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Home My WebLink AboutBuilding Permit #096-13 - 67 STONECLEAVE ROAD 8/2/2012 BUILDING PERMIT of"°DT" TOWN OF NORTH ANDOVER or ,�.;,,. °_ 6'° APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received ,[o'Pa'`.cy gSSACNus�� Date Issued: IMPORTANT:Applicant must complete all items on this page Ak n PROPERTT bWNER " 1 W,_ n syr, e. nn .} ' , 1t�lAP 2 RARCEL-/ � � ZONl1VtjDISTRICT astonc I)is#riot des ' no 7. achie'Shop V�llaet Ayes rice 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 e tac wWell Flood laxo �Weflards P P � Wers�aex� SD�strt 4 U1_/�ter/Sewer DESCRIPTION OF WORK TO BE PREFORMED: ort E /a /a A� II Identification Please Type or Print Clearly) OWNER: Name: -e t2°ES c. RI�e Phone: -7?,/- FF3-77YA Address: get &0IC CONTRACTOR ` laiI � a. r �. i 'avne � .t Add ressx � /p F up Jsor's Const ctidhltLi6e4se. l � p .ioftne I amprotudrai.ent'It' _ £ Exp Dae re 1' ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ ?7S- FEE: $ y Check No.: :2c2 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund ,1 Signature„of Agent/Ownei ., . Signa#ure ofacontractor` . ;i �! I 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 Decition: Comments Conservation Decision: Comments I Waie' ?& Sewer Connection/Signature&Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEP ►RTI T �fer�apDumpsteron�srt ;Located at 124 Main"Street Fire Departrraen,srgn�tulre%late .. f r 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 1 NOTES and DATA— (For department use 0 Notified for pickup - --Date 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 _ ❑ 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 o 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 j 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:Building Permit Revised 2008 Location 6 7 oly z ` "��j Date L No._a r� r . - TOWN OF NORTH ANDOVER � Certificate of Occupancy $ L bywri Building/Frame Permit Fee ` Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# _ 1/ ,... 25578 ,B Ming Inspector r 7- NORTH - W' '. : E c . : ve" � O - .:, No. oh ver, Mass, LAKIcoc Mlc„l WICK ��• A�AATED S u BOARD OF HEALTH Food/Kitchen PERMI T. T D Septic System THIS CERTIFIES THAT1.`/....`Q�' �s....�. .... �L.. :............................................. BUILDING INSPECTOR ' Foundation - has permission to erect ........................... buildings on ....6..7.......,,5 �.�r., �,,,� �v�. C�................. Rough to be occupied as...�.�........ :. .... .. . . .....�.......,��. ./...!/eterts ............................. Chimney provided that the person accepting thit shall in every respect conf rmto t 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 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough .. Service ........................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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 _ ' _ ty� -: - �� i � { - — s j�.J _. — — �� 4 _ _ L L -._ _.J �_� i- ---- �U— ---- _ �, — ,. �� — W -i _ _/i _ � _>> ' • _ �— X1:-1 — �— � � �-.,J r _ — � i C. _ — _� L' ' .. — __ i/� i 1 __ _ r- ;_ -- _ _�- -J � � I - �� Lt: i_) �� I ` �-� i-.. �.,- � I� .. ACO CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A NATTER OF INFORiv1ATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIr"2,g7_ HOLDER. T:-ii CERTIFICATE DOES NOT AFRIAMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE: AFFORDED d., THE POLI�,.=c BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING 1XISURER(S; REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. F IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the poiicy(ies) must be endorsed. If SUEROGA.T.IO'i IS 4`J Ali J7CCt We tzrm:s and conditions of the pc!icy, certain policies may require an endorsement A statement en this certificate does ;;c,,:_~ certificate holder in lieu of such endersement(s). - OUCER C'Jt!_ - v l r'_c, Ana " :onacorso insurance encFHCt7E81) __..