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Home My WebLink AboutBuilding Permit #144-16 - 59 SUMMER STREET 7/31/2015 f BUILDING PERMIT o NORTH qti TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATIONto 44 Permit NO: Date Received 0NAre o0, 4y �SSACHU`�E� Date Issued: (17 IMPORTANT:Applicant must complete all items on this page LOCATION_ Print PROPERTY OWNER Print MAP NO: �PARCEL: ZONING DISTRICT: Historic District yes n Machine Shop Village yes o TYPE OF IMPROVEMENT PROPOSED USE Res i Non- Residential New Building, One famil Addition Two-or more family Industrial tec 'on No. of units: Commercial Repair, eplacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer P PTI DESCRIN F WORK TO BE PREFORWD: W l'1 GC lrti $r' C 2 1�a Li1-�v,25 u, 0V k�r d4 e-, Identification Please Typ or Print Clearly) OWNER: Name: oc re Phone: / Address: CONTRACTOR :Name: C-� �kNl. Phone: 7Ao2 .^. Address: `r�1 U . ..._ Supervisor's Construction License: ff3 Exp. Date: ya r I . N Horne Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT.$12.00`PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F, 11V� �. Total Project Cost:'$ I d FEE: $ Check No.: Iy Receipt No.: NOTE: Persons contracting with unregistered c ntractors do not have access to the guaranty fund Signature of Agent/Owner ' Signature of.contractor . 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 1 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS , HEALTH' - Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes r 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 _..._......_..................................................................__ __.._.-__........._......................................._.................__.................. Doc.Building Permit Revised 2008 ,r 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 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 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 I � _ ._ .__ _� w...- .,ter _�_ ..-- �--�- •. ------ , Location ` .a No. Date • = TOWN OF NORTH ANDOVER • Certificate of Occupancy $ Building/Frame Permit Fee $ s Foundation Permit Fee $ ,^ Other Permit Fee $ t TOTAL $ i Check# t ~' 2 ' 14 3 Building Inspector r 1 NORTH w _ : ve. . 0 1 � No. '1 21 * ZkAh ,ti ver, Mass, o �A COC NICNl WIC 1{`y� t ORATED y S U BOARD OF HEALTH I' 1 Food/Kitchen P111E RIT T LD Septic System THIS CERTIFIES THAT .....MO..� ..�. .�f.A................................................................................. BUILDING INSPECTOR � Foundation has permission to erect . .................. buildings on ....:�••�•..... . �'!' .... ..................... Rough t0 be occupied as ...... ..... ..�. ! a�.ru.... Chimney p' ........ .......................................................... y provided that the person accepting this permit shall in every respect conform to the terms of the application Final 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 CONSTRUC S S Rough Service ............._.. .... ....... ............................................... BUILDING INSPECTOR Final GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. 6-14-2015 Valerie Kozdras Cow Shed Repairs Segmented Item Description Pricing Remove all tractors, boxes and debris from Cow shed—clean interior of cow shed; sister in ceiling rafters as required where suspect from winter snow and ice. remove all debris from site. $1,900 Keep structure same as it is. Repair any suspect interior rafters by sistering in new ones;wall studs same;the intent is to reinforce anything that may have become damaged by big ice dams. create enough roof support and straighten the roofline that was damaged by ice dams. $8,800 Project Total: $10,700 Approved by. Valerie Kozdras Red Tail-Steve McCullough Payment Schedule: Upon Approval— $1,500 Upon Start of Project—Demo and Start