HomeMy WebLinkAboutBuilding Permit #49 - 57 HITCHING POST ROAD 7/17/2009BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: 7 ► Date Received
Date Issued:
IMPORTANT: Applicant must complete all items on this naize
LOCATION $ 7 //,' /- 4 ,'-, 9 Pas 4- 9 V/
PROPERTY OWNER Print /' ° r �� .S�rint
!D Print
MAP NO: 039 PARCEL:0 ZONING DISTRICT: Historic District yes
Machine Shop Villaqe ves
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
Onefame
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 PREFORMED: /►
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Identification Please Type or Print Clearly)
OWNER: Name: -S Phone: -y179
A r -I--
r-%uulVOO. r - . • Tv + m y &,i .
CONTRACTOR Name: _ Qta,n M Cv "s Phone: 97f' J -4f - Y/7 9
Address: IW Ae-41,-r/ A,/ /Q o� Qr �� y /►�
Supervisor's Construction License: 3S Exp. Date: 9 M'2 7
Home Improvement License: I y 7 Fyn nate- Q- v 9
ARCHITECT/ENGINEER /119 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: $ 1,3,Soc� . 00 FEE: $ ��-`0000,
Check No.: 4 2.— Receipt No.: ZZ��
NOTE: Persons contractiftwithi'ez tered contractors do not have access to the guaranty fund
ignature of Agent/Owne Signature of contractor W-,-, �_
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
J' Building Permit Application
r( Workers Comp Affidavit
Photo Copy Of H.I.C. And/Or C.S.L. Licenses
c� Copy of Contract
Floor Plan Or Proposed Interior Work
�yg�Engineering Affidavits for Engineered products
TE: 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 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 2008
Dimension
Number of Stories: o� 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
Doc.Building Permit Revised 2009
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Building Department
The following is a list of the required forms to be filled out for the appro—
i
Roofing, -Siding, Interior Rehabilitation.P-'
cd Building Permit Applicatin- far
Workers Comp Af ;' kO00tP
rl Photo Cope Gel`
Cope -a`ved 5 N'l
r� NI
Pars
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Enginee,
NOTE: All dumpster p
In all cases if a variance or spe
that the appeal period is over.
must be submitted with the buila
Doc: Building Permit Revised 2008
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Dimension
Number of Stories: aZ 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
Doc.Building Permit Revised 2009
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 Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
e
. Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
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
Location "!
No. r Date
HGRT" TOWN OF NORTH ANDOVER
i • G�
:. Certificate of Occupancy $
Building/Frame Permit Fee $ i�
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
222.-3
Building Inspector
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The CommarZweaft of Massachusetts
DePartnteni of Industriar' Accidents
Office of Investi; adons
606 RzashhTMn Street
Boston, MA 02111
Wowraw n2rrss gov1dia ,
rkers' Campensation Iusku-ance Affidavit: Builders/Contractorsmiectriciaas/Piambers
scant Infnrmatian
Name
Address: --
_/(a
i Po
4
PF
city/state/zip:_Q / V ,, /
1 y l -I D,-y*bone
--_-___�-
k.
Are y:,�anjmployer? Cbeek.the appropriate box:
I: ❑ Ia ployer with 4. ❑ I am aQ neralcontractor end I
Type °f P�l�t (rexlair:=e
oy(fun and/or part-time).*
2• arts.a.sole proprietor or
PmPn
have lured the sub -cofactors
listed
6 ❑'New consil construction .
partner-
ship and, have no employees'
on the attached sheet,1
These sub-contaactors have
7. odeling
working for me -in' �}' capacity.
[No woti=' comp, instuan' .
workers' comp. insurance.
S. ❑ We are a corporation and its
g' Demtiiition
9 ❑Building addition
required.]
