Loading...
HomeMy WebLinkAboutBuilding Permit #459-13 - 78 SUTTON STREET 12/10/2012r/ TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received 1 Z 1 O I Z Date Issued: 1 V1 I L11 I V IMPORTANT: Applicant must complete all items on this page LOCATION' �2&,ea;;2 K -S PROPERTY`OWN ER,. / r�� '� Z L✓ ,o v Print' 100 Year,Old-St[ucture yes nog MAP NOJ) 12,. .PARCEL.M7-2 ZONING DISTRICT. Historic. District yes.. no Machine; Shop. Village yes, o TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial %iteration No. of units: q ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well, ❑,.Floodplain ❑ We- tlands. ❑ Watershed, District ❑ Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: 1 OWNER: Name: Address: CONTRACTOR. Name: - n Please Type or Print rly) asoPhone Address: ) %_.. 722 n..o�G, Supervisor's Construction License: X/ z� Exp. Date: Home. Improvementl IN ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST ASED ON $125.00 PER S.F. Total Project Cost: $ 3-5-0 ®� - FEE: $ Check No.: Receipt No.: aLa 0 2IC4�z NOTE: Pers ns contracting with unregistered contractors do not have access to the guarantyfund , Si Signature gnature of Agent/OwnerAr 'of contractor ;:. _ 1 Plans Submitted ❑ Plans Waived ❑ Certified Piot Plan 11 Stamped Plans ❑ s a It 4 Type of Sewerage Disposal - Public'Sewer Type of Water Supply - Town Water_ Septic Tank. Well COMMERCIAL SIGN OFFS DPW: Approved Rejected Engineering: Driveway Approved Rejected Comment Fire Department: Review 124 Main Street Comment _ Planning Department Comment Approved Rejected Approved Rejected Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date DPW Town Engineer: Signature: Locaiea ou4 us ooa bireei FIREDEPARTMENT'- Temp Qumpster,on site yes no Located at 124 Maini Street Fire: Department,signature/date. COMMENTS, THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF _ Historic District: Approved Rejected — Subdivision: Approved Rejected Water Shed: Approved Rejected Health: Approved Rejected _ Conservation: Approved Rejected Comment COMMERCIAL SIGN OFFS DPW: Approved Rejected Engineering: Driveway Approved Rejected Comment Fire Department: Review 124 Main Street Comment _ Planning Department Comment Approved Rejected Approved Rejected Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date DPW Town Engineer: Signature: Locaiea ou4 us ooa bireei FIREDEPARTMENT'- Temp Qumpster,on site yes no Located at 124 Maini Street Fire: Department,signature/date. COMMENTS, Permit NO: Date Issued: TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received IMPORTANT: Applicant must complete all items on this page LOCATION! PROPERTY OWNE.R,- P. [int 100 Yek old Structure yes Oo.. MAP'NO: PARCEL ZONING DiSTIRICT. _._ Historic District' yes nog Machine_ ShopVillage yes., no,,., TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family 0 Addition 0 Two or more family ❑ Industrial ❑ Alteration No. of units: 0 Commercial ❑ Repair, replacement ❑ Assessory Bldg 0 Others: 0 Demolition ❑ Other [].Septic.,, ❑Well¢ :0 Floodplain D Wetlartds, ❑ Watershed: District ❑':Water/Sewer, DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: Phone: Arlrlracc- 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: $ FEE: $ Check No.: Receipt No. - NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund �Slg'n to ure•of�Agent/Owner��.3 �w' :�''�: e'Signature1of co�ntractor� '� r _ - " µgl Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ v f 1 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ ` TYPE OF SEWERAGE DISPOSAL 'a Siqnature.' 