dale Streat
NORR, A,,9 OVER, it-'ASSACHUSEITS 01845
(r yC)
PROPOSA SUBMITTED TO��b �r� �-7 ? t< 6--7
STREET _ JOB NME
S •� /V D --s-r- —T-U--Y,) 'SSS
CITY,STATE and ZIP CODE JOB LOCATION
s-r-
ARCHITECT DAT NS OB PHONE
/lWe hereby submit specifications and estimates for:
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Ric propoSP hereby to furnish material and labor— complete in accordance with above specifications, for the sum of:
Payment to be made as follows: I
�,er& dollars($ .27
All material is guaranteed to be as specified. All work to be completed in a workmanlike
manner according to standard practices.Any alteration or deviation from above specifications Authorized
involving extra costs will be executed only upon written orders, and will become an extra Signature
charge over and above the estimate. All agreements contingent upon strikes, accidents
or delays beyond our control.Owner to carry fire,tornado and other necessary insurance. Note:This proposal may be
Our workers are fully covered by Workman's Compensation Insurance. withdrawn by us if not accepted within days.
Arreptance of Proposal —The above prices, specifications
and conditions are satisfactory and are hereby accepted. You are authorized Signature
to do the work as specified. Payment will be made as outlined above.
Date of Acceptance: Signature