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Home My WebLink AboutBuilding Permit #1033-15 - 56 BEVERLY STREET 6/10/2015 17� MU BUILDING PERMIT of NORTH ;tam TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 16�1-15 Date Received ' " Permit No#: � "�RATEo gSSACHUs�� Date Issued:--�J IDI IMPORTANT: Applicant must complete all items on this page LOCATION X576 �EVFP, t-y STn.E-E i PROPERTY OWNER 9 7E7y N R PJ3 t�W(f-H6-'4Q Print 100 Year Structure yes MAP _PARCEL: 33 ZONING DISTRICT: '�y Historic District yes Machine Shop Village yesno 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 I(Assessory Bldg 642466- ❑ Others: X Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: 6fh2 4 E AlyD Cca�v S M UCT IV640 &91e66E i i Identification- Please Type or Print Clearly C- 77 y' 2)8--967,0 OWNER: Name: CTt"V6/ B_ DEaQCP6-/Z Phone/1- 979-2,5'a 2779 Address: SG 31FVER(- S77?-a-7- Contractor 77?-a- —Contractor Name: Phone: Email: Address: a w d - /'-Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PERS 00.00 OF THE TOTAL ESTIMATED COST BASEDON$125.00 PER S.F. Total Project Cost: $ 2��° FEE: $ �� Check No.: Receipt No.: 2-8-16 S NOTE: Persons contracting with unregiste ed contractors do not have access to the guaranty fund Location vp 2 No. Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ , Foundation Permit Fee $� Other Permit Fee TOTAL $ 4 Check# " Building Inspector • ,i 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 COMMENTS I HEALTH Reviewed on Siqnature COMMENTS i i i' Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes a Planning Board Decision: Comments Conservation Decision: Comments Wafter& Sewer Connection/signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRED.ERAR�TtMENTT1Oft�.Dumpster onAsite� eyes __ - noa �. i,L�`ocatedjat 12�,4�(Main a. - Fire Depai;�tmeri�<<signature/d'ate. ..._.- ___ T _,__ COMMLNT& J Dimension i 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) R i I I I ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 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 Copy of Contract Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks 4 Building Permit Application Certified Surveyed Plot Plan Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract ;rF 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 OTE: 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) :rF Copy of Contract 2012 IECC Energy code 4� Engineering Affidavits for Engineered products OTE: 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 Doe:Building Permit Revised 2014 NORTH Town Of E I� Andover No. 1033-- 15 h ver, Mass, e. to 42a 15 COC "ICNl WIC.[ y1' A04ATEO S V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ........0 XQ�/ r>. .N.oCV%e& BUILDING INSPECTOR .... ........... ....... ...................................................................... has permission to erect . Foundation ........................ buildings on ..�....L��'I��. ... ..... p� /�� Rough to be occupied as ....... �..... .. . .... ....? .....2o t.ozA. i.. 1�_ . Chimney his rmit sh in every respect conform to the terms of the application Finalprovided that the person acce in 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 CONSTRUCTIO ARTS Rough Service B DING INSPECTOR Final GAS INSPECTOR Occupancy Permit Required to Occupy.Buildin 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. Bk 14256 Ps 2? 9 Q 112 Town of North AfCve-r1-2015 51a- RECEIVED ZONING BOARD OF APPEAI.