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 'a Siqnature.' COMMENTS L4)cck AEALTH - - -. on Si-qnature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Com Q Water & Sewer Connection/Signature &Date Driveway Permit V DPW 'Town Engineer: Signature: 'FIRE -:DEPARTMENT - Temp Dumpster on site yes Located at 124 MainStreet Fire Depart menfssignatureldate COMMENTS Dimension Number of Stories: Total land area, sq. ft.: Total square feet of floor area, based on Exterior dimensions. ELECTRICAL: Movement of fleeter 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 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 o 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 o 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 appal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm'ated with the building application Doc: Doc.Building Permit Revised 2012 Location N ! ` No. -469 Date 12 I TOWN OF NORTH ANDOVER Certificate of Occupancy $ ND Building/Frame Permit Fee $'� , Foundation Permit Fee $ Other Permit Fee $ TOTAL $ A Check # 26026 0 --.Building Inspector 1 t I 0 L cD z Q lL Z Jgf QH: IgE XCn� N Zi W�L zc. Y !Y LL 0 W CL 0 U W C7 z_ S Q ZW 00 ND � 0 0 y 2 `T W O Q - F- J w W o W v X N > 90 m C14 W O j w FW- 3 U Z v� w H 0 t0 Z J IL aC7 w O a w F O C7 V CL 0 z z Oz O— cU O 2 o~ oz �05F- �o = z= �Z �0 io �— J W __ H �g O ~ O U F- W �'_ -'w __ F- �g �� = N sU) ��LY W Z Q¢ J Ocn EDU) oZ)X 0 Ov> U z¢O Dcnw U?w-1 0 20 w z¢0 DU)W cn?�� 0 �Of 20 w Q 0> W > J J Q O W o O }j W (n J J¢ m -i = w U- fn wfV 0¢ Cn P n.�X >Q >Q m >>�'R LL. z P W F- L1 W QQ Q ? U- O a F- � 5 axxCn 4� W O 0 x ¢�- 00 C11 XW (] N LLV r0N S r �_�2CV N i .`- x N NN Cl) �ON V 2 CL (V L) to § E x (V N� Cl) W O j ¢ FW- 3 U Z v� H H 0 t0 Z J d w 1- d w F O IL D CL o U g z0LL z 0 z 0 W W W (7 ZWU `O X 0 O O `O X m - O ~ O U z 0 w J N X O N X O W Z Q¢ J w - N -J CL w - N J CL U m o0 0 0 0 m 0 its - m 0 0 oa X CU Cl) Qcl F- F- (VO�%5 M v M W O j vi e C� ' o a et -6.2 U) v /F vcn r S E g i •Sz <v W J 16. Ir v �- F0 Lj = to CL M E J L � O z N l� ' _ (D ca L n = N m O =-0 0 0 tm U) = O c> _ Q c t t O foo Qyz tm N p O (D 3 CF) �l c o H a CL = 0 m 0 o c c CD 1 ca45 .y i=c.= _ Q L w -a .o x6-5 N ).2 m t !L ncn = O O. t �O LU1— O+ -•++w+ Z L E �.a = O W i v • V Q. 0-0 d co '0 C J cn m FE o O F— t .O+ O. 0 L) > 2 z cfl z U) w CLx LUW CL w ,-=1 00 o Q Cc J -0 O O z CL C O O H O J U W O W W a a F- pW H H U Z ujd LL CL 0 CA Z W O Z Z U G m (LLI O v O m J NJ LL E m w Y C d LU a+ ?T Z Y V) ca a) N L N \ U- 'D L C L .0 U C0 CA E N j is 7 > v CL C C C C 7 Ll (n LL K U LL C' LL 9= VI LL LL CO ul V) vi e C� ' o a et -6.2 U) v /F vcn r S E g i •Sz <v W J 16. Ir v �- F0 Lj = to CL M E J L � O z N l� ' _ (D ca L n = N m O =-0 0 0 tm U) = O c> _ Q c t t O foo Qyz tm N p O (D 3 CF) �l c o H a CL = 0 m 0 o c c CD 1 ca45 .y i=c.= _ Q L w -a .o x6-5 N ).2 m t !L ncn = O O. t �O LU1— O+ -•++w+ Z L E �.a = O W i v • V Q. 0-0 d co '0 C J cn m FE o O F— t .O+ O. 0 L) > 2 z cfl z U) w CLx LUW CL w ,-=1 00 o Q Cc J -0 O O z CL C I 4 Massachusetts -Department of 'Public Safeh Board of Building Regulations and Standards Construction Supervisor License License: CS 48040 st TgbEUSZ DOWGIERT 17& BRADY AVE k, SALEM, NH 03079 - ,y-15� Expiration: 10/29/2013 Commissioner Tr#: 5561 The Commonwealth of Massachusetts Department of Industrial Accidents Ii Office of Investigations -1 ,-�;..��; 1 � .ff g 1 °�'?U i 600 Washington Street 9lil; : _� VIN, 1f �``v` Boston, MA 02111 °'f f www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print'Leaibly Name (Business/Organization/Individual): 1 )1.:2�� r f �(� 2 Address: City/State/Zip: ,_ �r , ��-�'/"� Phone #: �j' 2,C E`__,�"3 c Are you an employer? Check the appropriate box: 1. I ama. employer with t "' j 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am: a sole proprietor or partner- listed on the attached sheet. # ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I ain a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roofrepairs 13.❑ Other *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. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors acid their workers' comp. policy information. 1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. I Insurance Company Name:. !! i,4 _ L l.� Policy # or Self -ins. Lie. #: Q C-9 C s—�. `7 % Expiration Date: Job Site Address: % " i T CLZ 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 maybe forwarded to the Office of Investigations of the DIA for insurance•coverage verification. 