HomeMy WebLinkAboutBuilding Permit #098-2012 - 61 WATER STREET 8/3/2012 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: y "� Date Received
Date Issued: =x /
IMPORTA�N�T: Applicant must complete all items on this page
LOCATION ((
Print
PROPERTY OWNER c— z- Unit#
Print
MAP NO: _PARCEL: ZONING DISTRICT: Historic District yes �n
Machine Shop Village yes no
100 year-old structure yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑Addition ❑Two or more family ❑ Industrial
❑Alterat' . No. of units: ❑ Commercial
L-Fire'p—air, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑_-J`_- _ Other
° p`r '
19Septic T�Well ®Flood lain ®:�Wetla�d'� � WatershedDistrict �-
1OWa
te/Sew _
D CRIPTION OF WORK TO BE PERFORMED:
(Identification Please Type or Print Clearly)
OWNER: Name: 7�(a ,%�_ , 7 Phone:
Address: co . S �—
CONTRACTOR Name:= e c Phone: (.,p
Address: Z)i ft) 302
Supervisor's Construction License: °? (0- Exp. Date:
Home Improvement License: ( f '?`7 5"'C, Exp. Date: r / /
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT:$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED`ON$925.00 PER S.F.
Total Project Cost: $ FEE: $ 7� D
Check No.: Receipt No.:a
NOTE Persons contracting wik unregistered contractors do not have access to the guaranty fund
Signature,of�Agent/Owner�x:��.,� ,�:Y,� :� � ..�Signature of contractor/,t
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Taming/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
�I
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: . Comments
I, Conservation Decision: Comments
I
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
w
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
i
t
❑ Notified for pickup - Date
Doc:.Building Permit Revised 2011 June/mi
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 1
Hydraulic Calculations (If Applicable) 1
❑ Mass check Energy Compliance Report (If Applicable) i
❑ 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 ull ng Permlt 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
o 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: Doc.Building Permit Revised 2008mi
Location C!2-1- S�'
No. t '—/2 Date 3 //
NORTH TOWN OF NORTH ANDOVER
F 9
Certificate of Occupancy $
• E<� Building/Frame Permit Fee $
'�CHU
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ .
Check #
244 �)S
`$uiiding Inspector
IORTH
Town of .
O �_ VAIn
No. '`
- - --_
o , dover, Mass.,
Q tm_ LAKE
COC til CMEWICK V
SRATED P' C
BOARD OF HEALTH
Food/Kitchen
Septic System
lihnMIT T
�/')
..
BUILDING INSPECTOR
THIS CERTIFIES THAT,............ � .. re................................................................................................
Foundation
has permission to erect...........:.:.......................... buildin s on .... �. ......5 ......................................... Rough
to be occupied as . .......:...........................:.............:.......:..............................:................... Chimney
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
PERT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTIO STARTS Rough
.................... ..................... .. Service
..... ...............
BUILDING SPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
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.
50003
THOMAS DEFUSC-01 LLC
DBA-Tom D3 usca-GeneTJ- Coniamfing
23 Duuon ad..Pelham, NH 03076
Page No. of Pages
H3.iwg.8117756-Constr. Lic.8071037 DESCRIPTION OF-JOB
ARCHITECT DATE OF PLANS
PROPOSAL SUBMITTED TO: JOB
ADDRESS
CITY STATE ZIP
PHONE DATE
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I WE HEREBY SUBMIT SPECIFICATIONS AND ESTIMATES FOR:
Ti Ii
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We hereby propose to furnish material and labor, complete in accordance with above specifications, for the
sum of y . .0 7- "7(" i .� .ti. 1 - f t/< E�,� �i roc dollars ($ -�
with payment to be made as follows:
All material is guaranteed to be as specified.All work is to be completed in a workmanlike
manner according to standard practices. Any alteration or deviation from specifications Authorized
involving extra costs will be executed upon written orders, and will become an extra Signature
charge over and above the estimate. All agreements contingent upon strikes, accidents �
or delays beyond our control. Owner to carry fire, tornado and other necessary Note: This proposal may be withdrawn-by us if not accepted
insurance. Our workers are fully covered by Worker's Compensation Insurance. within , rdays.
Acceptance of Proposal -The above prices, specifications and condi-
tions are satisfactory and are hereby accepted. You are authorized to do
the work as specified. Payment will be made as outlined above. Signature
Date of Acceptance: Signature
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
UV. www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Name (Business/Organization/Individual): cl c �S
Address: C,)Tbui—)
City/State/Zip: lav Phone #:_ s 0
Are you an employer?Check the appropriate box: Type of project(required):
[2.0
.❑ I am a employer with 4. �I/am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6 ❑New construction
I am a sole proprietor or partner- listed on the attached sh%et. 7• ❑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. ❑ We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12: oof repairs
insurance required.]t employees. [No workers'
comp.insurance required.] 13.0 Other
Any applicant that checks box#1 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 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 Name: t c �,�� t, V
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the worke compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under 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 under the pains and penalties ofperjury that the information provided above is true and correct.
Signature: �� Date
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 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 burn 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 Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111.
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax#617-727-7749
www.mass.gov/dia
Office of Consumer Affairs andusiness Regulation
10 Park Plaza- Suite 5170
e Boston Massachusetts 02116 °
Home Improvement Contractor Registration
_ - Registration: 1.17756
= 7 Type: DBA
Expiration: 11/15/2012 Tr# 207026
TOM DEFUSCOGENERAL CONTR4NG �
THOMAS DEFUSCOf
23 DUTTON RD
PELHAM, NH 03076 t
Update Address and return card.Mark reason for change.
Address Renewal Employment Lost Card
DPS-CA1 as 50M-04/04-G101216
Massachusettst►nent of Pr)hlr Safety
130ar d of Built#in., Rc;nrl.uir�rts:tr11! Star)tl.)r ds
construction supervisor License
License: CS 71037
THOMAS A. DLF08CO
23 DUTTON ROAD
PELHAM, NH 03076
G—
"���� Expiration: 6(18M13
<'+iiunisia»er Tr#: 19072
e