$,.,-.,,,,.,,- OFFICE Albert P.Manzi 111,li.sq.Cbeinmin t%ORTH Filen P.McIntyre,Vire-Cbimiaii 1"Ito Richard J.Byers,Esq.Clerk 6 0 2015 MAY 19 AM 9: 16 D.Paul Koch Jr. % Allan Cuscia TOWN 0'7 Associate Members o NiaRTH AINDOVD, Michael P.1,iporto C-T Doug Ludgin c: Dewey Morganthal This is to certify that twenty(20)days have elapsed from date of decision,filed Tmvn Clerk Time Stamp without filing of an appey. Date� joyos A dshaw Any appeal shall be filed within(20) Notice of Decision Town C days after the date of filing of this Year 2015 notice in the office of the Town Clerk, er Mass.Gen.L.ch.40A,§17 Property at: )56 Beverly Street(Map 9,Parcel 33)North Andover,MA 01845 NAME: Steven and Patricia Derocher HEARING(S): 12 May 2015 ADDRESS: 56 Beverly Street(Map 9,Parcel 33) PETITION: 2015-002A North Andover,MAO 1845 The North Andover Board of Appeals held a public hearing at the Town Hall,at 120 Main Street,North Andover, MA on Tuesday,May 12,2015 at 7:30 PM on the application of Steven and Patricia Derocher for property located at 56 Beverly.Street(Map 9,Parcel 33),North Andover,MA 01845. Petitioner is requesting a Special Permit from Section 9.1 of the Zoning By-laws for a pre-existing,non-conforming structure or uses however may be extended or altered and also Variances from Table 2(Dimensional Requirements)for one rear yard setback and two side setbacks(left and right)in the R-4 Zoning District,to raze the old garage and construct a new garage. Legal notices were sent to all the certified abutters provided by the Town of North Andover,Assessors Office,and were published in the Eagle-Tribune, a newspaper of general circulation in the Town of North Andover,on April 28, 2015 and May 5,2015. The following regular voting members were present: Albert P.Manzi 111,Ellen McIntyre,Richard J.Byers,D.Paul Koch Jr., and Allan Cuscia and Associate Member Deney Morganthal. Byers made a motion to Grant the Special Permit from Section 9.1 of the Zoning Bylaw for a pre-existing non- confonning structure or uses however may be extended or altered at 56 Beverly Street(Map 9,Parcel 33), to allow construction for a new garage and to raze the old garage. Cuscia second the motion All in favor to Grant the Special Permit: Albert P.Manzi 111,Richard J. Byers,D. Paul Koch Jr.,and Allan Cuscia, Not in favor: Ellen McIntyre 4-1 approved. The Board finds that this use, as developed by the building and site plans, will not adversely affect the neighborhood. There will be no nuisance or serious hazard to vehicles or pedestrians, since there is provisions for the required off-street parking. Adequate and appropriate facilities are provided to the existing residential dwelling and will be provided for the proper continued operation of the newly constructed garage. The Board finds that this garage will not be substantially more detrimental, and that this use,to allow for the proposed garage is in harmony with the general purpose and intent of this Bylaw. ATTEST- A True Copy Town Clerk . Pagel of Site: 1 56 Beverly Road(Map 9,Parcel 33),North Andover,MA 0 1.845 Petitioner is requesting a Special Permit from Section 9.1 for a pre-existing non-conforming structure and Variances From Table 2 (Dimensional Requirements)for a rear setback and two side setbacks (left and right), located in the R-4 Zoning District to raze and construct a new garage. Plan(s)Title: 1)"Plan of the Land"containing one(1)sheet.Exiting&proposed, Prepared by Sullivan Engineering Group,LLC,22 Mount Vernon Road Boxford,MA 01921 Dated January 8,2015 2)"Proposed Rear Elevation"(Containing one sheet),"Proposed Front Elevation"(Containing one sheet),"Proposed 3-D front elevation"(Containing one sheet), 3)Truss details,E-1(Containing one sheet), Elevations and End Wall Column, and E-2 includes a Front Endwall Elevation ,Right Sidewall Elevation,Rear Endwall Elevation,LeftSidewall Elevation and Endwall Column,(Containing one sheet), Prepared by Stephen P. Maslan&CO,Engineers/Designers 8011 Paseo Suite 201 Kansas City, MO 64131, Dated arch17,20L5 Votmin favor: 4 Manzi,B ers Cuscia,and Koch Voting in the Negative: 1 McIntyre The Board finds that the applicant has satisfied the provisions fi-om Section 9.1 for a pre-existing non-confonning structure and Table 2 (Dimensional Requirements) for a rear yard setback and two side setbacks (left and right) of the Zoning Bylaws in the R-4 Zoning District to construct a new garage at the location of 56 Beverly Street(Map 9, Parcel 33),North Andover,MA 01845. Notes: I. This decision shall not be in effect until a copy of this decision is recorded at the Essex County Registry of Deeds,Norther District at the applicant's expense. 