The URL can be used to link to this page

Home My WebLink AboutBuilding Permit #478-14 - 554 FOSTER STREET 12/4/2016TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION_, PROPERTY. OWNER= MAP NO: - :-V 'Print_ - . ZONING DISTrRIC;Historic District Machine Shop, Y0. no: :• yes no .TYPE OF IMPROVEMENT. PROPOSED USE Residential Non- Residential ❑ New Building One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 11 Septic El 1Nell Floodplain ❑ Wetlartls 0 Watershed District El Water/Sewer DESCRIPTION OF WORK TO BE ,PIE-RFORMED: f CAO In0 4-'C _ ('k) �ncrt+�o �Ya on' Identification Please Type or Print Clearly) OWNER: Name: Phone: AfArInnece CONTSRACTOR' Narn _. Address: - WNh Supervisor's Construction. License _ -z� -_ Exp Date Home 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. Total Project Cost: $ U FEE: $ Check No.: � �y Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund §!gEa1LyreiQtk• a-genwner .. ��gqa ure�o :con rac _ , .: Plans Submitted ❑ Plans' ed ❑ U Certified Plot Plan ❑ Stamped Plans ❑ Location 5—� tY � r No. Check # 27155 TOWN OF NORTH ANDOVER Certificate of Occupancy ! $ _ Building/Frame Permit Fee - $� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE_OR SEWERAGEDiSPOSAL Public Sewer ❑ Tanning/MassageBodyArt ❑ .. .Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc_- -❑ -Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOROFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM . DATE REJECTED DATE:APPR-OVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Sianature COMMENTS HEALTH COMMENTS Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Planning Board Decision: Comments Conservation Decision: Comments Zoning Decision/receipt submitted yes Water & Sealer Connection/Signature & Date Driveway Permit DPW To`vo ]Engineer: Signature: Located 384 Osgood Street FIRE DEPARTME-*NT -Tethp Dumpster on site yes_ no Located at .124,Mair, Street Fire Departure►it signature/date COMMENTS " ; . Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area; sq. ft.: ELECTRICAL: Movement of Meter location, roast or service drop requires approval of Electrical Inspector Yep No DANGER ZONE LITERATURE: Yes No - MGL -Chapter -166 Section 21A -F and G min.$100-$1000:fine NOTES and DATA — (For department use El Notified for pickup - Date Doc.Building Permit Revised 2010 Building Department The folr-3wing is-a]ist of the required.forms to be filled out for the appropriate. permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits o,. B,Uilding 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 ❑ 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 apoaal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submAted with the building application Doc: Doc.Building Permit Revised 2012 5556-889 JMNN�i Td OP96-889 HL -Iva 0£56-989 NOLT1aA2Pdg(0o I 96-889 S'T6'd'd lvjo QuvoR, ao!Id=XE[ siauyLoomog auo-q 600Z'L pasrhaa ror� o amama go zVAo"dJTaV MMJ,VN DIS, sxammomqox puE sampaoozd pres'Il�r�t,flduloo rm a s a 'sluaulaxtlrbaz �.uaullzEdaa 9urpitngxahopUV g90X J0 IMO a / q E P� s}uauxaxntbaY puE sampaaosd uoPaadsut uzn�M y PuEszapun arks/ark �n sat�r� zaa «saut�oauio�, Pau$rszapun arty xa o pug a o but suor�Eiti�azpuE saint `sm-ef-kq `sapoo ojgeogddy gd P P PI.TnS a�E�S aq� rpxm saausridulQo _10J f ziTq,Isuodsax saumssE «zaumoaurorj„ pau�Tsxapun aqy oq jou Iieris porxad mqX-oto E M aurot� aua�Eq� azotu o •xaut�oatuoq u paxaptsaoo 01 papua}ur sl xo`si axaqg goTgn� uo `aplsa z 01 spua;ur xo sa Teaspq ri oq�attosxad y* -SO-Ir .omrls STIMP3 oN. so Quo u coq P. q rq w uo puerio laomdE such& oghl (s)uosxa� -daNh10Roff go hioLUMUgCt xaunto age �Eg� paprnozd `asllaoq E ssassad ecu saop oq/A azlggo IEoa nrp! r Tru a4pf �a o,� s a tcr�osrn ran5nxio E o, puE sSa; YO• SlIIIn Ohi1 0; SnuIiiahlp paldn000-IQUTAO apil[OLr off. pg' Go SEIiS «SzauhlOautOT& s0J aoPdruaxa qua un. aTiry saxcrav auoga x101A auoq aulox ss9,ppvl994S -r--) hvla� . 2IaN�O�i1tOkT • - xagutn� - }iaoI gor oxs�az laav ,LnAziad f)MC( .q - Noli-4127 �SI�I��II2T3Nh10�IOH U56-889 (SL6) X - s�urpimg oao�aadsu S-- .S6-889 (8L6) aaogdaiay uaoxg v PIEza.ro -9tSTO s�asn °xanoPUVTl�Iois 9£: G 2�.Tn dui S 009... 9y �y . •y1 � 49 $•� xffAoCKV jawox ao "o,Z �Gal' 3� Enter construction cost for flee cal - North Andover Fee Calculation Construction Cost $ 10,000.00 m $ - $ 120.00 Plumbing Fee $ 15.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 15.00 Total fees collected $ 250.00 554 Foster Street 478-14 on 12/4/2013 Kitchen Remodel The Commonwealth of Massachusetts - Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lep-ibly Name (Business/Organization/Individual): Address: City/State/Zip:, Phone #: 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 1 6. ❑ New construction employees (full and/or part-time).* 2. El am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. # �• E] Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance.9, ❑Building addition [No workers' comp. insurance 5. El We are a corporation and its 10. ❑ Electrical repairs or additions required.] 3. I am a homeowner doing all work officers have exercised their right of exemption per MGL 11. E] Plumbing repairs or additions yself. [No workers' comp. c. 152, §1(4), and we have no 12.E]Roofrepairs insurance required.] 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 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 N 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 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. I do hereby certify unger,the pgIns andpenaldes of perjury that the information provided above is true and correct. Offccial 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 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 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 Mossachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Poston, MA. 0211 t Tei, # 61.7-727-4900 ext 406 or 1-877 MSS.APP Revised 5-26-05 Fax # 617-727-7749 www_mass,govfdaa v C � 5 N 0 ''D O CD 0 Z N CD 0-0 CL r �' 2)o CL >c� N a O 0CD CD O CL cr `< = CCD CD o Go CD C o cn CD CO C � v 0 0 o of-1CD a CD O M Z C) CA 0 O Z-0 c Cl)- no m Z �m C Cl) .- j Z ': W& (7) --i z O v z h co N O 7 CQ O W C: cc CD rt 0 0. Q cn 3 rt 0 " O _ N 0:5 m CO) =�mr- o CD n c_CL o 0• -0 y C T 0 0 CL m S:* � u)i 0 _ m 0 D Q. Cs 0� to Q. U) 0 = r • 3 mom= o CO o0U) 0 ZNm 0,rt� c CL nn�: 0 °'- :• 0 0 C. < 0 (CD 0 W'� �CD r� �CD 0 o � to 00 S CD CD U) CD C� CDN aCD CD' o C 0 Q � I 1 4 -Ln O Ln Z o co f(D m m D m D=j C S D N H i O T N VI M-�t G fD .Z7 C S m r- M m 0 O1 S C o� Z m n O d S_ (D -G O do S O j N O W C Z Z r^ Q N r. rD d n s m W O n r _ v