-------_ -_ .. - .. .. 3-3200 183 Cam-bricige Street E4A;!�L 50: N.C. EvX �J�2 ADDRESS: rau-ER(s_a=Fcp.;:ri.0C0v0rV:. ERAGa sur1_^gto^ 1k 018G� _ Ir;suRERA'Bepublic Yrankiin Ins Co.Ifau=EG - ms,_RENravelers Cas & Sur c= I11i P'eterscn arC_V Center; InC . IbiS!JP.ERC�.1t1Ca T`iat'O:^:al insurance rG-=--- --- - 139 Swanton street INSUP=F:G:�ra�E1Er5 CcS::c1t`i c^ C•i -- 4Vi :ESto .r O1 �U INSURER F. .—.-_---- -...- --- - .. COVERAGES CEREFCATENUMBER2011 ISSTZP, REVISION NUMSE THS IS TO CEPTIFY THO THE POUJ OF N USTED e . i - 7,'I,IED TO T.-E _. v JJ - _ i :EJ. N':)T%`;!TH57NCQNG Any REDIREMANT, TERM OR CON_•T.it OF MW( 0011 R=CT OR OnER M0Jk;!ENT CART15CATE MAY __ ASUED OR MAY PERTAN, THE !NS!-R--'-NCE AFM'=.D_D BY TSE &WICi._S _RE IS _ EXCILIJIS!ONS AiND,CO N:)iTIC-;NS OF SUCH POLI DES LWITS SHUNN N!,AY HAVE SE-2N FzE,-;'JCE':)Er PhD CLAWS. L7- Ti FE C= A. ".L L Pc JCf c I P ICt = -- ----- c= PolicyJ't=-- ! Li -- C c LI. 000, - 4 ' —_ ---- `I C _ _ I G:;�_- I X. 1 X ,cr243E 5_ "'^, ,2711 �_C/-. =c-_2 r . AC UCOMET F_ ED -__>5=CJ ^,"' iC, >i-1_2 I - ...-.... _. _ ...... -..S U.c-ELL,LIAE f X I f. C I EXC ESS LIAo Iopo F90MON! 04351E _ iCi 7,' J,_ :. j/2C__ .a cot'-'=E.S..-To"q AND =LOYZR.S'LASILITf I X J^ ] _LIC - ,-- -,J l I i GF OF ,:•_..5:LOCA:if P;S 1 VEHICLES (Attach ACORD 1Ct.Addi;!cnal Rem arks Sche�d:le,If more space Is req�.irsd; I r I i L CER I IFEATE HOLDER CANCELLATION: SHO ULD.4N''OF TH,E ASO'.'E 0ESCRt2ED FO_!C+ES SE C..".0 THE EXPIRATION DATE THEREOF, NOTICE VUL EE CELT` -C KJ ACCORDANCE WITH THE PC'_ICY PRO'71PiON° I AL'Tti C•RI_cG ric?F.EE E.'--i�:E I I I ACORD 25(201(105? 5842A0ACORD CORPOR; -- TION. .. n��';ts „EN_ Th- orn^r; �t The Commonwealth of M assachusetts Department of Industrial Accidents F a Office of Investigations ' 600 Washington Street Boston,MA 02111 ` www.mass.gov/diva Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individual): c PSS G'i'> Q`L' co� < — Address: j� City/State/Zip: bv:tivti v/ / Phone#: 791` 22�z �"00 0 Are you an employer?Check the appropriate box: Type of project.(required): 1.® I am a employer witho?c--�-D 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. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition employees and have workers' 9 Buildin working for me in any capacity. E] ag addition [No workers' comp. insurance comp.insurance.= required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions D.El I am a homeowner doing all wort: officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 152 repairs insurance required.]Ti c. 152, §1(4),and we have no 13.®Other G fy1 employees. [No workers' comp. insurance required.] *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. tContractors 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 cern an employer that is providing workers'compensation insurance for my employees. Below is the policy rand job site information. Insurance Company Name: G,Y'��'�tS S�✓a ! T-Y °�- 104 e- Policy#or Self-ins.Lic.#: ( �3(9 3 CU Expiration Date: g Job Site Address:-67 ��-e c lea—g.. d 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. I do hereby certify tinder the prainsand penalties ofpeajuty that the information provided rabov is tr e sand correct. SrQnature: / ��w Date: 7 � ne#: _ C Pho � /_ �.� I -- Official use only. Ito not write in this area,to he completed by city or town official. City or Town: Perrnit/License Issuing Authority(circle one): Y.Board of Health 2.Building Ie artnent 3.Cit /Town Clerk 4. Electrical Inspector 5.Plumbing Inspector ector 6. Other Contact Person: Phone#: Office �-Ibiu�umcr License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: WIC t` Registration: Type: Office of Consumer Affairs and Business Regulation Expiration: 8/119/2013 Individual 10 Park Plaza-Suite 5170 ur Boston, AIA 02116 TRIANA MARK TRAINA 33 HANFORD RD. -------------- STONEHAM, MA 02180 Undersecretm-v Not valid without signature