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Home My WebLink AboutBuilding Permit #307-13 - 7 EMPIRE DRIVE 10/15/2012 BUILDING PERMIT NORrN OF�t�ac bq~O TOWN OF NORTH ANDOVER ►0 i p APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received ��ssAc►+us��t`' Date Issued: 2- I PO TANT:Applicant must complete all items on this page LOCATION'S? 6A AgI oq rin PROPERTY OWNER )4 � �C �� Pnnt MAP NOD C PARCEVL4/ Z'ZONING DISTRICT,-T2- Historic District yes es a n Machine Shop Village y TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building �,/' One family V' Two or more family Addition T y 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: CL C' ication Plea a Type or Print Clearly) OW L Phon Address: CONTRACTOR Name-_T + MIL5SIDU I$ Phone.5 72 -8'9 /-3l 90 E��,�PAddressa-? V)As+41l� ! 1 GeoU �,� - 6j -3 Supervisor's Construction License: � 3 Exp. Date: Home Improvement License: / 76 Z� Exp. Date: ARCHITECT/ENGINEER Phone:? Address: A)St, 4At/ Reg. No. Z77 e S FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ leo-ee) Check No.: :K225r Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owne Signature of contra .� �Y:-�,. _.- ::,n :-y.�rq.*Y¢:-'•�r+�w^;i"�--�nr.-x<5 .lsrf „�-.rF •.- E Location No 30 7 Date • - TOWN OF NORTH ANDOVER'` Certificate of Occupancy $ Building/Frame Permit Fee $ ti Foundation Permit Fee d Other Permit Fee $ p +•'`C TOTAL $ '4 f�- F♦ r. 1 t Check , 4 25834 130646 Inspector s ry �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 ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 l Plans Submitted Plans Waived Certified Plot Plan Stamped PlansV 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 l� COMMENTS D.P— HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes E Planning Board Decision: Comments s Conservation Decision: Comments 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 MainStreet Fire Department signature/date COMMENTS 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 rNO , RTH . _ wn- 0 . 3 .1 ozzz "N, h ver, Mass, /C� COC NICNIWICK �d pDRATED S V BOARD OF HEALTH Food/Kitchen PE.RMIT D Septic System 7� THIS CERTIFIES THAT ........oe1 �ft!' � ' ` '"`� . BUILDING INSPECTOR � has permission to.erect ............ .......... buildings on . .. ! ''l /..cloo .. ./alle........................ Foundation Rough to be occupied as .........................ris eim . ... ,/ .! {....C. /.... ....................................... Chimney provided that the person accepting trmit severy respect conform to �e 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. A PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STA TS Rough Seruice� .y. .................................. 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 The Commonwealth of.Massachusetgs Department oflndustrialAccidents Office of Investigations JJ j •! E 600 Washington Street Boston,MA 02111 www.massgov/dia Workers, Compensation Insurance Affidavit:isuilders/Contractors[Electricians/Plumbers APPlicant Information Please Printi Legibly Name(Business/Organization/Individual)D—F=C A9D `, ILSE - 2—LC Address:-0:27 \k)PG-ti I IJ61 O/y City/State/Zip:Q606�)Wfa . A - PZLV Phone& 51�73- Are you 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 2X I am a sole proprietor or partner= listed on the attached sheet.t 7. ❑Remodeling ship and have no employees These sub-contractors have S. []Demolition working forme in any capacity. workers'comp,insurance. g ❑Building addition [No workers'comp.insurance 5. El We are a corporation and its required.] officers have exercised their I0.❑ElectricaI repairs or additions 3.❑ I 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.E]Roof repairs " insurance required.]i employees.'[No workers' 13.❑Other .comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showingtheir workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doingall 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 acid their lworkers'comp.policy information. X am an employer that is pro viding workers'compensation insurance for my employees. Below is t/ie policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: 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 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 ofthis statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. t do het eby cerci under the gins and penalties ofpeijuty that the information provided above is true and cof ect.' Signature: Date: Phone#:�/7T 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 Inst uct'iOns 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 indivi' • dual,partnership,association,corporation or other legal entity,or any two or more ofthe 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 Iegal 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 andif necessary,supply sub-contractors)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. He advised that this affidavit maybe submitted to the Department of Industrial Accidents for confinnation 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 ifyou 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 ofthe 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 pennit/11cense 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 pen-nits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or pen-nit 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 foryour 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 De,partmont of luduslrial Acoidents Office of Tuvestiptions 600 Washington Street Boston MA 02 Boston, Xll Tel. 617-7274900 X406 or 1-877 MASSAFE Revised 5-26-05 Fax#617-727-7749 WWW.Mass.gov/dia,