2. The granting of the Special Permit as requested by the applicant does not necessarily ensure the granting of a building permit as the applicant must abide by all applicable local,state,and federal building codes and regulations,prior to the issuance of a building permit as required by the Inspector of Buildings. 3. If the rights authorized by the Special Permit are not exercised within two(2)years of the date of the grant,it shall lapse,and may be re- established only after notice,and a new hearing. I Nor Andover Zoning oard o Appeals Al ert P. Manzi III,Esq., Chairman en McIntyre, Vice Chairman Richard J. Byers, Esq., Clerk D. Paul Koch Jr. Esq. Allan Cuscia Decision 2015-002A Page 2 of 2 Bk 14256 Pa3l -0-13572 06-091-2015 & 11 :51a Town of North Andover i n RFCEIVED ZONING BOARD OF APPEAL�,,,,,, Albert P.Manzi III,Esq.Chairman t%0RTjj Ellen P.McIntyre,Fice-Chairman o`SSLao 1.6. 0 Richard J.Byers,Fsq.Clerk 0 Y_ 2tio 015MAY 19 AM 9: 16 D.Paul Koch Jr. Allan Cuscia TOWH 011" Associate llfmbers xRTHANDOVEIN Michael P.Liporto is rep ACHUSETT'S Doug I,udgjn CHU Deney Morganthal This is to certify that twenty(20)days have elapsed from date of decision,Illed Town Clerk'rime Stamp without filing of an al. 'n Date TSmdsy OY h w Any appeal shall be filed within(20) Notice of Decision irk days after the date of filing of this Year 2015 notice in the office of the Town Clerk, er Mass.Gen. L.ch.40A,§17 Property at: )56 Beverly Street(Alap 9,Parcel 33)North Andover,MA 01845 NAME: Steven and Patricia Derocher HEARING(S): 12 May 2015 ADDRESS: 56 Beverly Street(Map 9,Parcel 33) PETITION: 2015-002B North Andover,MA 0l 845 The North Andover Board of Appeals held a public hearing at the Town Hall,at 120 Main Street,North Andover, MA on Tuesday,May 12,2015 at 7:30 PM on the application of Steven and Patricia Derocher for property located at 56 Beverly Street(Map 9,Parcel 33),North Andover,MA 01845. Petitioner is requesting a Special Permit from Section 9.1 of the Zoning By-laws for a pre-existing non-conforming structure or uses however may be extended or altered and also Variances from Table 2(Dimensional Requirements)for one rear yard setback and two side setbacks(left and right)in the R-4 Zoning District,to raze the old garage and construct a new garage. Legg]notices were sent to all the certified abutters provided by the Town of North Andover,Assessors Office,and were published in the Eagle-Tribune,a newspaper of general circulation in the Town of North Andover,on April 28, 2015 and May 5,2015. The following regular voting members were present: Albert P. Manzi 111,Ellen McIntyre, Richard J. Byers,D.Paul Koch Jr.,and Allan Cuscia and Associate member Doug Ludgin. Byers made a motion to Grant the Variances from Table 2 of the Zoning Bylaw for 56 Beverly Street(Map 9, Parcel 33),to construct a new garage. The Variances are for one rear yard setback,the proposed is 5.2 feet, required is 30 feet(relief is 24.8 feet), also a left side setback and right side setback are needed,the proposed is I foot,required is 15 feet(relief is 14 feet) in the R-4 Zoning District. Cuscia second the motion All in favor to Grant the Variances: Albert P. Manzi 111,Richard J. Byers,D.Paul Koch Jr. and Allan Cuscia. Not in favor:McIntyre 4-1 approved The Board finds that owing to circumstances relating to soil conditions, shape, or topography of the land or structures and especially affecting such land or structures,but not affecting generally the zoning district�M' general, a literal enforcement of the provisions of the Bylaw will involve substantial hardship, financial or otherwise, to the petitioner or applicant. The Board finds that desirable relief may be granted