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Home My WebLink AboutBuilding Permit #428-13 - 78 UNION STREET 11/26/2012 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: 4 �_—lj Date Received Date Issued: 7 - ��— IMPORTANT: Applicant must complete all items on this page LOCATION _ - to Y '`� *42 L { nnt- PROPERTY OWNER Print 100 Year Old Structure yes 6no MAP NO: PARCEL ZONING DISTRICT: Historic District yes Machine Shop Village yes 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: 1Xpemolition ❑ Other ❑ Septic ❑Well ❑ Floodplain El Wetlands ❑ Watershed District- 0 istrict❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMEQ., rc_ D�4 qp= tificat� Please,Type or Print Clearly) OWNER: Name: v.r 0J3 Phone: Address: �� v CONTRACTOR Name: [ Gt' Cl6 '✓ Phone: Address: Supervisor's Construction License: ( 440 - Exp. Date. LHome Improvement License: .�3 Exp. Dater l r 3 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED N$125.00 PFR S.F. Total Project Cost: $ Odd FEE: $ Check No.: Receipt No.: . q NOTE: Persons con ratting with unregistered contractors do not hav ac o the a n u ;Signature of Agent/ ner Signature of contract Qw Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ t ed PI s 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ 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 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 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 i 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 D Notified for pickup - Date I 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 ❑ 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 Y 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: Doc.Building Permit Revised 2012 Location WE' V/V No. Dat + - TOWN OF NORTH ANDOVER ru Certificate of Occupancy $ , Building/Frame Permit Fee $ x • Foundation Permit Fee $ �acap" 1 Other Permit Fee $ rc � TOTAL $ Check#q 25988 Building Inspector I .M800 ■ BOARD :UP 2 6 2 - 7 3 8 7 Victim Services • Securing Buildings • Protecting People&Property 4 ter: r �g - y � T 1 i "`"I r �/"�` '� � •��' ."� _r 'fit� � y ' `. 4 it �+ a �� Sf�,�V fl�. �K • • 00 Al io {{ 40 we 't m �� ti • . { T r = l ny'. �J',� •+,'• ^ .. w t�.,. r , � .�y�. ..m6 V\`+w'l ati+,aq{1 F ` oil I 01111111 Ills # G.r' � . o✓ ' t Aim{'h#�) 1,\F?. �3�ssJ- 3 �s i I, 1 i m8OOmBOARDbP 2 6 2 - 7 3 8 7 f= Victim Services•Securing Buildings•Protecting People&Property 'YAM _ - r � r 1 -800-BOARD P ^Securing Buildings•Protecting People•Minimizing Damage it I 38 Crafts Street Emergency:800-262-7387 Newton,MA 02458 Phone:978-815-9742 Fax:978-664-6312 Rharrisl800Boardup/f gmail.coni 1-800-BOARDU P.com 2012 Orate Pat��e Each Office Independently Owned and Operated 1-800-BOARDUP Post Incident Summary 80 Union Street North Andover, MA Board Up Call Home Owner: F Paul Dubois Primary Contact#: 978-420-8266 _771 F.D. incident Commander: Primary Contact#: Insurance Details: Liberty Mutual BOARDUP Manager: Michael Parow Manager Contact#: 781-589-4119 BOARDUP On-Scene: 03:00 Approx. FD Left Scene: BOARDUP Left Scene: 13:00 Disposition of Occupant: 3 family house. Fully occupied. Paul Dubois is the property owner. Red Cross called to take care of occupants. Summary of Services Provided Windows Doors Roof Housing Loaner Cell Property Covered Secured Tarped Provided Phone Recovery 27 windows Notes 1: Homeowner called 1-800Boardup. Referred to him from his insurance company Liberty Mutual 2: Boarded 20 upper floor windows and 7 Basement windows 3: Reassembled a few windows that were just taken out of the sash 4: Jeff Rain from ARS on scene to help homeowner with the Emergency Service work,such as clean out and drying 5: 6: t 1-800-BOARDUP Report Submitted by: Jack Parow Phone: 978-490-4736 Misc.Contact Info: If you should have any questions please do not hesitate to contact Jack Parow Eor Mike Parow 781-589-4119 Richard Harris <chiefrharris@gmail.com> byCA)OSIC North Andover 1 message 9 ChiefCFD@aol.com <ChiefCFD@aol.com> Mon, Jul 9, 2012 at 3:19 PM To: chiefrharris@gmail.com Rich, attached are the pictures and the after action report for North Andover. Thanks Jack Chief Jack Parow (Ret.) 1-800BoardUp 32 School Street Chelmsford, MA 01863 Parow1800BoardUp@aol.com Cell 978-490-4736 In800@80ARD SO4 P 8 attachments t DSCN0270.JPG 1821K Inr DSCN0271.JPG 1833K DSCN0272.JPG 1822K i f t. DSCN0273.JPG 1860K } W TT j DSCN0274.JPG 1818K ,i ...s.rr .fk h. �R s }a _ DSCN0275.JPG 1829K q, ,• 1 DSCN0276.JPG . 