1 do hereby certify under the pains and penaltiespeijury that the information provided above is true and correct 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 Phone #• 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 "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 and, if necessary, supply sub -contractors) name(s), address(es) and phone numbers) along with their certificate(s) of w insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the j members or partners, are not required to cavy workers' compensation 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 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 pen -nit 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' III 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 pennit/license number which will be used as a reference number. In addition, an applicant that must submit multiple-pen-nit/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 marred 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 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-MA.SSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia 03/23/2012 14:05 9786833147 r_f4%M U41 C" 4 CERTIFICATE OF LIABILITY INSURANCE DAM (MM/DDYV Y) 3/23/: TMS CERTIFICATE IS ISSUED AS A MATTER OF INFORIIIIATION ONLY AND CONFERS NA RIGHTS UPON THE CERTIFICATE HOLDER IM CERTIFICATE DOES NOT AFFIFNAIMLY OR NEGAMMY AMEND, EXTEND OR ALTER THE CO MPAGE AFFORDED BY YHE POLICIES BELOW. THS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT W MEEN THE ISSUING IMURER{s), ALITHORIZED REPRESENTA-MME OR PRODUCER, AND THE CERTIFICATE HOLDER, terms and cGlndifions airthe ppilcK CerRaiR policies may require an endorsemeltt A gatement On this certifi9ate does nal canfar righ14UWL &V ts to the certificate holder in frau of such eroorsemen 81. PRODUCER NCONTACT M. P, Roberts insurance Agency NAME:10 1_- 1060 Osgood Street North Andoviar, MA 01945 s: tNSURI;RfS1�iFFDRp_ IAC c0_VERgtpE NAICq IMRER.A� Q.�t4.. u41 INSURED RERa;Guard insurance_- - nolavG2ERT CONSTRUCTION CC). , INC INsu>9o: � 616 3SSEX STREET LWRR2R D • - LAwR13NCz, MA 01841 L�LNSjR1_RE; nHv '-' Inc rVL.yi rGml%ju INDICATED. NOTIAATHSTANDING ANY REQUIREMENT, TERM OR CQNOIT6 OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE MUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONCITIONS OFSUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. .. A� . B _ . . ........ .. .._. R LICA F P F .._._.._.._-.. . TR' .p� 1'YREOPINBURIWCE P LY � 1Y GIYYYY .... ._. LA fi py oENariAi.dueeiLrrr CMP9151606 3/23/12 3/23/x3 EACMOCCURRENCE 91 1,,000•COI X cDMMHRCIALI'aENErIgLL648aITY DCMISEit�A °naal s 100.00,.t G6+41MSaV1ADE OCCUR I MED OP tAruerw A_.—I rc M nnv LAGGRtGATG LNTAPPLf6S PEPe ANY A UTO ALLOWNEO SCHEDULED AUTOS AUTOS nIRE0aUT08 _ AIITOSEO PRODUM . COMP/017 AGG a B BODILY INJURY (Per peman) S BODILY INJURY (Per ecmIdent) S FR ant �gUA3 �[ OCCUR A u10'IZ ?� C[JP9142034 3/23/12 3/231 E=9691.Uka Manse .u. � H bWRIKEM COMPEMIATION AND EMPLOYERS' LMMILITY ;ucwC122432 iD/2 NI E DESCRIPTION OF OPERATIONS f LOC MNS I VENICLES (Adaeh ACOFM 909, Add WM R Mft 3d-Atla, if mora apaee ImmgdMd) 70VZR-TNG OPER&TIONS OF THE RAMI) INSURED AS REQUIRED 9'OR WORK PERFORMED AT HERITAGE PLACE 239 SOUTH UNION STREET LA,MmNca. MA - 3ERITA3E PLA(=,, LLC .AM OZZY PROPERTIES, INC. ARE LIS'T'ED AS AN AtOZTIONAL INSURED HERITA..GE PLACE, LLC SHOULD ANY OF THE ABOVE MaCRIBED POLICIES BE CANCELLED 1100ir C/O OZZY PROPERTIES, INC. THr; EXPIRATION DATE THEREOF. IMICE WILL BE GEWEFfE4 N A�ORQANCE WITH THE POLICY PROV►SIOMB. 1600 C'SGOOD STREET NORTH ANODVER, MA 01845 AUTNORIZEDREPRESENTATNE ACORD 25 {Z07 DIO$) F1988The ACORD name and logo are registered mark of ACORD RD OORPORATI4N, A!i rights fre�rved. Phone: Fax: E -Mail: Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 35,000.00 m $ - $ 420.00 Plumbing Fee $ 52.50 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 52.50 Total fees collected $ 625.00 72-78 Sutton Street 459-13 on 12/10/2012 Interior Renovations