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HomeMy WebLinkAboutBuilding Permit #363-15 - 521 DALE STREET 10/16/2014 t%ORT11 BUILDING PERMIT °�<t�eO "tio TOWN OF NORTH ANDOVER ,,__-APPLICATION FOR PLAN EXAMINATION10 / _ '~ Permit No#: 1 Date Received SSACHU`-+� Date Issued: /IMPORTANT:Applicant must complete all items on this page LOCATION Print � y PROPERTY OWNER 5z I ;�- t Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT:`Historic District ye n Machine Shop Village ye no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building -k-One family ❑Addition ❑ Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial 41kRepair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: py� V Identification- Please Type or Print Clearly OWNER: Name: Js., vrA, Phone: Address: 52\ -C v e Contractor Name: Phone: Address:���������enuc: ,, \.K(enuic, '�1� Supervisor's Construction License: -Ts '&-1 Exp. Date: -7--mss Home Improvement License: LS-1 a 09 Exp. Date:��. ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON 25.00 PER S.F. Total Project Cost: $����FEE: $� Check No.: ( ) R1 Receipt No.:��� NOTE: Persons contracting with unregistered contractors do not have access to the guara> und rT c Signature of Agent/Owner Signature of contrac +UM, � rLocation No. Date . - TOWN OF NORTH ANDOVER a '4 Certificate of Occupancy Building/Frame Permit Fee it e v Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# 28139 Building Inspector 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 PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature CO3MKOENTS 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 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 Call Email Date Time Contact Name Doc.Building Permit Revised 2014 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/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 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 ❑ 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 2014 � NORT►.r Town of s EAndover o " - to No. - �� Z o�h ver, Mass, coc"Ic"awicw 1' S U BOARD OF HEALTH Food/Kitchen PER Septic System THIS CERTIFIES THAT ............... .. .. �„ BUILDING INSPECTOR T T L D Foundation has permission to erect .. ...... buildings on . ............... . ...... . .. .....Date. ... .... ........... • Rough to be occupied as .a.. .....S, 4..... ... awl .... Jr. . .... � ..rPation ........ Chimney provided that the p o ccepting this permi all in every respect confor the terms of thion Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, 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 I MO ELECTRICAL INSPECTOR . UNLESS CONSTR TS 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. i Massachusetts - Department of Pubic Safety Board of Building Regulations and Standards t.un.n•urti ,rt Sup�nirn _:cense. CS-098189 TIMOTHY F OSUJUVAN 45 FARDON STREET BILLERICA MA 01821 07/28/2015 ...Office of Consumer Affairs&Business Regulation License or registration valid for individul use only TOME IMPROVEMENT CONTRACTOR before the expiration date If found return to: klegistration: 156094 Type: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Expiration: 6/4/2015 DBA Boston,MA 02116 YSULLIVAN INSTALLS TIMOTHY O'SULLIVAN 45 FARDON ST 31LLERICA,MA 01821 Undersecretary id without signature .d a A�R©® CERTIFICATE OF LIABILITY INSURANCE DATE(MAAIDD/YYYY) 6/25/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. if SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER FRED C CHURCH CONTACT 41 WELLMAN STREET PHONE FAX LOWELL, MA 01853 E-MAIL `�"°' ADDRESS: INSURERS AFFORDING COVERAGE NAIC# INSURER A: Liberty Mutual Fire Insurance 23035 INSURED INSURER B: TIMOTHY F OSULLIVAN DBA OSULLIVAN INSTALLS INSURER C: 45 FARDON STREET INSURER D: BILLERICA MA 01821 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 20638731 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR I TYPE OF INSURANCE ADDL SUBR POLICY NUMBER MM/DD/YLICY YYF MWDD/YYYP LIMITS LTR COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE F1 OCCUR PREMISES Ea oc�vrrence $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑jE O- LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY MBINED SINGLE LIMIT EaCOaccident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED L SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Peraccident UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ A WORKERS COMPENSATION WC2-31S-379398-034 2/20/2014 2/20/2015 ,/ STRTU E ETH AND EMPLOYERS'LIABILrrY ANY PROPRIETOR/PARTNERIEXECUTIVE Y/N E.L.EACH ACCIDENT $ 500000 OFFICER/MEMBEREXCLUDED? ❑Y N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 500000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500000 DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached it more space is required) THE WORKERS COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR TIMOTHY F OSULLIVAN. This Certificate cancels and supersedes all previously issued certificates,only as they relate to workers Compensation coverage. Workers compensation insurance coverage applies only to the workers compensation laws of the state of MA. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Liberty Mutual Fire Insurance ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD CERT NO.: 20638731 Anne Chandler 6/25/2014 9:07:42 AM (EDT) Page 1 of 1 �`� CERTIFICATE OF LIABILITY INSURANCE 06„8�t4MMIDD/YYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Susan Merriam Fred C.Church,Inc. 41 WellmStreet PHONE 97832272% (FAA/C. (978)454-1865 an Lowell,man E-MAIL (800)225.1865 ADDRESS: smeniam@tredcchurch.com INSURERS AFFORDING COVERAGE NAIC 8 INSURER A: USLI-United States Liability Insurance Company 25895 INSURED INSURER B Timothy F O'Sullivan,DBA O'Sullivan Installs INSURER C: 45 Fardon Street Billerica MA 01821 INSURER 0: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:30106 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL UBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MIDDNYY MIDD/YYY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES EaTUWEoccumence $ 1�'� CLAIMS-MADE a OCCUR MED EXP(Any one person) $ 5,000 A CL1640148 2127/2014 2/272015 PERSONAL 8 ADV INJURY $ 1'�'� GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2'000'000 POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS UAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION WC STATUUMT- I OTH- AND EMPLOYERS'LIABILITY Y/N EfL ANY PROPRIETOR/PARTNER/EXECUTIVE❑ N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,it more space is required) CERTIFICATE HOLDER CANCELLATION ~" SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Clients Mst# Cert Holder# ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents u Office of Investigations w c l Congress Street,Suite 100 vpa Boston,MA 02114-2017 M y" www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): O'Sullivan Installs Address:45 Fardon St City/State/Zip:Billerica, Ma 01821 Phone #:978-994-5027 Are you an employer? Check the appropriate box: Type of project(required): 1.0 1 am a employer with 3 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. E]New construction 2.El am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.+ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ 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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:Liberty Mutual Fire Insurance Policy#or Self-ins. Lic. #:WC2-31 S-379398-034 Expiration Date:2-20-15 Job Site Address: ,'S2-� 19r_ fim City/State/Zip:.A), ©t% 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do here ertify under the pains and penalties of perjury that the information provided above is true and correct. Si ature: Date: 1 —1 Phone#: 978-994-5027 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority (circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: O'Sullivan ' Installs / WINDOWS - SIDING - DOORS Q .A. Billerica, MA 01821 888-8716-3777 Date: V ) CUSTOMER INFORMATION � / j f I- Q^u.`d �i ►ll Ko rQ Home Phone# f,1 t+"7(� CO d� "q� �� 7 �t Work/Cell# i b -T7 6t 1 [ Z] NJ A o d o y t e M& 01 `29 S Work/Cell# + iation Address E-Mail SIDING&TRIM WRAP WITH PVC COIL Siding Strip Gutters Soffit&Fascia Frieze Board Soffit Only Fascia Only Qty *COLOR* Front Front Fron Front Front Windows/Doors Left Left ' 0 ..... L.e,ftLift— L°eft Left Garage/Patio Door Back Back too Bn B Back Back PORCH CEILING Right Right R' Ig Right RtM "` Right Traditional Soffit Color: OtherfL( '41 Other Other Calor Color Color Cblork.