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HomeMy WebLinkAboutBuilding Permit #010-2011 - 6 ALLEN STREET 7/1/2010 BUILDING PERMIT aF AORTf TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION Permit NO: 0/0 — Lill Date Received �RArE.00 Date Issued: �SSC14UE IM RTANT:Applicant must complete all items on this page 7 Ox �2 4 LOCATION, 4� t T,� A ji Y- P 4_in t 6t�'_ * " _4 7� t R R Q P E 1:,ZIT .14Z i,Phffit 'PARC U M Y b ',6,'� _7z VN 'no no TYPE OF IMPROVEMENT PROPOSED USE RegLidemb Non- Residential New Building One famil Addition Two or more family Industrial Alteration No. of units: Commercial Re?<r, re Jacement Assessory Bldg Others: De Other -0 ep Ic Z'� 'd- I in .... ........ '17; et &10 A;,�17; DESCRIPTION OF1WORK TO BE PREFORMED: Lf_,tZ,-q 4?PLO e",SFz/"-'Y�-4CC ':?e-r 0 6!4,df Identification Please Type or Print Clearly) OWNER: Name: /V A/- Phone: Address: 6 00, n �At�)�Iki 117 I — q, RA .1 7,ozw P T -T 60N,J �:.67 .7 4� . Address or J. 14. S.U.P.0ISO'r 'stftfCti-, I., ga I ffi H_me lmprouement ans'o _?W= ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE"BULD'NGPERM'T_$'ZOO PER$1000-00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 'cl, FEE: $ Check No.:. ,le,2 Receipt No.: NOTE: Persons contracting with unregistered contractors do not ha access the g ran fund Signature_LY 2_9 Location No. 0/0 — -2011 DateJI 7 , gORTM TOWN OF NORTH ANDOVER 0 41 •i • Certificate of Occupancy $ ��s ^�•E<�' Building/Frame Permit Fee $ s►cMus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check 2 Building Inspector Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/BodyArt SwllnmingPools 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 Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments ., W ter & 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 MAWStreet wsi retDepart- - -m t tgnature/date COMMENTS _ ..� ■ I 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 i i Doc.Building Permit Revised 2010 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 o 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 o Building Permit Application a Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract -o 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 o Photo of H.I.C. And C.S.L. Licenses u .Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) a 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 Ju 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 NORTH Town of And o dover, Mass., COC NIC HE ICK 7�pS'QA T E D P'P�L 7 V BOARD OF HEALTH Food/Kitchen .PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT.................... /c, .....�)x. ..�I.r....................................................... ................................. Foundation has permission to erect........................................ buildings on .....6...4C�Y.....51....................................................... Rough pl'r/.> ... e�.... LI.d. Chimney to be occupied as ` ..... 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 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough Service ,,e BUISPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR I 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. SEE REVERSE SIDE Smoke Det. TRAVELERSWORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (6KUB-663X466-A-09) RENEWAL OF (6KUB-663X466-A-08) INSURER: THE TRAVELERS INDEMNITY COMPANY NCCI CO CODE: 11347 1: s INSURED: PRODUCER: RAYMOND DAMPHOUSSE & SONS PERRY INSURANCE AGENCY ROOFING CO INC 522 CHICKERING RD 75 BUTTERNUT LANE NORTH" ANDOVER MA 01845 METHUEN MA 01844 Insured is A CORPORATION Other work places and Identificati numbers are shown in the schedule(s) attached. 2. The policy period is fro mC�-2:21-09 �08-?�-i 2:01 A.M. at the insured's mailing address: 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: MA lii �= B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state sted n Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident: $ 100000 Each Accident Bodily Injury by Disease: $ 500000 Policy Limit Bodily Injury by Disease: $ 100000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: `_— COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A D. This policy includes these endorsements and schedules: SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information is subject to verification and change by audit to be made ANNUALLY. ST ASSIGN: MA DATE OF ISSUE: 08-26-09 LP OFFICE: ORLANDO INDUS AFF 161 753Xf PRODUCER: PERRY INSURANCE AGENCY 000349 I • Office of Consumer Affairs&B sines Regulation HOME IMPROVEMENT CONTRACTOR ~ . Registration:_ 1,01862 Type: 'Expiration: 62-W2612 Private Corpora lRA V OND E.DAMR. SONS Raymond Damph�tj�s�: 75 Butternut Methuen,MA 01844 Undersecretary Massachusetts- Department of Public SafetN 801trd of Building Re(Fulutions and Standards Construction Supervisor License License: CS 46636 Restricted to: 1G RAYMOND E DAMPHOUSSE J 75 BUTTERNUT LANE METHUEN, MA 01844 Expiration: 6/2/2011 . (llnunissiuncr Tr#: 16386 The Commonwe¢lth of Massachusetts Department o f£ndustrial Accidents Office Of Invesk ations 600 ff,,ashintr on Street Boston, AL4 612.711 ' H'►1'►+'-mcassgov/did • • Workers' Compensation Insurance Affidavit: guilders/Contractors/Electriciaas/Plumbers . A lieant Informab.oa Please Print Legibly Name(Business/Organization/Individual): „ Address: z , City/State/Zip_� '/a.