HomeMy WebLinkAboutBuilding Permit #648 - 733 TURNPIKE STREET 5/27/2009BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: �OY� Date Received
Date Issued: 27 Q
I PORTANT: Applicant must complete all items on this pate
•
LOCATION
Print
PROPERTY OWNER 'GUkAc.-, X -00 - t -e
Print
MAP NO: PARCEL: ZONING DISTRICT:C1- �> Historic District yes no
Machine Shop Village ves 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:
Identification Please Type or Print Clearly)
OWNER: Name:
Address:
CONTRACTOR Name: Phone:
Address:
Supervisor's Construction License: Exp. Date:
Home Improvement License:
Date:
N.,.
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: $ FEE: $ /2
Check No.: 3 Receipt No.: 2 2 �y
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
ignature of Agent/Owner Signature of contractor
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
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE REJECTED
DATE APPROVED
Reviewed on Signature
Reviewed
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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 on site yes no
Located at 124 Main Street
Fire Department signature/date
COMMENTS
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 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
Location 733 -71
No. . w - Date Of
j0*Toj TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
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Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
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Date .............
RT"
TOWN OF NORTH ANDOVER
PER�MIT FOR PLUMBING
This certifies that
............. .......................
has permission to perform
. ........... ..........
plumbing in the-b-aildings
.................................
at. ....... I North A ndover, Mass.
Lic. No ....... .. ..... ............
E�U ;��N
Check # GINSPECTOR
�w
M
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Date
Building Location Z 33 %Vj" Sj Owners Name TV i� �C3 � Permit #
j)OkTf &Jbi Vbk Mt� olg K A ount
Type of Occupancy F0 0- S9/2l/ 10— e S A 1-6
New Er-, Renovation Replacement 1:1 Plans Submitted Yes 1:1 No
W1
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' DR
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(Print or type) Check one: Certificate
Installing Company Name 4 ❑ Corp.
Address 1` L �� t"C S u �'! %% '0 1��7 ❑ Partner.
Business Telephone '7 Q —1 IL. g0 Firm/Co.
Name of Licensed Plumber:
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy n � Other type of indemnity ❑ Bond ❑
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts SSAtOPlumbing Code and Chapter 142 of the neral Laws.
BY Signature or Licenseariumma
Title
Type of Plumbing License
'
City/Town License 1,4um5er Master Journeyman ❑
APPROVED (OFFICE USE ONLY
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 IMashington Street
Boston, MA 02111
www-nwss gov/dia .
Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
riniicant Tnfn.•...., :,...
Name (Business/Organizafion/lndividual);_
Address:
City/State/Zip:_ `/1��,. ,� /�% (> Phone #: 4"� j
Are you an employer? Cheek.the appropriate box:
I • am a employer with_
4. ❑ 1 am a general contractor and I
employees (full and/or part-time).*
2. ❑ I am.a-sole proprietor or
have hired the sub -contractors
listed
partner.
on the attached sheet ?
ship and have no employees
These sub -contractors have
working for me in any capacity,
[No workers' comp. insurance
workers' comp. insurance.
5. ❑ We are a corporation and its
required.]
3. F7 I am a homeowner doing
officers have exercised their
all work
right of exemption per MGL
myself. [No•workers' comp.
c. 152, § 1(4), and we have no
insurance.required.j t
employees. [No workers'
comp. insurance required.]
*Any appiiearn that checks ba # l rqust also f"'out the section below showing their workers' com set'
Type of project (requires():
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
I I.❑ Plumbing repairs or additions
12.0 Roofr-pairs
13.❑.Other
Homeowners who submit this affidavit indicating they are doing an work and then hie outside contractors m
�Cmust submit a new affidavit indicating such'Co'ntractorsthat check this box must z7aeired an add:tioaal sheetsho vir the
mum the subcontractors and their workers' cerrp. RoliC, info rne8on.
or an employer that is providing:workers' comp
nsation insurance for RV employees: Below is the policy unit jab site
q
Insurance Company Name:_
Policy # or Self -ins, Lic. #:
Expiration Date:
Job Site Address,,_ Z �itf�r j�i j
City/Staie2ip:/C�f4
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 e. 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.
! do hereby c under the pairs and penalties of perjury that the irtfnrmaiion provided above is lr�e onurrorreet
Si tune: �2
Phone #:i �i�j
Ofj`iciat 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):
L Board of Health 2. Building Department 3. City/Town Cierk 4. Electrical Inspector 5. Plumbing Inspector
6.Othe'r
Contact Person• Phone #:
Information a i1d Instructions
Massachusetts General Laws chapter 152 requires all emp 3 oyers 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 mom
of the'foregoing engaged in a joint enterprise, and includirig 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 Gcensing 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-contractoi(s) name(s), address(es), and phone number(s) along with their certificates) 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' co,7rtpensation 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 .app.iication 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'
carrtpemsation policy, please call the Department at the numberlisted below. Self-insured companies should enter their
self insurance"iicense number on the' appropriate Tine.
City or Town Officiais
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 permittlicense number which v►-ilI be used as a reference number. In addition, an appiicent
that must submit multiple permitAimnse 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 starnped 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. When a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a flog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit
The Office of Investiptions would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give as 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 1-8.77-MASSAFE
Revised 5-26-05 Fax # 617-727-7744
www.mass.gov/dia