HomeMy WebLinkAboutBuilding Permit #682 - 520 FOSTER STREET 3/28/2012BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued L�
IMPORTANT:
TYPE OF IMPROVEMENT PRC
Res
Ei NA Building
ddition
❑ Alteration
❑ Repair, replacement
❑ Demolition
USE
U,bne family
❑ Two or more family.
No. of units:
❑ Assessory Bldg
❑ Other
Non- Residential
❑ Industrial
Q Commercial
❑ Others:
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❑Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
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�` Ident`�cation Please Type or Print Clearly) C—Irj� /"d3� Z
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ARCHITECT/ENGINEER
Address: Reg. No.
FEE SCHEDULE: BULDINERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ 0f2. 00 FEE: $
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Check No.:
�-o �j Z 1 Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access tye lalkyfund
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Date
'40RT�j TOWN OF NORTH ANDOVER
PERMIT FOR MECHANICAL INSTALLATION
This certifies that -4 A
has permission for mechanical installation ...
in the buildings of �A. 14�;. ........
at ............ North Andover, Mass.
Fee. Lic. No ............ ....... 130�1� ........
GASINSPECTOR
WHITE: Applicant CANARY: Building Dept. . PINK: Treasurer
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
Tanning/Massage/Body Art ❑
Seng 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
PLANNING & DEVELOPMENT ❑
COMMENTS
4
CONSERVATION
COMMENTS
HEALTH
COMMENTS
X
DATE REJECTED
DATE APPROVED
El
DATE REJECTED DATE APPROVED
DATE REJECTED DATE APPROVED
❑ ❑
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comments
Conservation Decision: Comments
Water & Sewer Connection/Driveway Permit
Located at 384 Osgood 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, 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
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
❑ 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
o 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
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The Commonwealth of Massachusetts -
Department of lndustriglAccidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):.
Address: 07 e) dle�sh' Gt-
City/State/Zip:hn,16v�, /yjA Phone #: q76 -,5908-7A,)-4,
Are you an employer? Check the appropriate box:
Type of project (required):
1. K I am a employer with 3
44. ❑ I am a general contractor and I
6. ❑ New construction
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partner-
have Hired the sub -contractors
listed on the attached sheet. #
?• ❑ Remodeling
ship and'have no employees
These sub -contractors have
8. ❑ Demolition
working for me in any capacity.
[No workers' comp. insurance
workers' comp. insurance.
5. El We are a corporation and its
9. El Building addition
required.]
officers have exercised their
10. El 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.] i
employees. [No workers'
1313.2i OtherA /
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
I Homeowners who submit this affidavit indicating they aie 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.
lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. I/
Insurance Company
Policy # or Self -ins. Lie. #: O
TF -69D -f'IRE ( i4 Su4L--r
W E C LA4 q 14 3 Expiration Date: 10/2-3 /,)-
Job Site Address: �2� ° s -a— Sl • City/State/Zip: Q i8
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as requiredunder 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.
Ido hereby certio rider the pai andpenalties o rhat the information provided above is true and correct.
Si ature: �j Date:
Phone #:
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
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 j oint 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 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 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 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 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 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 ofIndusttial Accidents
Office of In-Vestigations
6.00 Washington Street
Boston, MA, 02111
Tel # 617-727-4900 ext 406 or 1-877:MA.SS.A.BB
Revised 5-26-05 Fax # 617^727-7749
www.mass.gov/dia
Commonwealth of Massachusetts
kk Sheet Metal Permit
Date: � U
Estimated Job Cost: $ �,qoo
Plans Submitted: YES NO
Business License #
Business Information:
Name:
Street: �.'.1
City/Town: 'j
Telephone:
Permit #
Permit Fee: $
Plans Reviewed: YES NO
Applicant License
Property Owner / Job Location Information: ji)
l t
Name:
Street:
City/Town: 4 Ft
Telephone:
Photo I.D. required / Copy of Photo I.D. attached: YES NO
Staff Initial
J-1 -1-unrestricted license
J-2 / M -2 -restricted to dwel ngs 3 -stories or less and commercial up to 10,000 sq. ft. / 2 -stories or less
Residential: 1-2 familyy Multi -family Condo / Townhouses Other
Commercial: Office Retail Industrial Educational
Institutional Other
Square Footage: under 10,000 sq. ft. over 10,000 sq. ft. Number of Stories:
Sheet metal work to be completed: New Work: Renovation:
HVAC -x./ Metal Watershed Roofing Kitchen Exhaust System
Metal Chimney / Vents Air Balancing
Provide detailed description of work to be done:
Qi1 U
3 SPE" _Rq
F
SURANCE COVERAGE:
ve a current liabili insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes ❑ No ❑ou have checked Yes, indicate the type of coverage by checking the appropriate box below:
A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
Owner ❑ Agent ❑
Signature of Owner or Owner's Agent
By checking this box0, I hereby certify that all of the details and information I have submitted (or entered). regarding this application are true and
accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be
in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws.
Duct inspection required prior to insulation installation: YES NO
Date
Date
By
Title
City/Town
Permit #
Fee $
Inspector Signature of Permit Approval
Progress Inspections
Comments
Final Inspection
Comments
Type of License:
❑ Master
❑ Master -Restricted
❑Journeyperson
❑Journeyperson-Restricted
Signature of Licensee
License Number:
Check at www.mass.gov/dpl
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-915ZZIT
Sheet Metal Residential Guidelines / Inspection Checklist
Yes No N/A
Detailed description and sketch of sheet metal system to be installed has
been provided
All workers performing sheet metal work onsite has valid Massachusetts
sheet metal license
All sheet metal work being performed with proper journeyperson-to-
apprentice ratios
Equipment sized per heating / cooling load calculations
' uct work sized per manual "D" calculations
Bath / shower rooms contain mechanical exhaust fan vented outdoors
Electric dryer exhaust properly installed maximum total run 35'-0",
maximum flexible run 8'-0"
Flexible duct runs installed 14'-0" maximum length
Volume dampers installed for each supply air branch duct
Ductwork installed using proper gauges and hangers
Ductwork / plenum connections sealed substantially airtight
Ductwork insulated by means of external covering or internal lining
New/clean - properly sized filter installed (final inspection)
Testing and Balancing report complete (final sign -off)