HomeMy WebLinkAboutBuilding Permit #654 - 614 FOREST STREET 5/6/2008BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO:
Date_ Issued:
IMPORTANT:
LOCATION 61q tT
Date Received
must complete all items on this p
Print
PROPERTY OWNER'_
Print
MAP NO: PARCEL: ZONING DISTRICT: Historic.Distr
Machine Shc
yes ,�`:no
ves no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One family 111*1
Addition
Two or more family
Industrial
Alte '
No. of units:
Commercial
Reair, relace
Assessory Bldg
Others:
Demolition
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: 114-1 AadzRsan Phone: V7032�0-69W
Address:
CONTRACTOR Name:Q-
�"'�.� Phone:
Address: _1
Supervisor's Construction 'License: Exp. Date.'
Home ImprovementLicense: �3 i~ �1 Exo. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BOLDING RMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ �� ®d FEE:
Check No.: /d U / Receipt No.: 03l 1
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Location 6�1y"
No. as- Date
TOWN OF NORTH ANDOVER
:011 -
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
2 i'i 37 "-J Building Inspector
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
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
;�i•7iv1'ii
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 signatureldate_
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
Doc.Building Permit Revised 2008
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
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. Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registry# 004 115195
EWtdfipn 1/3/2010 Tr# 263969
�.` Type D`BA
EXPERT ROOFItdGy$J —e OVEMENT
SCOTT EMMONS t %�
2295 MAIN STREE,�
TEWKSBURY. MA 01878 ♦ A
"Your one call roofing specialists„
SpeciWising in Additions-RonovaUon-Rodding Painting -Carpentry
2295 Main Street Tewlra:bury Me. 01878
978-890.0511 CELL# 978-794-9893F°AXI
EXtexpP@veriwn.rtet
Customer name; 15at*: •
n129 d4df,12S-6f)
Address: job location
Contact numbers. Day/lire:
�p 14r1AA,4 -
We submit the following:
Ile -nailing any loose boards ars needed and replacing up to® meq f;. of $oof board. Any
additional boards will be at a cost oL___per sq, ft. New shingles will be tied into flashing
and will be counter flashed as needed. installation will include the fiAlowing;
Removal and disposal of _____layers 49f over e=istiuq
The edges will receive 6" drip edge or No
All lir edges will have t of ice and water shield -YES oticl �
Valleys will have feet of ice and water sb iald- YES r NC
year shingles, THREE TJWMIIdATED PECM, —
15 kb ;Belt paper -YES
Quality ridge vent to be installed(gor No
Soffit vents to be installed -YES o O)(Xy.---- ....
Vent pipe flanges to be installe(Y8S y NO
All labor will be guaranteed for five yeare tom the Completion date.
All material is guaranteed to be as spud. Ali work to be completed in a workman -like
manner according to standard practices. Any alteration or deviation #rorty above specificatiora<
involving ex&a costs will be executed only solder written agreemen4 of oxtra charge. All
agreements are continent upon accidents or 4oisys beyond our control.
We propose to tarnish materta� and labor -Complete in accordance v above
Fog a total cost of $]cellars """CC" l�¢
Pa ws
Payments to be made as follo: �
All checks payable to Stott lass 3 C ��
We accept the above specifications and pri�atd You are herby aitissed to the work
specified above. Payments to be made outlined above {�
SUBNI BY; ACCEPTED Bz,:_64'z:
WFJ 9 i@ 2007--T0-,'.F)VA
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
d 600 Washington Street
t
Boston, MA 02111 ,.
wM 5 V www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print I.,eLuibly
Name (Business/Organization/Individual):��/���✓1/'`
Address: �.
� Q
City/State/Zip: Phone
Are you an employer? Check the appropriat�e bo
1. ❑ I am a employer with '
4. L7 1 am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These .sub-contTactors have
working for me in any capacity.
employees and have workers'
[No workers' comp. insurance
comp. insurance.$
required.]
5. ❑ We are a corporation and its
3. ❑ I am a homeowner doing all work
officers have exercised. their
myself. [No workers' comp.
right of exemption per MGL
insurance required.] t
c. 152, §1(4), and we have no
employees. [No workers'
comp. insurance reauired.l
Type of project (required);
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10..❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13. ❑ Other
"Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t 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.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: ! .fir✓ (ta4t7✓Cz_
Policy # or Self -ins. Lic. #:'u W(f 5/3 e -7 Expiration Date: Jt C1
Joh Site Address;_ 1p/q City/State/Ziff &w ,rleole
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of M.GL 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.
,�;T- j c) - C9!5 l l
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,opera'te-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 rnay'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 permittlicense 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 bum 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-NIASSAFE
Revised 11-22-06 Fax # 617-727-7749
www.mass.gov/dia
03/27/2008 10:25 9786570201 TL SO THMAYD INS PAGE 01/01
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