�f�-� .�,�1 0/ Phone#: A xe youu an employer?Check the appropriate boa: m a to 4. ❑ I am a Q Type of project(required): . general contractor and I plo es(full and/o part-time have hired the sub-contractors 6 ❑New construction m a sole Er listed on the attached sheet x 7• ❑Remodeling p and have no employees These sub-contractors have rking for me in any capacity, workers' com . ' 8 ❑Demolition o workers'camp. P rnsurance. 9 El Building addition p insurance S. ❑ We area corporation and its uired] officers have exercised their 10.❑Electrical . .I am a homeowner doing all work right of ex repairs or motions eznption per MGL 11.❑Plumbing repairs or additions myself.[hTo workers'comp. c. 152,§1(4),and we have no insurance required.]t em 10 ees. 12•❑Roof repairs t,� R coP•ice mquirn..d.] 13.[] Other ttrst checks boi M mast also a.cut the section bdor.�sov:n= � alc40meowhets who submit this affidavit indicating mg tihel' 'comp and thm'hire outside coatrectcrs m+st��:t bion +Contraeto.s that eh=k this box must attached as additional sheet rho a new asndavit indicating such. the acme of the sa!+ccn a to s and their workers'co 0 I am an employer that is ovidinQcompensation P�5 informafioa. Pr a wor&ers insurance for my employees Below is thepolicy and job site information. lam— Insurance Company Name: s Policy#or Self-ins.Lie.#-� 6 4/71 h 0 Expiration Date: 0 v Sob Site Address:_ Attach a copy of the workers'compensation policy declaration age shoe ir,R /S Zip:�(/ Failure to secure coverage as required under Section 25A ONC L . 152 can lead to the imposition of oficy number and expiration date). fine up t$$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and affne Of np 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 here cerci.f1 y un r e pains and p •es of perjur07 fhixt the information provided above is true and correct Sisnattire: Phone#: Official use only. Do not write in this area, to be completed by c)or to o cwt City or Town: Permit/License# Fssuirzg Authority(circle one): I.Board of Health I Bi ilding Department.3.City/Town Clerk 4.Electrical Inspector3],6. Other Contact Person: Phone ff. Information an` d Instructions Massachusetts General Laws chapter 152 requires all employs provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every Peon 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't3be legal representatives of adeceased employer, or the receiver or trustee of an individual,partnership,association ag 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 maintc--mance,constructionor repair work on such dwelling house or on the grounds or building appurtenant thereto shall not be:cause of such.employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or lo..al licensinv 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 contact far the.performance of public work umfl 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 subcontractor(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'comp easation i.,cmra.,ce. If an LLC or LLP does have employees,apolicy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insursance coverage. Also be stu'e to sign and date the affidavit. The affidavit should be Mtu�ued to the city or totem that the appIicatiou Ur the permit or license us bring reaeees*rd nceE the.DepE*tmt of Industrial Accidents. Should you have any questions rcgardir_v;the law or if yon are req�T d to obtain a workers' compensation policy,grease call me Dep ar ment at the number listed below. Self-insured companies should enter their self-inamrance 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/Iicense number which will be used as a.reference number. In addition,an applicant that must submit multiple permit/liceme 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 pmt 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 oflnvestigations would Bice to thank you in advance for please.do not hesitate to give us a ca1L your cooperation and should you have any questions, The Department's address,telephone.and.iax_number._.._... The Comrnonwnaltk oaf I fassacht sefi�s. Dept�ent of lndttstzial Acoicleni� Office.of Irtvestiggatians 6:00 wssl ing,_bn Street Boston,M_A 02111 `I'e1. #617-727-4900 ext 406 or 1-9 77 MASSAFE Revised 5-26-05 Fax#6.17-72.7-7749 VMM'.mass_-0v/cha.