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Home My WebLink AboutBuilding Permit #245 - 65 SPRING HILL ROAD 10/6/2008 BUILDING PERMIT °� NORTH q ` 161 tiO TOWN OF NORTH ANDOVER 0� ° APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received lel� 7-OP ��SSACHU Date Issued: 10 0� 'IMPORTANT:Applicant must complete all items on this page LOCATION , tint PROPERTY OWNER Print MAP NO: '1o7 PARCEL:�NING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: V U � Iden ' i tion Please Type or Print Clearly) OWNER: Name: �'e �/� f1/, S15� Phone:9ly;�Z. ;4(� Address: CONTRACTOR Name: V � Phone: - .. Address &6 k-'E r S frf. i ' Su ervisors Construction License: G P 0,Y f e _ :Exp. Date: Home Improvement License: fI�Z3'W Exp: Date: /( -Z ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$1200 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ �fj(I " FEE: $ Check No.: �3 Receipt No.: "67 3 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund ignature of Agent/OwnerSignature of contractor i Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Swimming Pools Tanning/Massage/Body Art 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 I 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 Water & Sewer Connection/Signature&Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT Temp Dumpster onsite yes no Located at 124 Main Street Fire-Department signature/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 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 PP 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 f The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Olt- 600 Washington Street Boston, MA 02111 f iw www.nzass.gov/dia Workers' Compensation Insurance.Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):__J�J / Z4. Z � Address: Sar City/State/Z' Ph _ Phone#: Z--- �7�--- Are yo In employer?Check the appropriate box: I. I am a employer with / 4. Type of project(required): ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. $ 7• emodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp.insurance, o workers' comp. insurance 5. 9. E] Building addition [N p. ❑ We area corporation and:its required.] officers have exercised.their 10:0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 I.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' comp. insurance required.] 13.7 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Hoineowners who submit.this af,`tdavit indicating t ley arc dGiug nil work and then hire outside contract ors must submit a new amdavit 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:_ 614 Policy#or Self-ins. Liic�c.#: Expiration Date: Job Site Address: W 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 qutred 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 c c u r e pal and penalties ofperjury that the information provided above is true and correct S i artature: Date: Phone#: Official use only. Do not write inn 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 cant'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".lob 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 Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia Page No. of Pages DAVID MORIN REMODELING CONTRACTOR 41 Balmoral Street ANDOVER, MA 01810 (508) 475-2672 Lic. #040898 I PROFOSSUBMITTED TO r - / PHONE DATE /V STREET ✓✓`l IV/ / ^ JOB NAME' L/ CITY, ATE and ZIP C`bDE JOB LOCATION ARCHITECT DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for: Or 13r0p0Sr hereby to furnish material and labor—complete in accordance with above specifications, for the sum of: dollars($ Payment to be made as follows: 1� All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices.Any alteration or deviation from above specifications Authorized involving extra costs will be executed only 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 insurance. Note:This proposal may be Our workers are fully covered by Workman's Compensation Insurance. withdrawn by us if not accepted within days. ACCPptariCP !1f Proposal —The above prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized Signature to do the work as specified. Payment will be made as outlined above. Date of Acceptance: Signature i r F I ✓/ie �oo�irnoozureall� o��/lifaaaac�uiaetta:-- Board of Bmlding Regulationsslid Standards, Construction Supervisdt=License 1_16e6se: CS 40$98 c,.. Bitthdate" 7/4/1954 piOtt _ 4/2009 Tr#' 73 Restncti n r 00 f s-- DAVID M- MORIN 365 SUTTON ST P NO ANDOVER Commissioner t k. � _� _. _✓/ie i�o7re�r�,oncueallfz o�,�%�ccrlucaelZa Board of Building Regulations and Standard; HOME IMPROVEMENT CONTRACTOR- Registrati'on'110320 Expiration. 10/20/2008 Tr# 124 50 Type: Individual DAVID M.MORIN j DAVID MORIN 365 SUTTON ST. I NO.ANDOVf=R,MA 01845 Town of 6 Andover 0 No. Z S = _ 2- LAK over, r Mass., 0 0 COC MIC ME WICK y` RATED U BOARD OF HEALTH Food/Kitchen PER .MIT T D Septic System BUILDING INSPECTOR re"-le"te .112/ . THIS CERTIFIES THAT.......................................... .......................................................................................................... Foundation has permission to erect........................................ buildings on ...... IV........................ Rough to be occupied as........................ .......61_A:5�'11 ................. ....... 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 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCT STARTS Rough ............................... Service BUILDIN INSPECTOR 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 j Smoke Det. Location No. Date MORTM TOWN OF NORTH ANDOVER F•r • . oX. 9 i Certificate of Occupancy $ ♦ i # Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 2 15 3 Building Inspector