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HomeMy WebLinkAboutBuilding Permit #179-15 - 681 GREAT POND ROAD 8/19/2014 BUILDING PERMIT NORTFI OF,z��° TOWN OF NORTH ANDOVER F� APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received04 gSSAC HU`��� Date Issued: Y-11111 Z I PORTANT: Applicant must complete all items on this page 1 LOCATION -"" Pt _ _ PROPERTY O_WNER 1... ! � Pnnt 100 Year Strueture� yes.. no MAP PARCEL ZONING ISTRLCT - - ---Historic - strict 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 , Iteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other El Septic ❑1Nell' ❑'.Floodplain- Wetlands ❑ UUatershedDistrict. .❑Water/Sewe.r - w DESCRIPTION OF WORK TO BE PERFORMED: Id tific tion- Please Type or Print Clearly OWNER: Name: Phone: 61 Address: /P Co ntractor'Nome:- _ - Phone: L41 : i 6-V ,{"`may/ Address: z �Am, S=upervisor's Consfiruction License:-. _ - _ __Exp. 'Date: l'ildome IMprovementy License: Exp_Date: 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: $ �8� p© FEE: $��1C Check No.: Receipt No.:� NOTE: Persons contracting with unregistered contractors do not have access to e Panty fund Si nature of,A ent/Owner. ___ a Lt. /ti nature of contract 9 _g..___ 1 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swirmning 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 PLANNING & DEVELOPMENT Reviewed On Signature_ 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 b. Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street "IFIRE DEPARTMENT Tern lDum -_sterfon site p p,= Located45t 124. Main Street J, Fir e'Departmentsigna-yre/date, fi 4C'OMMENTS. _ y 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 , ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 i 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 Li Building Permit Application Li Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract ❑ Floor Plan Or Proposed Interior Work j o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application o Certified Surveyed Plot Plan Li Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract ❑ Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o 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 o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be. Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Li Copy of Contract ❑ Mass check Energy Compliance Report o 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 i Doc:Building Permit Revised 2014 I 1 Location� 1 ' �r 7 QdriG! No, Date . - TOWN OF NORTH ANDOVER .� Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# a 27917 Building Inspector + Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 389000.00 m $ - $ 456.00 Plumbing Fee $ 57.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 57.00 Total fees collected $ 670.00 681 Great Pond Road 179-15 on 8/19/14 Kitchen Remodel R, Q4 ear TOWN OF 1;KORT AND 3�6b'lt •`k,xa a OPTICE OF BUMDING)DEPARTMENT . ' a <� -1600 fJsgoad StrOct Building 20,-Suite,2-36 7p ,IWa 55 .: NorthAndovex,Massachusetts 0 .845 s�p Gerald A.Brown - 'Telephone(978)688-9545 InspectorofBuildings - Fax (978)688-9542 HOMEOW:NERUCENSE MEN PTION BM) NG)?RRWT APPLICATION TION Please�rinf , DATE: �� I , JOB LOOATiON: Number 3 reaAddress Map/Lot xM A Name O -(13; to HomePhone WorkPhone PRESENT MAILING ADDRESS O� �i.�i'Pnz m G'fatP dip Cods The currenf exempfion for"homeowners"was extended to n co alloly M6 hrn opo.T e,s- t cIude owner-occupied dwellings to two units•-OT;ess and uto engsge an?it vidual•for hire-wino does notpossess a license,provided that the owner acts as supervisor). 8siate130cling (Code Sect-on 10S.3.5.1) DEF.IN.LTION O.VRO�EOWNER. Persons)who awns apazce3 of land on which he/she resides or intends to reside,on w7lich there is,oras intended to considered ahomeowner. ' be,a one or two farxiily structures. A person who constructs more that one home in.a two yearperio d shall not be The undersigned".homedwner"assumesresponsibilifyforcompliances with the State Building Code and other Applicable codes,by laws,n&s andr-egalafions. The undersigned"bomeownez"certi, os that he/sheimderstands the Town of90TIhAn.doverBuilding.Deliaztment minimum inspection procedures and requirements and that he/she w ll comply with,said procedures and requirements, , HOMEOWNERS SIGNATURE A�TROVAL OF 13UJLDING OFFICIAL Revised 7.2009 Foran Siomeotivners Exemption SOARD OFAPP.EAIS 689-9541COhSEP AMN r r r Y; 699-9530 HEALTH 689.9540 PL.fi.NNING 688-9535 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA.02111 www.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): A?, � �, � Q�1 I—l J ' . Address: PJ) - `` City/State/Zip: Phoonl e#: —7 Are you an employer?Check the appropriate box: Typo of project(required): I.❑ 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.El am a sole proprietor or partner- Listed on the attached sheet. ?• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g, ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions I am a homeowner,doing all work right of exemption per MGL 11.E]Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and wehave no 12.❑Roofrepairs insurance required.] i employees.[No workers' � 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 7 Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors 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% Policy#or Self-ins.Lic.M Expiration Date: Job Site Address: 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 ofMGL 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 ofup to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ceril er tli ai and e 'es ofperjury that the information provided above is true and correct. I - Si afar • 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 Instructiolms 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 employd 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 uotinore than three apartments and vrho zesicles therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or rep 'i work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment Wdeeir ed to be an'ei aployex:" - MGL chapter 152,§25C(6)also states that"every state or local lie-ensing 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 LL C or LLP does have employees,a policy is required. Be advised that this affidavit maybe 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 laves tigations 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 o n e affidavit indicating cu rrentPolicY information and Job Site Address the applicant should write 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 ofM-assarhwotts Department offadustdal Accidents Office ofIayestigaffoas 600 Washington Stroet Boston MA 02111 `l`el,#617 .7-4900 0A 406 or 1-8.77— SSAkF Revised 5-26-05 Fax#617-727-7749 IFrlxn7r Yn n 4A.I.- NORTH Town of : _ ndover No. - - h ver, Mass, COC MIC Ml W1CM 1_ 'x,95 Rare o �Pa��S U BOARD OF HEALTH Food/Kitchen PERMI-T T LD Septic System THIS CERTIFIES THAT ......................N.A...r .L............ ..... . 1 ......................... .... BUILDING INSPECTOR ... has permission to erect t ....... .................. buildings on ....4. ..t............6..,....PoAd......e4ld.a... Foundation Rough to be occupied as ..... ................................................................. Chimney provided that the person accepting 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 MONTS ELECTRICAL INSPECTOR UNLESS CONSTRU N S TS Rough Service ...........D­ ­.... ..................... ............................. 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. 154" 3 39 4 17 2 46" 46" 4 5 8 4 44" 51 3vi Ca�ie+ Sides -el- F✓zwie � U�,t 5ide .Cbwv. 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