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HomeMy WebLinkAboutBuilding Permit #26 - 643 SALEM STREET 8/11/2012 NORTH BUILDING PERMIT RD 0 TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION 4L 0- C 4 Permit NO: Date Received ACHU Date Issued. IMPORTANT:Applicant must complete all items on this page �2 i. 4 7 V, r P.Jot! ­QRE) ERT�46- KEW . P TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteratio No. of units: Commercial Repair replacement Assessory Bldg Others: Demolition Other -'-_-,.Wdter0bd District',-",-- W - ar Rllr�,V'. Wetlands S e P ti c�,t, \�AIIN pp� A. 4 !W_t 7i DESCRIPTION OF WORK TO BE PREFORMED: C.& 11`71 �ywS Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: R 4 IN G,Q N T R, ACT.0 0 Name 5 '(c?'*" 't 61 S tESII - _7 777v is 117M,1011 7 SP, -Wicense -, 5 U , -N7 T affib-Im r ehblIflcefts�(j =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. Total Project Cost: $ 0 6 FEE: $ G I Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty 8 Si'6ature of he- 4/0' he--- ignaure6fcontractors 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 a 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 J 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 Siqnature 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 Water & Sewer Connection/Signature&Date- Driveway Permit DPW.Town Engineer: Signature: Located 384 Osgood Street ;nFIRE .^ DD"""1'eti+prava4t,lA,r,`t=t,tiwm.rTM..cn.•�PE�t�'. iTg -Ra'tu-r.�e•.°/p cat'uen-'. aJ}s,�)<�"ayt1.e.i[,,$rar�w.o,.�', n sPa§ithe y y est ycatedat1Main-Stre'e & � '�t �r a* a, •.C�;r'„�`��.v 1s. z:_ ��""r r �'_ ""h� ;i �'h�Y� 9;' `;, }*a'��-" �` .r��. � '.4r 6<�'-rp.+�•�, c!'it t#4�in. ii�'.��a''<a�- ��yL ��;;;.��� i o.. �".r�:� ,�„ # •`�,�`�:�!¢,4 ��`����6��t Cs,`y'4� ��4.���.'"'w?'s .'�'-� 'tl���'x-r�~d,�t���;��C+�;., A a a.„.: .. r .. .<..� ..` ,.h e ..... .........t� a`$i�=... ,x s.,:,_:4.5"`T},`nra...n...�,W:.•A..s��+.�w-'J�.4:t��Y'�..:4..`-'srK:iG .s i�`3�-... 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 Location `9 sil No. DateJF + � • - TOWN OF NORTH ANDOVER o b r -. Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ i xtam) TOTAL $ Check# 25501 building Inspector NOTICE N NOTICE W TO a TO EMPLOYEES EMPLOYEES Oq M Sv� The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 — http://www.mass.gov/dia As required by Massachusetts General Law Chapter 152 Sections 21,22&30, this will give you notice that I (we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: THE TRAVELERS INSURANCE COMPANIES NAME OF INSURANCE COMPANY P .O. BOX 1450 MIDDLEBORO, MA 02344-1450 ADDRESS OF INSURANCE COMPANY 7P UB- - - - - - - ( J 4423P86 9 11 ) 10 28 11 TO 10 28 12 POLICY NUMBER EFFECTIVE DATES M J FOSTER INS SVCS INC 163 MAIN STREET NORTH ANDOVER MA 01845 a— NAME OF INSURANCE AGENT ADDRESS PHONE# a MOLLA, DENNIS DBA 148 MAIN STREET UNIT 0-102 0 DM PAINTING AND CARPENTRY NORTH ANDOVER MA 01 845 a EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE r MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS 001466 W20PIG02 TO BE POSTED BY EMPLOYER IQ, ]'j!11 Birtr cl of&riitlirtDcpat trru:nt of P ublic —'- R �• Sit c Construction .Iulatio Sns antl Stand,tr�4 . 