�@ Beaded Soffit Color: CODE INFO NEW SHUTTERS COLOR AND STYLE F L B R #of Pairs *COLOR* Siding Typ A!r h ' Corner Insulation = == 4Louvered Profile '1 ,J"/J-+0r- Color m 5'J Year House Built Meter . Raised Panel Color W4A A_Q IRCt,other If rotted wood is discovered AFTER removing the existing siding,or if it could not be identified at the time of sale there will be an additional charge of$ per Sq.Ft.for Plywood and$ per Lin.Ft.For Dimensional Lumber. EXCLUSIONS: ADDITIONAL SPECIFICAT_IO_,1(NS: 1`�,-,�Q1�"+ 4- BN C- j` a n {h�C��j�rC L b (v KAkf �R,r&.� 1 P_ft �'Q t44 ` � l`ST rne,.n ha V;:�� @ CUSTOMER RESPONSIBILITIES: I Remove all items on interior walls,shelves,cabinets that may vibrate and fall due to work being done, pull back or cut shrubs surrounding the outside of the house to allow for a minimum of 18 inches.7 .�1 O'Sullivan Installs will remove and dispose all project related debris and provide material as sepecified above.O'Sullivan installs maintains proper liablility and Workers'Comp Insurance.Binders available upon request.O'Sullivan Installs honors all manufacturer warranties and offers a five year craftsmanship warranty. O'Sullivan Installs will obtain all permits and will be reimbursed by the customer for said permits and any city/town fees. You may cancel this transaction,without penalty or obligation,within three business days(excluding Sundays and Holidays)of the date of this transaction.To cancel this transaction,mail or deliver written notice to O'Sullivan Installs,45 Fardon St,Billerica,MA 01821 no later than midnight of the third day of this transaction(excluding Sundays and Holidays).After the third day there will be a service charge equal to 25%of the total contract. DELIVERY LOCATION MATERIAL Df','v e wpm, DUMPSTER br,✓e (� / � s Authorized By: .� I- t n1.� PernlwO'Sullivan Installs ACCEPTANCE OF PROPOSAL PAYMENT _ authorised to do the work a The above prices,specifications and conditions are satisfactory and are hereby accepted.You are ! Total Investment (�SQQ TYPE specified.Payments will be made as outlined. Deposit (1/3 at signing) • 4�2 Signature: �-1. Date: Balance (2 13 letio �� g ( / p GE account# S348 1217 3066 4297 Signature: Date: Finance Code f tAORTH q 61 6 ' BUILDING PERMIT -Ari TOWN OF NORTH ANDOVER ° APPLICATION FOR PLAN EXAMINAT * - H Permit NO: Date Received /' 9q��•,�.,:K. �q SgcNus���y Date Issued: IM O TANT: Applicant must complete all items on this page "�n'. tz4CATl A' , Qi rtq� W� -�S �'�'r Y�}�.+.! J tt o , �' &ar}f I MAP NO P RCEI'` ZONING QISTRICT istoric District" yes to » ,., n.� t x" n Machine Sho Villa' e . es no V '. TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial Iteration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Sepic � !!n;- #, opfain' �?, tr ,, Ta. Q 1Na rr%Sewer,* r, R r �,; } ,, �: n.a ,p,:• `"'l^�� t�•�J� V L� Identification Please Type or Print Clearly) OWNER: Name: Q� 0_0\.6 1 �fiOr'Cti. Phone: Address: �... r ' CANT T � , { Ev y r��+#`$ �' 7}.:, � !" r`r w �` t d' Nt ":i `°"�-} j r�, Agdres aka 1 }rr f il� R� «£ S�p� Isar Gc�►�'s� � ,r�� t, �� t � ��� h�Mi����er�� � ��,� �����.��� ' 1-joQ Mri� iN x iFCmx Et,��� NX Date ti� k t� -a F' �r�.`� ;.�, � h� �.,L+ 'rrrH'1 r�;ui�u��1i rE'�i.4„� [.� ����P �'(l, w”a- Y•'(���^>•, t' 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. A Total Project Cost: $ 100o FEE: $ Ch o.: Receipt No.: NdTE: ratting with unregistered contractors do not have access to the guaranty fund i Signa ure-of Agent/Owner R• V Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ I TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swinuning 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 Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS 4 Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments 1 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 j 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 Call Email Date Time Contact Name - ._._..___. Doc.Building Permit Revised 2014 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 o Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ 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 Addition Or Decks o Building Permit Application a Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Cross Section/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) Lr Building Permit Application o Certified Proposed Plot Plan ❑ 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) a Copy of Contract o 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:Building Permit Revised 2014 Location e C42-0A No. Date 7 • - TOWN OF NORTH ANDOVER Gc v Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# 2-730 • r r• �, � 2 ! , 24. Building Inspector NORTJI Town of 2 : t Andover No. - - *� o h ver, Mass >1 A coc«ic«ewIcw a. 7,95 r#A Te o 0 A��5 U BOARD OF HEALTH PERMIT. LD Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT ............... *4 ..... Q.. ... .........:.......,........................ ........................... , . Foundation has permission to erect .......................... buildings on ....W.A ...Dxlew..,,, '�......,,, ,��,,,,.�ee , to be occupied as '� .. 0 .. . .rl t'!�?�,►.. . .. Na... ........... .. • Chimney t Rough heY provided that the person accepting this permit shall in every respect conform to the terms ohe a lication p pp 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCT 'S TS Roug h 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. t NORTH Town of �.. s E Ir ndover o No. D - 11 th ver, Mass %1 AH 7qCOCMICN11WICK A04ATED s U BOARD OF HEALTH Food/Kitchen PERMI-T T D Septic System 00, THIS CERTIFIES THAT ....... �.. ... BUILDING INSPECTOR ....... ... � .... ...... ......................... .... . . ........ .... ......... .. has permission to erect .......................... buildings on ....Wi.... .. Foundation . '!. '� ^4..V�. �..1:t:�1!.. .�! ., ........ Rough to be occupied as t • Chimney provided that the person accepting this permit shall in every respect conform to the terms o1he 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCT S TS 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. or; TOWN OF NORTH ANDOVER N ►� r OFFICE OF .� BUILDING DEPARTMENT * 1600 Osgood Street Building 20, Suite 2-36 North Andover,Massachusetts 01845 9SS�1C14 Gerald A. Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION Please print DATE:August 20, 2014 JOB LOCATION: 521 Dale Street Number Street Address Map/Lot HOMEOWNER David Sikora 978-682-6376 978-749-3227 Name Home Phone Work Phone PRESENT MAILING ADDRESS 521 Dade Street North Andover Mass 01845 City Town State Zip Code The current exemption for"homeowners"was extended to include owner-occupied dwellings to two units or less and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned homeowner assumes responsibility for compliances with the State Building Code and other Applicable codes,by-laws,rules and regulations. I The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures irements and that he/she will comply with said procedures and requirements. HOMEOWNERS SIGNATURE —ZLz 2 Ok APPROVAL OF BUILDING OFFICIAL I Revised 10.2005 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 v�� lrrc �,vnrrnvrrrvcuurr vJ ir�ua�ua.rru�cu� � ■ Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 c Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): David Sikora Address:521 Dale Street City/State/Zip:North Andover, Mass 01845 Phone#:978-682-6376 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 employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction ?.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑✓ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition workingfor me in an capacity. employees and have workers' Y P �'• 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions ;.❑✓ 1 am a homeowner doing all work officers have exercised their 11. Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no Repl door employees. [No workers' 13.0 Other comp. insurance required.] p q 4ny applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ,ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have nployees. If the sub-contractors have employees,they must provide their workers'comp.policy number. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site iformation. isurance Company Name: olicy#or Self-ins.Lic.#: Expiration Date: )b Site Address: City/State/Zip: ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 f up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Ivestigations of the DIA for insurance coverage verification. do hereb certi under the andpenalties ofperjuty that the information provided above is true and correct. i nature: 1 ---- - — - Date: T'2_0 -, zooc hone#: 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 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 an questions regarding the law or if you are required to obtain a workers' Y any g g Y q 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 of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Zevised 7-2010 www.mass.gov/dia