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HomeMy WebLinkAboutBuilding Permit #756-16 - 461 STEVENS STREET 12/22/2015BUIL®INO PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: l Y� Date Received Date Issued: I oL' IMPORt'ANT: Applicant must complete all items on this page LOCATI KZ-5;� -...-9--�-•- -- �. Elrtrt�©P iffi-N ©W_I-E cA� of o %y06dY}y O 4t LED j �l�r ®� sal 'Q_ <acr�i< <F �• Y Eyes 1 (nom TYPE OF IMPROVEMENT PROPOSED USE Contra or Name-Jut._-j`t' Residential Non- Residential ❑ New Building ❑ Addition ❑ Alteration ❑ One family 'Two or more family No. of units: ❑ Industrial ❑ Commercial ARepair, replacement ❑ Demolition ❑ Assessory Bldg ❑ Other ❑ Others: —TTLf7T7lfl7Septic We IIIA r'Y ,[rr Water/ewer Floodpl, ain INefl nd'r' 4 ` ®1Nater� shedDstrctPi ` DESCRIPTIO.F WORK TO DE PERFORMED: �f�f'�Ul+'`J��s� - Please Type or Print Clearly �4-- OWNER: Name: Address: Phone: ARCH ITECT/ENGINEER—N / Phone: 4 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: $la°, '� FEE: Check No.: Receipt No.: S NOTE: Persons contrac ing with unr%i�spjd contractors do not have access to the guaranty fund Signature of,coritractor Contra or Name-Jut._-j`t' ,.!a7,`7 5�-rr�` =--"- m-�� �._ ErnaIR -.�(Ph.o.ne .I Su e visor sl[C no strop License=} 5, 9 71 ("Home Imp_ro ement Rr ne se i ARCH ITECT/ENGINEER—N / Phone: 4 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: $la°, '� FEE: Check No.: Receipt No.: S NOTE: Persons contrac ing with unr%i�spjd contractors do not have access to the guaranty fund Signature of,coritractor Plans Submitted ❑ Flans Waived.[] Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody Art ❑ Swinnu g 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 e U FORM PLANNING & DEVELOPMENT COMMENTS Reviewed On Signatu CONSERVATION Reviewed on Sianature COMMENTS HEAUH Reviewed on Signature COMMENTS s- . Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Pj inning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature &Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street DEPART TFlipDukmpster,on,site nyes,,;�f , ;#notF� 'd ate 4 Main �� ...� ._. 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 MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine NOTES and DATA — (For department use) [HO I ® Notified for pickup Call Email I f Date Time Contact Name Doc.Building Penait Revised 2014 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 OTE: 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/Cross Section/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 DTE: 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 ATE: 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 2014 Permit iso#: Date Issued: LO•�®N BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received IMPORTANT: Applicant must complete all items on this ®, 4SLED I� •`��� PL TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ Addition ❑ Alteration ❑ One family I�Two or more family No. of units: ❑ Industrial ❑ Commercial + kRepair, replacement ❑ Demolition ❑ Assessory Bldg ❑ Other ❑ Others: ;��.SM; "t''„?"`.'- (® Se 3 ®V1lell I® Water/�ewe- . .v.,,e ,rCF-�y"+w ��y � ®Fl,,�.00 lain" I® Wetlands �j ®V1latershed D'istr`ict " DESCRIPTION OF WORK TO BE PERFORMED: r i11Gi1'� i�7ZI S�'I �/S` '4014w7- S7#,4q//7 S" /fid` /`'nG' ✓ %� Cdr /j��%t.�S i y Identification - Please Type or Print Clearly OWNER: Name: T,>; t_ sM,,Phone: I 111 Address: �ontra.�cto,��Nam�k ..tom, � � .�._:..,..�Pho. e:•�? ��'7��5 G 9 � � E a I� �Atl;�.ress. Supe uas:( sCoh, cttrruct on Lac ne se (5�~ ? ? 7 ? _ s_ Exp a ®ate `� `!0 � '7 i Home Im .. ement"L nse"- " /3t� y � .� x ®ate'. . ARCHITECT/ENGINES Address: Phone: . No FEE SCHEDULE: BULDING PERMIT. $12.0b PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $10oo• "a FEE: $, Check No.: Receipt No.: 4 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fined -------- ------ -- 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 e U FORlilll PLANNING & DEVELOPMENT COMMENTS Reviewed On Signature CONSERVATION Reviewed on Sianature COMMENTS HEALTH COMMENTS Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signafure &Date Driveway Permifi DPW Town Engineer: Signature: Located 384 Osqood Street Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, wast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: lies No MGL Chapter 166 Section 21A —F and G min.$1o0-$10o0 fine NOTES and DATA -- (Fordepartment use) ® Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 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 OTE: 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/Cross Section/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 DTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Perm it'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) o Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products 3TE: 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 Clerics 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 2014 O Z x F•, Q x LL cl: mC C uai E O W of Z Z m O W Vf Z Z O yVj Vf Z u F- W W O W ZLLI Q Z LLI � H a W cc O LL Ln u Ql to oO 'a r O LL O K c t U C u.. s p �' C LL 3 O v N In C LL .7' O d' N C I.l C �. m Z 41 v N cu O N O L CL 4) .c Q �c c w E 0- 0 0 O tm O ca CL �\; O O � � C N i C O C j C-7 O .