3. ❑ 1 alit a homeowner doing
officers have exercised their
10.0 Electrical repairs or additions
all work
myseI£ [NO-workiTs' comp,,
P
right of exemption per MOL
C L5 2, § I (A�),'and we have no
11. ❑ Plumbing repairs or additions
insurance -required.] .t
employees. [No workers'
12.Fj Roofrepairs
comp. itzstisanco required.] 13.[] -Other
*Ally
`f►ny appficattt that shanks bo�'!� f must ahio fill out the section beiow showing their workers' oompeesation policy information
who submit this efiitlavh indjading
they an doing all ww* and than hire outside comsat= must submit a new afndavit indi
- ;Canttactors that check this box rnustattecbed an additional sheat show' , oafins such'
ing the name of the sub and their workers' cc s: irfnrmstion
i"'iw
% alc.an enFpioyer that is r» _
{► trratrtg waw&��'
ufornrafio�
. pc..3•
car-pensad6fr nsurance or
i -f nr anPloJ'� B'clow is the poficJ' m+d job site .
Insurance Company Name:
Policy # or Self -ins. Lie. #
Expiration Bate:
Job Site Address:
Attach 8 copy of the workers"com nation CttylState/Zip.
Pe policy declaration page (showing the policy number and ezpiratioa date]
Failure to secure coverage as required under Section 25A of MOL C. 152 can lead to the impos}tion of criminal
fine up to $1,5050.00 .a d and/or one-year irnprisonment; as we12 ELS civil penalties in the form of a STOP Wap , O p � and a fine
in a to tions 0 a day against the violator. Be advised that a copy of this statcment 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 erfary that thein nrntaiion ro
f p vtded above is true and con=
Of -ficial use only. Do not write in (iiia area, m he conrldred
by GICy Or town 0
City or Town;
Permit/License #
Issuing Aufbori{y (circle one):
1. Board of Healtb 2. Building Department 3. City/Town Clerk 4. Electrical Iusnector ; Qs.....c.:__
6.Otbe'r
Contact Person:
Phone #:
Information a lad Instructions
Massachusetts General Laws chapter 152 requires all emp 3 overs 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 ofhim,
express or implied, oral or written."
An employer is defined as "an individuals partnership, assodiation, corporation or other legal entity, or any two or more
of the'fomping engaged in a joint enterprise, and includi"g the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, asaociatiort or other legal entity, employing employees. *However the
owner•of a dwelling house having not morn than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do mail rte:rumce, construction or repair work an 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, 925C(6) also states that "every state oar local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or *o construct buildings in the commonwealth for any
applicant who has not produced acceptable evidenceaiF compliance with the insurance coverage required."
Additionally, MOL chapter 152, §25C(7) states "Neither title commonwealth nor any of its poli€ical subdivisions shall
enter into any contract for the pedbram ce of public work- until -acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the cartt<-acting authority."
Applicants
Please fill out the workers' .compensation -affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub -cont acior(s) name(s), address(es): Arid phone manber(s) along with their certificates) of
in=znce. LimitedLiability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required,to cavy workers' ccsrnpensa#ion insurance. Van LLC or LLP does. have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidam for confirmation of insurance coverage.. Also 'be sure to sign and date the affidavit The affidavit should
be� retuned to the city or town that the application fo;.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 nursiber listed below. Self-insured companies should enter their
self-insurance license oumbw.on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complex and printed legibly. The Department hes 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 numberwhich will be used as a reference number. In additioa, an appiicant
that must submit multiple permit/lic'MM applications in any given year, need only submit one affidavit indicating current
policy :information (if necessary) and under "Job Site Address" time appiicant should write "all locations in (city or
town)." A copy of -the affidavit that has been officially starnped or marked by the city or town may be provided to the
appiicxrit as proof that a valid of-dmit is on file for futmz permits or licenses. A now affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license: or pormitnot related to any business or commercial venture
(i.e. a dog license or permit to bum leaves este.) said person is NOT.required to camplete this affidavit
Tho 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 Commonwm lth of Wmsachusetts
Department of lmdustW Accidents
Office of Lnves6batViotns
600 Washington Street
Boston, 1A 02111
TeL # 617-727-4900 ii= 406 or 1-9.77-MASSAFB
Revised 5-26-05 Fax # 617-727-7744
www.mass.gov/dia
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