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HomeMy WebLinkAboutBuilding Permit #330 - 700 SALEM STREET 10/30/2007 tIORTH BUILDING PERMIT Of,t�.o , - TOWN OF NORTH ANDOVER _` ° APPLICATION FOR PLAN EXAMINATION00 Permit NO: Date Received AT p' �,� \ � Date Issued: A0 0 .07 �SSACHUSF� IMPORTANT:Applicant must complete all items on this page CA 0- t * C" „�' ,3 � -u�` ,�,Cyn PRROT'KERT1xC3WT�ER s °" 4Yk t rt h ♦ r�epk`" ?, ..si:. .x tt y y.», s 7, ��- f` �,; dn YI` '"'1 �` `i"4,..1 '«'v+ � £:. � "S-N�L ,�k Y..� 4 - .2`r�c 'S uk J4^�"' 1 '� 4•;,% ]lANO PA2CEl_ ON1'NO"DISTI]C Fislor�c°t�s#rct deso µµ xh�- � 4Igrp�i/L yp�iJer+ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building a amity Addition Two or more family industrial Alteration No. of units: Commercial Repair, replacement / Assessory Bldg Others: Demolition 0/ Other Septic tl /ell l ' h �oodpla�rt u£ eflands' , ty 1Na#ersied��str�ct ter/Sewer _"�� .w`w.. ...7.h 9 ;. "s�dtY ' - ;s�,?• ., f `r".a vi`.�r .r<' q,.43Y�" x' 'r .'`t; a 'yr DESCRIPTION OF WORK TO BE PREFORMED: Identification Please Type or Print Clearly) OWNER: Name: /4r - ip Phone: — g-07 7� Address: A — 'e... 11 t r }vpLy-{3 CONTRACTOR Namexrt �t�hone kx ' ", 4x,e y-.-i u .� ro P t - n "` t : rFt a -dress dot P �z �- ►� r +- � 1=�x�p 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: $ o 000�OG_ FEE: $ Check No.: '7 /7n� Receipt No.: 2 7 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund iY Signature. A" ent/flwner' ' Signature of contractor '' �. 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 et this recorded at the Resist of Deeds. One co and roof of recording g Registry PY P g must be submitted with the building application Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 i Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL l i Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private(septic tank,etc. Permanent Dumpster on Site I THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS - - DATE REJECTED DATE APPROVED `CONSERVATION 'COMMENTS DATE REJECTED DATE APPROVED HEALTH 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 Located at 384 Osgood Street FIRE'DEPARTMEIT Temp rDumpster on site yes no ,:at.124 J Street 64D 6p' a"r' me'n"t s�gna#urefc�a#e ;b "COMMENTS ~'A c 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 2 1 A—F and G min.$100-$1000 fine NOTES and DATA— For department use) i ❑ Notified for pickup - Date Doc.Building Permit Revised 2007 Location No. 7O Date MORT� TOWN OF NORTH ANDOVER 0 ; y " Certificate of Occupancy $ _ s i i ;,SIACMUS t� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 20739 Building Inspector i NORTH Tovm Of No. 334) ~ LAK dover, Mass.,v ` o7 . ' D 1. A_ COC MIC NE WICK ORATED BOARD OF HEALTH Food/Kitchen PERMIT. T.. D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT a �R 70 .................. ..................... .................:............. ............ ....................................................... Foundation has permission to erect........................................ buildings an on ...2.� ................:............... ..................................:.............. Rough �/<<' to be occupied as......................... ?.............n6...../`............../10-- 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 CONSTRUCTION FARTS Rough Service BUILDING INSPEC R 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 Smoke Det. The Commonwealth of Massachusetts Department of Industrial Accidents W Office of Investigations a d 600 Washington Street Boston,MA 02111 b` M 5� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zip: r/A-f5-kAt/ G3M6S— Phone.#: Are ou an employer?Check the appropriate box: Type of project(required)':,, 1.VI am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. El New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp.insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.�Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 131-1 Other comp.insurance required.] *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. lContractors 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 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: A . z—/—n t J44 L/ Policy#or Self-ins. Lic.#: AwC-7o Expiration Date: Job Site Address: /e/11 (5�L City/State/Zip: I/O— .�t•��i �C lt�'S 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 under the pains and penalties of perjury that the information provided above is true and correct. i Signature: /`" " %�� � �/ Date: 161— 19_0 _ 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#: I' 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"ever 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(' )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 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 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 1-40T 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 11-.22-06 www.mass.govfdia OT, _6omnwncaea i o�./�aaauc�ivae i Board of Building Regubdons and Staid a& lj HOME IMPROVEMENT GONTRACT;OV g Registration X127972 Exp�ratj�n 2/$/ 009.` Tr# 1 (3£,25y f j fr Type Individual MICHAELW.'GOSSELIN: r�j MICHAEL GOSSEUNry 38 FORREST..ST ` / �.sQ. y PLAISTOW,NH lieomvnzo�zasekCt� o�✓l�a�scul uaetta BOARD OF BUILDING REGULATIONS - License:, CONSTRUCTION SUPERVISOR Number..CS 072971 Blrthdate�11/04/1957 „ y,&6 11/04/2007 Tr.no: 17490, 'NMI Restncted: 00 �II MICHAEL W GOSSELI N Y 38 FORREST ST PLAISTOW, NH 03865-' commissioner NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: SWC- is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section I 0A. The debris will be disposed of in: P1r.1,G 0 (Location of Facility) I Signature of Permit Applicant Fire Department Sign off: Dumpster Permit Date WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Industries of Massachusetts Mutual Insurance Company Burlington,-Massachusetts - ---- -- __ _ i (800)876-2765 NCCI N02615 8 POLICY NO. AWC 7013481012006 ITEM PRIOR NO. AWC 7013481012005 1. The Insured Michael Gosselin dba M W G Construction Mailing Address: 38 Forrest Street Plaistow NH 03865 (No. Street Town or City County State Zip Code ® Individual ❑ Partnership ❑ Corporation ❑ Other FEIN 01-9506249 Other workplaces not shown above: 2. The policy period is from08/12/2006 to 08/12/2007 12:01 a.m.standard time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here; MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident Bodily Injury byDisease $ 500, 000 policy limit Bodily Injury byDisease $ 500,000 each employee C. Other States Insurance:Coverage Replaced By Endorsement WC 20 03 06A D. This policy includes these endorsements and schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating plans. All information required below is subject to verification and change by audit. Classifications Premium Basis Rates Code Estimated Per$100 Estimated No. Total Annual of Annual Remuneration Remuneration Premium INTRA 300911 SEE EXTENSION OF INFOR14ATION PAGE Minimum premium$ 500.00 Total Estimated Annual Premium $ 550.00 As indicated interim adjustments of premium shall 1 p be made: Deposit Premium $ .550.00 ® Annually ❑ Semi Annually ❑ Quarterly ❑ Monthly MA Assessment Chg. $308.00 x 4.1920% $0.00 G� This policy,including all endorsements,is hereby countersigned by aa 07/25/2006 Authorized Signature Date GO V GOV KIND PLACING CLAIM NAME SAFETY STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP Byfield Insurance Agency Inc MA 5645 2 1705 P O Box 400 WC 00 00 01 A(11-88) Byfield,MA 01922 Includes copyrighted material of the National Council on Compensation Insurance, used with its permission.