� O C N m Q E o (D z N=o 0 =o 8 L'o CL 4) 0— W F- v O c = Q L L cc 0 Q O •O LUco _ Ut�m W O 'o O O LLN C F- N "= t O W E v O V U a) 0-0 N CL N� O C F- .� 0 Q 0 V Z C cc _Z U) uia W H W CL w 2 O E i LL ,O O v Z Q O N D C CD CM r- _c � 0 U •� m m CL O �+ d CD 0 L Q CL o Q t .v J Co CL o a) CZ O U N CL U) 0 z QN, I I R I IN www mass.gov/dia sV• Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers- TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/individual): Address: C.iiv/�fiatP/7,in:l.�Gl� /44 Dl0� Phone #: 7/ -?7 %` Are you an employer? Check the appropriate box: 10 I am a employer with employees (full and/or part-time).* 2.KI am a sole proprietor or partnership and have no employees working for me in any capacity. (No workers' comp. insurance required.] 3.FJ I am a homeowner doing all work myself [No workers' comp. insurance required.] t 4.FJ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. Q I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.# 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no, employees. [No workers' comp. insurance required.] Type of project (required): 7. Q New construction 8. [] Remodeling 9. Q Demolition 10 Q Building addition l l.Q Electrical repairs or additions 12. Q Plumbing repairs or additions 13.0 Roof repairs 14.FJ Other *Any applicant that checks box 41 must also fill out the section below snowing meu worxers- compensarrun policy information. T Homeowners who submit #his 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 state whether or not. those entities have employees. If the sub-c6ntraci6rs have employ ees,icy must provide their workers' comp. policy number. lam an employer that is providing workers' compensation insurance for my employees.' ,below is the policy and job site information. Insurance Company Policy # or Self -ins, Lic. Expiration Date:. fob 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 MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby rtify der th s nd enalties of per 'u cc>t'ilie informationprovided above is true and correct. Si nate Date: Phone #: � - �—���'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 The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street, Suite 100 Boston, MA. 02114-2017 www mass.gov/dia sV• Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers- TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/individual): Address: C.iiv/�fiatP/7,in:l.�Gl� /44 Dl0� Phone #: 7/ -?7 %` Are you an employer? Check the appropriate box: 10 I am a employer with employees (full and/or part-time).* 2.KI am a sole proprietor or partnership and have no employees working for me in any capacity. (No workers' comp. insurance required.] 3.FJ I am a homeowner doing all work myself [No workers' comp. insurance required.] t 4.FJ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. Q I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.# 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no, employees. [No workers' comp. insurance required.] Type of project (required): 7. Q New construction 8. [] Remodeling 9. Q Demolition 10 Q Building addition l l.Q Electrical repairs or additions 12. Q Plumbing repairs or additions 13.0 Roof repairs 14.FJ Other *Any applicant that checks box 41 must also fill out the section below snowing meu worxers- compensarrun policy information. T Homeowners who submit #his 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 state whether or not. those entities have employees. If the sub-c6ntraci6rs have employ ees,icy must provide their workers' comp. policy number. lam an employer that is providing workers' compensation insurance for my employees.' ,below is the policy and job site information. Insurance Company Policy # or Self -ins, Lic. Expiration Date:. fob 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 MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby rtify der th s nd enalties of per 'u cc>t'ilie informationprovided above is true and correct. Si nate Date: Phone #: � - �—���'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 r Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS -077036 Construction Supervisor DAVID F DODGE 38 CHAPMAN ROAD WAKEFIELD MA 01 r r r"j-•^K CA— Expiration: Commissioner 09/10/2017 7ky W6MMVv'W_e'a& Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 ----;Boston, -Massackusettsn02-,-!- 1:6 � r N Dome Improvement Contractor Registration Registration: 138375 Type: Individual Expiration: 3/28/2017 Tr# 264432 DAVID F. DODGE DAVID DODGE ------ 38 CHAPMAN RD. - ---- ---- — WAKEFIELD, MA 01680 — Update Address and return card. Mark reason for change. CAI Co 20M-05/11 �� Address -I Renewal ❑ Employment < Lost Card �arrr�irorrrcteal� nf`�a:ua�rire✓t � .�.�. #1egistration: ice of Consumer Affairs & Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: 138375 Type: Office of Consumer Affairs and Business Regulation piration: ,.,:3/28%201.7; Individual 10 Park Plaza - Suite 5170 Boston, MA 02116 )AVID F. DODGE )AVID DODGE S CHAPMAN RD. VAKEFIELD, MA 01880 Undersecretary Not valid without signature