105898 j License: CS upervisor License DENNIS MOLLA 148 MAIN ST UNIT 0102 NORTH �. ANDOV ER, MA 01845 Expiration: I! 9/212014 rr#: 105898 fie �iair�nzaouuea/C�i o�,/ aaaacfuaelZa - Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration:„-c 170582 Type: Expiration: V-/40%2013 DBA DM PAINTING&CARPENTRY. DENNIS MOLLA ,# . Kr148 MAIN STREET NORTH ANDOVER, M MA:,0,1.8.45;.'' Undersecretary Dennis Molta, CsL#105898 INVOICE 148 Main St, Unit 0102, North Andover, MA 01845 Ind IIti ng&ca;t l„►cent r)r 978.609.8673 dm.painting.carpentry@smail.com Randy Heins 107.11.201211 643 Salem Street, N Andover, MA 617.821.9347 ... M89fift v- 1000 Remove old windows. Install new 5 double hung windows by Anderson 400. 65 Dispose of all trash. I I By signinsthis es ' ate the client agrees to the services outlined. Client: Randy Heins Date: /l 2014 _ Contractor: Dennis Molla Date: = (r ?z1 i I i I Make Check out to DM Painting& Carpentry Send to 148 Main St, Unit 0102. North Andover, MA 01845 I TOTAL 1065 THANK YOU The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 s. www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leizibly Name (Business/Organization/Individual): 9M Address: L� 14,14 `7T— � �v `1r � �1`�� q�Z /N'A- City/State/Zip: Phone Ae 'on an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. t ?• Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition workingfor me in an capacity. workers' comp.insurance. 9 y p ty ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.El Electrical repairs or additions 3.❑ 1 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' 13cher.epa comp,insurance required.] Ui *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 their workers'comp.policy information. I I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 3-AveQ S [NpSyl I&A),)C.E LO 1K P N Policy#or Self-ins.Lic.#: (�3�1,t(� "��{Z�j 1"�j G -1- 11 Expiration Date: (0 •2� 1 Job Site Address: 6(4 3 SA'cfM S f— City/State/Zip: 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 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. 1 do hereby ify under the pains a d p n It. of perjury that the information provided above is true and correct. Si nature: Date: ©4 • I . Phone#: I--�R, rj09. 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 --ml,moon �Ias+achusetts- r t) ol,. Dcll' rtn c n�p Builclin Rcr. ublic Sat�.t Construction's u "'uons and Stanclar'il:�. -j License: CS Pervisor L-icense 105898 DENNIS MOLL,q 148 MAIN ST UNIT 0102 "` NORTH ANDOVER, MA 01845 f'u�nmis,iur�er Expiration: I _ n: 9/y2014 � ' rr#: 105898 _ _�rhe i�arrarreaoucea� o�._/�c�aaacfivae�lb Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR s Registration:,-"70582 Type: Expiration;_. 1:1/4012013 DBA DM PAINTING&CARRENTRY { l DENNIS MOLLA 148 MAIN STREET IJNI�p1:02'' ' NORTH ANDOVER MA 01845.=:rc Undersecretary NORTH • �( � E j own o 2 ndover O ; . - 0 No. L*. . h ver, Mass, ` COCHIC.2WICK y�• Q�RAT E O I '�C S U BOARD OF HEALTH Food/Kitchen PER I T. LD Septic System • ...................... . THIS CERTIFIES THAT .......... .. ........ .................................................................. BUILDING INSPECTOR has permission to erect.... ...................buildings on .......�. ...... ... ................ Foundation 1�...�.....`. Rough to be occupied as ... .. .. . �J�!:��14.1. y provided that the per acc ting 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 MONT ELECTRICAL INSPECTOR UNLESS CONSTRUCTIQ S TS Rough Service .............17D Final BUILDING INSPECTOR 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. SEE REVERSE SIDE