without substantial detriment to the public good and without nullifying or substantially derogating from the intent of the purpose of this bylaw. The Board also finds that this use, as developed by the building & site plans, is an appropriate location for such a use and will not adversely affect the neighborhood. There will be no nuisance or serious hazard to vehicles or pedestrians,since there are provisions for the required off-street parking. Adequate and appropriate facilities will be provided for the newly proposed garage. The Board finds that the proposed.garage will not be substantially more detrimental to the neighborhood and that this use, is in harmony with tho neighborhood and gep-.ral purpose and intent of this Bylaw. ATTEST-. A Tru6 C60 P�f Pagel of2 Town Clerk LAWRENCE, MASS. A TRUE COPY:AT REGISTER Jr'DEEDS ---- -- —-- ----- Tax - RECORD OWNER +APPUCAW fAt- 8 1 OT 15 #50 MARBLEHEAD STREET ASSESSOR, MAP 9, LOT 33: N/F ASi< REALTY TRUST STEVEN & PATRICIA DEROCHER m (Existing) 56' BEVERLY S1 RcE-T. GSTRY OF SEED'S` _ NORTH ANDOVER, MA 01845 ! Nortbom Dbtrkt of Essex SSS S01°04'00"E 5.2' - DEED BOOK 8712, PAGE No. 247 wand '�ded 47.00' �� 6.0' 1 i ,ZO-,. 45.,x'i .—i.3' ENCROACHMENT (EXISTING) wo in---At 4.a i Ex. GARAGE TO BE RAZED �'ci ck� I F�'IA."t NO. Q ( ` 106 LL_ - caq & EX. FRONT GARAGE CORNER �° I N ° .S ON LOT LINE0--) a yam, GRAPHIC .SCALE PROP. 1� 1/2 STORY SCALE: T =20' 2 X 45 FEE 20 0 ?0 �0 FOR RE G/S TR Y OF DEEDS USE ONLY GARAGE L NORTH ANDOVER ZONING YqARPAF APPEALS ' E � ' S LOT .AREA= 9,385 S.r` > oc X - UD � ` m > �.. r! Z rnr- � v)co r ;,-1 -0 Q0 c.� r- v I D U (2) L t U APPROVED _. 20_ CA n w 0 — m -+ ' ZONI>Q lAgLE� 0 n co I PROP. GARAGE ZONING Oi.STR-11T.- R4 REQUIRED 160.2' PROVIDED EX. GARAGE i MIN. L 0 T AR-._A ! 12,500 S.F. 9,355 S.F. ! MAX. HEIGHT ! 35 FEET 20 FEET -- 10 FEET 6.7' i MIN FRONT SETBACK_ I 30 -FT i 160.2 FT 168.8 FT j MIN. SIDE SE TBA CK I 15 FT I 1.0 FT 3 FT � � I I l°EJ`�Ivf?CiACNt�E�V T' { MIN. REAR SE.TBAC:K ?0 FT 5.2 FT * I 6 r G EXISTING i 1.5 5T I * A. VARIANCE iS REQUIRED FROM THE 7BA I STRUCTURE EREB ��r� r rr n r, , tr \L4� 'vLt� I1FY Ir�HT !r-7E PRLIP"E Y ZINE zSHOWN ON THIS PLAN ARE THE LINES DIVIDING I i �.,,, EXISTING OWNERSHIPS, -AND THE LINES OF THE 6.2' I I ##58 STREETS AND WAYS SHOWN ARE THOSE OF PUBLIC 17.2 _ '--- - OR PRIVATE STREETS OR WAYS ALREADY ESTABLISHED, AND THAT NO NEW LINES FOR 17.3' 117.3' Q DIVISION OF EXISTING OWNERSHIP OR FOR NEW _ WAYS ARE SHOWN AND THIS PLAN CONFORMS TO THE N01`30'00"Ut% - 1 J RULES AND REGULATIONS OF THE REGISTRY OF DEEDS- " 50.00' 150.00' -SB W/ I DECLARE; TO THE BEST OF MY PROFESSIONAL PIN KNONIL`DGE, INFORMA TION, AND BELIEF, THA i Ic THIS PLAN WAS PREPARED IN ACCORDANCE �c FOUND WITH THE RULES AND REGULATIONS OF THE REGISTERS OF DEEDS, Imo, BEVERLY (40' W!D ) STREET � f I z PAUL J. -iNOCC.H10, PLS DATE 56 BEVERLY STREET SBDH PLOT PLAN OF LAND € FOUND LOCATED IIV NORTH ANDOVER, MAS►.S'. (ESSEX CO DINT Y) PREPARED FOR Am STEVEN & PATRICIA DEROCHER SCALE: I "= 20' DATE J_AN. �; 2015 1 PREPARED BY C'TTT T TTT 4 AT , AT1� TATPJ ! 7-) TAT;� nF)nTT *-I r 7 r� TOW OF NORM ANDQYM . K OMCE OF _ �•�✓%�. )RING WMT.t7 .NT r • v :' GOD i)5gD0[ SLeB�BR€I[�� 2a 'r�'17x$e`?36 ing : _ 7 p�R•sirn F4p�•[5 NoithAndovmb Massac�Z-asattg 01845 �$�F10E1115��' Gerald A.Brown - Telephone(979)688-9545 lnspeetorofBtiildings Pam (978)6889542 MMMO ER-LICENSEEM&T`ION B"DWG)?FPMT"PLICATION pleaseprinf • , ' ATE: YO_B LOCATION,. aUY-6�L y s �fi 33 Number Stxeet Address map- of ' • OMEGER ,STNV �EI2oClf�2 lf� 97� -SSS - 775' c Y.a/ o 7g x me. 77 5 _ �3omel'hone �J'ork�'I1one -"RESENT MA N•GADDRE 77'EST n/o2 i# 1►1v3)o ve2 �S - C"Tuts . - zp Cods The current exempfzonfoz"liomeownexs°'Wasuxtenaedin cludeownez�oceti ieddfse7lu'rgs�oi�uou ts,;es, d fa allow sub, 3�omco, ffis fo engage au bra.Vadual•for M'e-Who does aotpossess a llmme,provided that the owner acts as supervisor). 