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HomeMy WebLinkAboutBuilding Permit #306-13 - 5 EMPIRE DRIVE 10/15/2012 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: ©cam lDate Received Date Issued: I OR ANT: Applicant must complete all items on this age *4 LOCATION - 5- �M Pl��` Op-lye 4,�f* 32� Print PROPERTY OWNER 0AC9A jZ n U! LL AG 8- 1-6C- Print MAP NO:102C PARCEL/�ZZONING DISTRICT:rJ Historic District yes o Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ew Building ne family ❑Addition ❑Two or more family 0 Industrial ❑Alteration No. of units: 0 Commercial 0 Repair, replacement ❑Assessory Bldg ❑ Others: 0 Demolition 0 Other Ki Se tic 00Well0 Flood j MR 1 Katershedistrict �Jatcr/;Sewer DESCRIPTION OF WO ERFORME� 2! - MuMCIPAL (Identifica ' Please Type or Print Clearly) OWNER: Name: ��// GAO Phone: 3/9�Address 77 SIrJG 14 JTR-C+ y CL AM a 4- n CONTRACTOR Name:. Phone: Address;2777s-1 A) DitJ f'Pr Qaou&L-mio Supervisor's Construction License: Exp. Date: 3I Home Improvement License: '#,�y�Z9 Exp. Date: 9 ARCH ITECT/ENGINEE P.otr7, Phone:97� Address 2 A/NReg. No.=1100 7�s FEE SCHEDULE:BULDING PERMIT:$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Tota! Project Cost: $ FEE: $ �DO Check No.: Receipt No.: 2.5''93 3 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund L gnatbre of Ager UOwne x FFR,Signature�of�conti*acto +� •'"iii t 4 M. _ _ _ - _ _ �a _ _ . r�-_ Location No.-306 '—/ ? Date �0 • • TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ - Foundation Permit Fee $ Other Permit Fee $ TOTAL $ ` Check 25833 130146g' Inspector Plans Submitted Plans Waived ❑ Certified Plot Plan VStarnped Plans I� 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 Si nature 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 yes no Located at 124 Main Street Fire Department signature/date COMMENTS i 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 2008mi 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 o Building Permit Application o Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract o Floor Plan Or Proposed.Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit I Addition Or Decks Li Buildingi Permit Application Li Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Crossection/Elevation Plan.Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o 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) o Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o 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 frust be submitted with the building application Doc: Doc.Building Permit Revised 2008mi r1° NORTH *• _ w. .. . t s u. " ve'. . 0 No. o h ver, Mass, A_ COC NIC Nl W.CM S U BOARD OF HEALTH Food/Kitchen PERM I-T T L D Septic System THIS CERTIFIES THAT � ` BUILDING INSPECTOR ......... .,..:.!G.6.�. :............�.. .F....��. ......... ..................................... r 4,�� /� '. Foundation has permission to erect .........:.......... g ,.ems ....... buildings ....... ........... ..........f.�..... �/..11,�'...................... Rough d� . ��/tobe occupied as ...............r��.....................'Y................... .. Chimney .................................................... provided that the person accepting this permit shall in every respe conform to the terms of the application Final on file in 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough Service ................... . ........................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. Smoke Det. SEE REVERSE SIDE The Commonwealth of Massachusetts r ,�a Department oflndustrialAccidents Pu =fin Office of Investigations , IV U H I 600 Washington Street � •�`= Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit-.Buil!ders/Contractorsll;+lectricians/Plumbers Applicant Information . Please Print'Legibl� NaMe(Business/Organization/Individual):_©PIC_N Address:_2-7-7 WASH ►M cMonj efef City/State/Zip:._q E( UIQ O�� Phone #: 9;7,'' Are you an employer?Check the appropriate box: • Type of project(required): p 1.❑ I am a employer with 4. ❑ I am a general contractor end 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, g []Building addition [NO workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.El Electrical repairs or additions 3.❑ I am a homeowner doing all work right ofexemption per MGL - 11.❑Plumbing repairs or additions myself.[No workers'comp, c. 1,52,§1(4),and we have no 12.[]Roofrepairs insurance required.]i 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 infnmiation. t homeowners who submit this affidavit indicating they are doingall work and then hire outside contractors must submit anew affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors acid their workers'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees: Below is the policy and job 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 ofthis statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby cgjZ&under the pains and penalties ofpefjury that the information provided above is true and cos',r ect.' Si ature: Date: S Phone#: Official rase 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#: I Information. and Instruefi®ns 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 Iicensing 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 PIease fill out the workers'compensation'affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)naine(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 maybe submitted to the Department of Industrial Accidents for confinnation 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 I�eing 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 Deparhnent has provided a space at the bottom ofthe 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 pennit/lieensenumber 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 affidavitmust be filled.out ea ch year. Where a home owner or citizen is obtaining a license or Pen-nit not related to any business n 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 Dgpartm(rnt of Industrial 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's 617-727 7749- Www mass.govldia i'