Restructuring $3,500 Upon Start Painting inside $2,900 Upon Substantial Completion: $1,800 Completion of Project: $1,000 Start Date is expected to be late JuIX 2015 and will be completed no later than early September 2015 to) fLf /U, CS �q �C33 The Commonwealth ofMassgehusetts . Department of IndustrialAceldents X Congress Street,Suite 100 - Boston,AM 02114-2 017 ww rv.massgo v/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WIITH'TBE PERMITTING AUTHORITY. Aplilicant Information r Please Print Legibly NaMe(Business/Orga nization/Individual): Ar—d �- Address: > Tf"� 1PWz �--- v� + I T 2— City/State/Zip: A &c -fes- Phone#: 2/ 1 Are yo an employer?Check the appropriate box: Type of project(Tequired): 1. am a employer with employees(full and/or part-time).* 7. co 0 2. 1 a sole proprietor or p ership and have no employees working for mein g. Remodeling U any capacity.[No workers'comp.insurance required.] 9. Demo t ion 3..❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t 4.F1I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 10 0 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. • 12.0 Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ 13.�]Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.F1We are a corporation and its officers have exercised their right of'exemption per MGL c. 14.❑Other 152,§1(4),and we have no,employees.[No workers'comp.insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. i 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 state whether or not those entities have employees. If the sub-contractors have employees,they,must provide their workers'comp.policy number.' d am an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name: l �j� Policy#or Self-ins.Lic.#: / � v Expiration Date: .�' Job Site Address: � �� City/State/Zip: Attach a copy of the workers' compensation po icy 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. X do hereby certify under the painsnalties ofperjury that the information provided above is tru and correc. Signature: fL Date: 4 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): i 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-'contractors)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. I£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 fox 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 pernvit/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 It�OGt357E = ACO1R�, CERTIFICATE OF LIMILJTY INSUR E 06/30/2015 ABA �DOtiD�ILYt 1 +'� . CY OR liErlarA LYNI��i�GRALlrE�RIM 7 j�TtliEACOMRALT R&MMMAMNE OR PtiODlft�EKANDTJIECERUW.JSE is tto no c Rr doss e# �8ts $teU�� ai'Ueep�oe�P�g► gn A ��ae�Cdtca�e a®a tem��l.�fisach - �'0001 xnle+ :782.438.3fl81! 781.438.5028 11 l� E�iand �, �' 33S �e Street Ste, Ph 02180 w� '[ 14788 2S65aeeeo pcCuiioejb, Steve - Vis: . Trav07er5:7tY �- 8 IMA: tied Taff COUSt'ett'icu = 733 TarnOke St- !_limit 192 = Nor! Andoo�, MA 0I84S CATEIftieF 2Z-23 YiHAT 1i�P tw►vE .- WRH�rTOVAGMTM 7B8t/O�tt�OA AKY 11 c3It D AL7HETER Ahff 7U LJ= �7�. UAYEjM CR fAYPEiAK7i�� 8Y EN _EBtl67SPAVEf�iltl33tJCEDFp _ - - t�1S 1lPEdf R� ! PE1 wF := - s -1,000 LOMLOYs7 03 7fQ32016ty $ 5m X LLMO TY {}�a'[/ ` s 5 . t7A l J� &AVf S Z,OOO,.. A X Asti Insd Mith s 2 M; . te'ittee contract __''.. A� t 2 000 m= X � Lac s LWARATAWAM eooacxa�esnt�r ) s a _ rsatte3 s AMM s IMUDeuttos AUMS SUMOCCUMEME s Doers: s I 4MAUASMMs arm Eleors st X6-9— oa)o9/2a ID4%ag/M6 EMMOVEWMIKUY rte - -j- AW AW ptCtr7�I Y 141A B EL -ASE3 SOD �pD16ltiD7V9>�{gli�At70r�t0l:A �s9�t4•��e�� "ect t+o the terots, conatiow. gndwsmp Iand excimon an they Policy. m "fieate voider is iisted"as an additisi >ati#fi CERTMAWROLDER CIWCi3LAnoH. . i=A1E: -b17:9bS.3313 - gE � OY Valerie Koidras 59 Summer St North Andover,MA.01845 _ _ Lnw— NlA*ftM -a: : ALOM-25 0" 1 _ Tft-ACOW n=w and tojv aM nalks of ACOItB