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Home My WebLink AboutBuilding Permit #28-12 - 55 PARK STREET 7/13/2011 f TOWN OF NORTH ANDOVER r APPLICATION FOR PLAN EXAMINATION Permit N0: L /Z Date Received Date Issued:, IMPORTANT: Applicant must complete all items on this age LOCATION S`5- P�Q_� S-T _ Pr'nt PROPERTY OWNER t R( ?S2\) S Unit# Print MAP NO: PARCEL:�ZONING DISTRICT: Historic District yae Machine Shop Village y100 year-old structure y TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New BuildingOne family ElAddition wo or more family ❑ Industrial ❑Alter tion No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer DESCCRIPTION OF WORK TO BE PERFORMED: c � (Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: CONTRACTOR Name: 4/1 C X d lG S �21e�� Phone: r Address: (�(S �i� �Sl�� c�' S7- � J`�c , e 1 (ty Supervisor's Construction License: 'S f(4 Exp. Date: Home Improvement License: Exp. Date: 9�- a o/ i ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ d FEE: $ 30 Receipt No.: Check No.: (f —� _z 0_`f 3 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on I Signature COMMENTS HEALTH Reviewed on Signature i 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 - Date f Doc:.Building Permit Revised 2011 June/mi J 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 o 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 ❑ 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 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.2008mi i Location . 7 No. w 1 Date- //- 13 ^ NQRT" TOWN OF NORTH ANDOVER + • , Certificate of Occupancy $ aCMUs<�' Building/Frame Permit Fee $ { Foundation Permit Fee $ r Other Permit Fee $ TOTAL $ Check # 2 �rJU .J Building Inspector NORTIy � ToNvn of over O No. 8 - - _ CON o , �` lover, Mass., Q - IAKE COCMICHEWICK DRATED AP�t�S U ` BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT........CAN.Wodo.......... .....,5.%- . ...... ... ..., .. .... Foundation has permission to erect buildings on ....... ............ .... ......... .... Awl.......o... .....�.. Rough p ,- ..... t0 be occupied as........ �!!,.,, Chimney .............. ......... .. . ..... .. .. .. ....................... provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final 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 NTHS ELECTRICAL INSPECTOR UNLESS CONSTRU ST S Rough ................................................................................................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To BeDone FIR_E-DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner - Street No. SEE REVERSE SIDE Smoke Det. Mari n�on onstru Ct i Date:June 14,2011 Homeowner Information: Carrie PszyBysz 55 Park St. No. Andover Ma. 01845 Contractor Information: Marion Construction Nicholas Marion 615 Prospect St Methuen Ma.01844 Construction Supervisors License#085497 Exp.8/19/12 Home Improvement Contractor Registration# 141257 Exp. 1/27/12 WORK TO RE PERFORMED AND MATERIALS USED Contractor agrees to do the following work for homeowners: See attached proposal# 1520 Anything else is excluded Materials expected to be used: pressure treated lumber for entire porch The following schedule will be adhered to unless circumstances beyond the contractor's control arise: Expected date of completion: Work schedule to begin: TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE: above for The contractor grees to perform the work,furnish the material and laspecified the SUM OF $1,790.00 Payments* will be made according to the following schedule* *Please make checks a able to Marion $250.00 Deposit to be or start pt of project on signing $750,00 one week be 790.00 Due upon com Ip etion DO NOT SIGN THIS CONTRACT IF THERE ARE tANY BLANK SPACES yPle_ase_ma_ke sure to si n all three d �e� Date: *****Homeowners Si nature Date: A Contractor Signature NORTFf 9 Town of over 00 o , '� dover, Mass., O - LAKE COCMICMEWICK V �dSDRATED AP�t 77 U \\ BOARD OF HEALTH PERMIT T Food/Kitchen Septic System • BUILDING INSPECTOR THIS CERTIFIES THAT......... ��.......... 5... .... ...... ... ... .. ..Av* ........................................ Foundation has permission to erect ..................... buildings on ....... ......... .............. ....... Rough 4LMMMMMM to be occupied as*""*?" W** i �!!...........T .. .. Chimney ........................................... provided that the paraccepting this permit shall in every respect conform to the terms of the application on file in Final 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 NTHS ELECTRICAL INSPECTOR UNLESS CONSTRU ST TS Rough Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do- Not Remove Final No Lathing or Dry Wall To Be Done FIREDEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 'Y www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leg><bly Name(Business/Organization/individual): Address: City/State/Zip: ,I� &1-1 A. phone#: S- - 3 a� Are you an employer?Check the appropriate box: 1.❑ I am a em to er with 4. FTE] f project(required): p y ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors New construction [2.P I am a sole proprietor or partner- listed on the attached sheget. t Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity, workers'comp.insurance. [No workers comp.insurance 5. 9. E]Building addition ' p ❑ We are a corporation and its required.] officers have exercised their 10.❑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 El Roof repairs required.]temployees. [No workers' comp.insurance required.] 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: V6 Policy#or Self-ins.Lic.#: y_/ P6 Expiration Date: Cal Job Site Address: �'� ��2(C S , City/State/Zi : /IK/ r c CNer2 V TG, 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. Ido hereby certi j and Ithe sins an pena ties ofperjury that the information provided above is true and correct. Si nature: Date: Phone Official use::Dnrite in this area,to be completed by city or town official. City or TowPermit/License# Issuing Aute):1.Board of ing Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.OtherContact PerPhone#: 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 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 Gomrlaonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1877-MASSAFE Revised 5-26-05 Fax#617--727-7749 www.mass.gov/dia ulatio`n Office of Consumer rCONTRACTOR �- HOMEIMPROVEMENT Registration: A0257 TO 292672 Expiration= "112712012 Type - Individual ONS'C[�uCTION MARION C NICHOLAS 309 MT•VERNON Undersecretary Lp WRENCE MA 01843" - Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License License: CS 85497 NICHOLAS T MARION 615 PROSPECT ST ! METHUEN, MA 01844 i Expiration: 8/19/2012 Comillissiuner Tr#: 1392 1