1849K 1101 Post Incident report No.Andover.doc .--� ---w - ■ � u . � 4ty - . , «: . . x. . \ - > . . photo-1 p oto Enter construction cost for fee cal- North Andover Fee Caku/atlon Construction Cost 129000.00 m $ - $ 144.00 Plumbing Fee $ 18.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 18.00 Total fees collected $ 280.00 78-80 Union Street- 428-13 on 12/5/2012 Demo interior and expose fire dama e 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 Le0bly Name (Business/Organization/Individual): I/ut 6+ Address: b�� City/State/Zip: Phone#: `7 ?�� G r 23 Are you an employer?Check the appropriate box: Type of project(required): 1.1W I am a employer with 1' 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.ElI 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. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical 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.❑Roof repairs insurance required.]I employees.[No workers' comp.insurance required.] 13F]Other kny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site formation. tsurance Company Name: :)licy#or Self-ins.Lic.#: Expiration Date: ►b Site Address::l ( �' 1 y City/State/Zip: ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). tilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ae up to$1,500 and/or one-year imprisonment well as civil penalties in the form of a STOP WORK ORDER and a fine up to 0.00 a day aga' t th iolator. Be vi ed that a copy of this statement may be forwarded to the Office of V igations of the DIA fo i u ance cove ge i ication. io he certify a� er th ai_ a p lties f perjury that the information provided above is tru7,aco,,rrect. na Date: 6 tone#: &CY/-- Ea? �c 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 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-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 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 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 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. #617-7274900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 evised 5-26-05 www_m a ss.unv/cl i a r 1_ NORTH - n " ve" . 0 AJZS 00 J- 13 "'k- hver, Mass, MCOM11.1414w,coc y1. A—Ad �,Q ADRAtED �Pa,�'(5 S U ..IT BOARD OF HEALTH Food/Kitchen PER D Septic System THIS CERTIFIES THAT ..y. .. �. BUILDING INSPECTOR ............................................ has permission to erect . .:...... buildings on .. .. Foundation • Rough to be occupied as ► f�. ..............,.. �... .....��...... ...... . ... ..... .. ... .. Chimney provided that the person a ting this permit shall in every respect conform to th 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 NTH ELECTRICAL INSPECTOR UNLESS CONSTRUC T Rough Service ............. ...... .......... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildine 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. v *- Massachusetts- Department of Public Safet. Board of Building Regulations and Standards Construction Supervisor License License: CS 86299 TIMOTHY A GIARD PO BOX 782 (-31 NO ANDOVER, MA 01845 Expiration: 7/15/2013 Commissioner Tr#: 19281 / :r Timothy A: GIard Plumbing & Heating Inc. Esti mate, Date Estimate# N ame/Addre ss.... 11/5/2012 1484 Paul Dubois 75:Mea6ow,Lane ' forthAndov-er, Ma '01845 _ Project Description Total Re:Union Street Project _ Demolition only of all wall and ceilings. Exposing framing l st and 2nd floors Clean out basement and pressure wash to expose:damage. Removal of wire; insulation;and,piping All material to be�shooted to'dumpster Total Cost 12,000:00 *** Doesn't not include dumpster(3 Approximaidly)***.` *** Doesn't not include"any':permit fee's for'-demo,or dumpster* Total .` $12,000.00 Signature ' P.O. Bo x 782; North Andover; MA 01$45! Telephone (978)689-8336