8-late-Duilding (CodeSeef_f•on 1�ff,3.5.11 DEIi.INjTjoN OFHOMEOIV; R , Persons)who Qwns aparcel ofland on which Iie/sireresides or Mends to reside,an Whiah there is,or is infended to b�,aoneorfWo�a-cniIysfroetures. A.person.wltaconslr¢ctsznozethat.onehontein;at�eyearperiodslzallnothe considered�.IlOZE1.1e()wrler, , The uudersigaed"3zorneowner"assumes responsibility foz compliances with the Statulhilding Code and outer .Applicable codes,by lam,rales and-iegalations. T.benndersigned`fiomeownee,certtfiesthat be/slieiindersiaudsthe Town ofNori .,AndoverBuil&gDeliarbm at 0in�m,inspecfion.proceduresandrecluirementsandthathejslzewellcomplywithtsaidpzaceduresand requirements, HOMEOWX $$SIGNNrM Q� APPROVAL OF BUJLDWG OFSCAL Revised 7.2009 ' )Fon-anomcowners Bxernption - �Y 30ARD OFAPPEA7�688-9541 •, COhrSERVAMN 688-9530 DEAL' S SMS40 pL.AT1TTWCT fiRR 9;4n The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 q` www mass.gov/dig Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMUTING AUTHORITY. ..Please Print Le 'bi A licant Information Name(Business/Organization/Individual): TSV 6_N 2 E oCJd tic Address: 9(o L r C-E/ 9�t;-�s�-,9779 o18�J,s City/State/Zip: 1 ANS✓t`)e mA Phone#: C- '7741-,218-507e Are you an employer?Check the appropriate box: Type of project(required): If]I am a employer with employees(full and/or part-time).* 7. ❑New'construetion 2.❑I am a sole proprietor or partnership and have no employees working for me in 8 Remodeling any capacity.[No workers'comp.insurance required.] 9.Aemolition 3.�I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 0 ```Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my properly. I will 11.❑Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 12.[�Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 14.[]Other 6.Q We are a corporation and its.officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no empldyees.[No workers'comp.insurance required.] *Any applicant that checks box#1 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 suck tContractors 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: Expiration Date: Policy#or Self-ins.Lic.#: 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 MGL c. 152,§25A is a criminal violation punishable by 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.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 and penalties of perjury that the information provided above is true and correct />l� e• Signature. Dat _ 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 Z.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Phone 0: Contact Person: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their emPto ees. 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-contractors)name(s),address(es)and phone number(s)along with their certificates)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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia Th. Cbmmonwealth o -Massa.chusetts Departm'ent-of Fire Se' rvi.Ges Office of the State Fire Marsha! P.0.Banc 1025 State'Road,.Stow,MA 01775 ' PERMIT Date: North Andover )Permit No Dig Safe Num er -(City of Town) (If Applicable) i In accordance.with the provisions of M GLI 4 8 Chapter, 10 as provided in section S 7 7 C R 3 4 r Stan Date This Permit is granted to:. 41 .S ► 1 f�C� Full name of person,Firm or Corporation Pcrmissionto locate dumpster • for construction/renovation/demolition of building. Comments: dumpster. must be . 25 ` from structure if unable to place with required Acstrictioas:clearance dumps-ter must be covered with plywood or tarp end of 'work -day at (Give Location by s (cet and no.,or describe as to provied adequate identiEcation of 1'ocation) FcePaids 50 .00 Fire Chief This Permit will expire- / (Signature of officesgranting permit) Offica granting permit (Tide) NQ FD 1 0512 Date. poarH o�•` � 9 TOWN OF NORTH ANDOVER RECEIPT C7 cy ,SSgCHUs�� ' This certifies thaw. Z(l &-7..r_ZD,,r..,ezle��4,,Wit..