HomeMy WebLinkAboutBuilding Permit #528-13 - 53 FERNVIEW AVENUE 1/23/2013TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: ✓ vDate Received f
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION 5?J Fern ww Ave • 4
not
PROPERTY OWNER T�_O,( I
r Print 100 Year Old'Structure yes no j
MAP NO: PARCEL: Ob ONING DISTRICT: Historic District ye no
Machine Shop Village Ye�� no
. g
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
epair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septic ❑ Well
❑ Floodplain ❑ Wetlands
❑ Watershed District
❑ Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Identification Please Type or Print
OWNER: Name: Phone:
Arirtracc•
CONTRACTOR Name: (AA� \A�1k Phone:
Address: �6 1112 A4 hi kh 911 03811
Supervisor's Construction License 12 q 6 Exp. Date:
Home Improvement License: 170 9t �> Exp. Date: /Z,7
ARCH ITECT/ENGINEERAt Phone:
Address:
Reg. No.
FEE SCHEDULE. BULD/NG PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ 41 FEE: $ ho -o
Check No.: Q V7 p W bw(-) Receipt No.: 2�p 0K
NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund
`Si nature of A ent/Owner �,L Si nature of contracto
-g - g.. t' 11 g
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
le—
Location
-{ 4
No. rD 2 % r Date , 2zk5
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $.�4"'
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # Z()2 S b 110 "6" "
26108 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
COMMENTS
DATE REJECTED DATE APPROVED
❑ ❑
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comme
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town ]Engineer: Signature:
Located 384
FIRE DEPARTMENT - Temp Dumpster on site yes nc
Located at '124 Main Street
Fire Department-signature/date
COMMENTS
ood 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
NOTES and DATA — (For department use
® Notified for pickup - Date
Doe.Building Permit Revised 2010
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
Addition Or Decks
❑ Building Permit Application
o 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)
❑ 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
o 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)
E3 Copy of Contract
Li 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: Doc.Building Permit Revised 2012
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Workers' Compensation ]
Applicant Information
Name (Bus iness/Organization/Indivi
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, Mass. 02111
www.mass.gov/dia
'ance Affidavit: Builders/Contractors/Electricians/Plumbers
Please Print Legibly
City/State/Zip: 4 Kf050n)VH 0 3 Yl ( Phone#: 6° 3 ' �! R - 6`%/
Are ou an employer? Check th
1. I am an employer with
employees (full and/or part 1
2. Ll I am a sole proprietor or par
ship and have no employees
working for me in any capac
[No workers' comp. insuran
required]
3. ❑ I am a homeowner doing all
myself [No workers' comp.
insurance required] t
*Any applicant that checks box #1 must also
Momeowners who submit this affidavit indi
*Contactors that check this box must attach
the sub -contractors have employees, they me
I am an employer that is providing w
information. I
Insurance Company Name: p
Policy # or Self -ins. Lic. #: f.1
Job Site Address:
Attach a copy of the workers'
)pr priate box:
_ 4. ❑ 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. $
5.0 We are a corporation and its
rk officers have exercised their
right of exemption perm MGL
c. 152, § 1(4), and we have no
employees. [no workers'
cotnp. insurance required.]
out
add
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. ❑ Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12. ❑ Roof repairs
13. ❑ Other
to section below showing their workers' compensation policy information.
°y are doing all work and then hire outside contractors must submit a new affidavit indicating such.
onal sheet showing the name of the sub -contractors and state whether or not those entities have employees. If
e their workers' comp. policv number.
compensation insurance for my employees. Below is the policy and job site
X6'3 053
1
— T City/State/Zip:
Expiration Datej
policy declaration page (showing the policy number and expiration (date).
Failure to secure coverage as requited under Section 25a of MGL 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
$250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the
DIA for coverage verification.
I do herby certify under thepains �ndpenalties ofperjury that the information provided above is true and correct.
Print Name: 40;—? (C( -
Official use only
City or Town:
Date:
Phone #:
Do not write in this area to be completed by city or town official
Permit/license #:
Issuing Authority (circle one):
1.Board of Heath 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact person:
Phone
1999-01-01 00:00
Off
tiomE impRoveMENT CONTRACTOR
Tor
Explration: 1!,R/?PU DSA
i4. . . .....
X�C)NSTRUCTIQTIV`.:
RICHARD WHITE.,
226 NORTH RD
SA t JDWICH, MA 03b3
t1ndersecretary
3,*
CS -097296
YARD C Will.-rf
BOX 1112
I I
iiison N.H 03611
04/01/2014
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9507
Date. .7AI4;:
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
Vp
This certifies that ... eoow,9Xg4
has permission to perform A Wfl ....... lea
plumbing in the buildin sof Avp/
at .............. North/" A4pdover, Mass.
Fee Lic. No..
PLUMBING INSPECTOR
Check #
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY i MA DATE/fir/ ia_ L PERMIT #
JOBSITE ADDRESS OWNER'S NAME'
OWNER ADDRESS A T I TEL FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL O RESIDENTIAL
PRINT
CLEARLY
NEW: RENOVATION: REPLACEMENT: t PLANS SUBMITTED: YES ® NO
FIXTURES 7 FLOOR- BSM 1
2
3
4 5
8 9
10 11 12 13 14
BATHTUB�CROSS
J67
CONNECTION DEVICEDEDICATED
SPECIAL WASTE SYSTEMDEDICATED
GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR (INTERIOR)KITCHEN
&W =' j e P
(.---..-__-
LAVATORY J __-_J-___...__� ..-.__._---!---__._.{ .._.-...._i __..__.l ___ € _-.__.__( .___.-__J _-___--! ..-._..___€ .._ �I ► __..___1
ROOF DRAIN I _.__J _....._._{ .____f .._..-.i J f_.{ .__.__j
SHOWER STALL
SERVICE / MOP SINK
TOILET
URINAL._--.-.___i __.____J __.._.__1
WASHING MACHINE CONNECTION �; _, -€ IF t ;
WATER HEATER ALL TYPES
WATER PIPING
OTHER
I I ! € { t
INSURANCE COVERAGE:
have a current liability insurance its
policy or substantial equivalent which meets the requirements of MGL Ch.142. YES 9-9-011"D
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY O BOND 0
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER O AGENT 10
SIGNATURE OF OWNER OR AGENT
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 plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME (-�_m L_____JjLICENSE# / ,5 , SIGNATURE
MPO € JP M CORPORATION Q# PARTNERSHIP O# LLC E
COMPANY NAME _A,? H,; a►,'rr,� / N !ADDRESS
CITY ��y /nIOUje, cl STATE ZIP b� �y�--- TEL
FAX CELL I EMAIL
W
Q
w
W
LL
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
swww mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information / Please Print Legibly
Name (Business/Organization/Individual): f- //4 Clr'4 nj fl, /T
Address: qtSF 4711i,,'�u S T
City/State/Zip: Y-ee,rPVe-et� ,U // Phone #: 6 O 3 r 3cP } y?oe:�
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
ployees (full and/or part-time).*
have hired the sub -contractors
2. I am a sole proprietor or partner-
listed on the attached sheet. t
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, §1(4), and we have no
insurance required.] f
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11. F1 Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
*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 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 of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains aSj�penalties of perjury that the information provided above is true and correct
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 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 pen-nit/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
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
www.mass,gov/dia