�............... I haspaid�� .:.D. .......................................................................... for (�/!? �:CT� Eirm ..cS'z. EI�L ..... , Received b ............................. Department..... /G .................................................................. Crod WHITE: Applicant CANARY:Department PINK:Treasurer NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: 6 R&Vrn ty ST. is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. - Also, note Permits are required under Fire Prevention laws Chapter 148 Section I OA. The debris will be disposed of in: bJ M1,-V67-V/v lnASS (Location of Facility) Signature of Permit Applicant i /o Date du llp 5-�� t2l?7;7 4 nee- a RECEIPT Printed: June 9, 2015 @ 11:51:17 Essex North Registry M. Paul Tannuccillo Register Trans#: 11288 Oper:LRRECKM STEVEN DEROCHER Book: PL Page: 17296 Ctl#: 106 Rec:6-09-2015 @ 11:51:13a DOC DESCRIPTION TRANS AMT /0 f PLAN ----- --- F/ Surcharge CPA $20.00 20.00 -5-,0-0--IEC+Lf-EE—_ 5 -00--- Plan 0 Plan recording 50.00 Total fees: 75.00 ------------------------------------- Book: 14256 Page: 29 Inst#: 13571 Ctl#: 107 Rec:6-09-2015 @ 11:51:13a �' e C-j a NAND 56 BEVERLY ST P DOC DESCRIPTION TRANS AMT Pe Pr-7 i -� DECISION Surcharge CPA $20.00 20.00 50.00 recording fee 50.00 5.00 TECH FEE 5.00 Total fees: 75.00 Book: 14256 Page: 31 Inst#: 13572 Ctl#: 108 Rec:6-09-2015@ 11:51:13a NAND 56 BEVERLY ST VA )? DOC DESCRIPTION TRANS AMT --- ----------- --------- DECISION Surcharge CPA $20.00 20.00 50.00 recording fee 50.00 5.00 TECH FEE 5.00 Total fees: 75.00 ** Total charges: 225.00 CHECK PM 0000 225.00 I a 4 4 Site: 56 Beverly Road(Map 9,Parcel 33),North Andover,MA 01845 Petitioner is requesting a Special Permit from Section 9.1 for a pre-existing non-conforming structure and Variances From Table 2 (Dimensional Requirements)for a rear setback and two side setbacks(left and right), located in the R-4 Zoning District to raze and construct a new garage. Plan(s)Title: 1)"Plan of the Land"containing one(1)sheet. Exiting&proposed, Prepared by Sullivan Engineering Group, LLC,22 Mount Vernon Road Boxford,MA 01921 Dated January 8,2015 2)"Proposed Rear Elevation"(Containing one sheet),"Proposed Front Elevation"(Containing one sheet),"Proposed 3-D front elevation"(Containing one sheet), 3)Truss details,E-](Containing one sheet),and Elevations and End Wall Column,E-2 includes a Front Endwall Elevation,Right Sidewall Elevation, Rear Endwall Elevation,LeftSidewail Elevation and Endwall Column, (Containing one sheet), Prepared by Stephen P.Maslan&CO, Engineers/Designers 8011 Paseo Suite 201 Kansas City,MO 64131 Dated -- C-11 17-20]-5 ----- Voting in favor: 4 Manzi,Byers, Cuscia,and Koch Voting in the Negative: 1 McIntyre The Board finds that the applicant has satisfied the provisions from Section 9.1 for a pre-existing non-conforming structure and Table 2 (Dimensional Requirements) for a rear yard setback and two side setbacks (left and right) of the Zoning Bylaws in the R-4 Zoning District to construct a new garage at the location of 56 Beverly Street(Map 9, Parcel 33) ,North Andover,MA 01845. Notes: 1. This decision shall not be in effect until a copy of this decision is recorded at the Essex County Registry of Deeds,Northern District at the applicant's expense. 2. The granting of the Variance as requested by the applicant does not necessarily ensure the granting of a building permit as the applicant must abide by all applicable local,state,and federal building codes and regulations,prior to the issuance of a building permit as required by the Inspector of Buildings. 3. If the rights authorized by the Variance are not exercised within one(1)years of the date of the grant,it shall lapse,and maybe re- established only after notice,and a new hearing. Q�— North ndover Zoning oard of Kppeals Albe P.Manzi III,Esq., Chairman Ellen McIntyre,Vice Chairman Richard J. Byers, Esq., Clerk D. Paul Koch Jr. Esq. Allan Cuscia Decision 2015-000B Page 2 of 2