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HomeMy WebLinkAboutBuilding Permit #804-12 - 83 OLYMPIC LANE 5/8/2012BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: ?a Wig- M -L_ TYPE OF IMPROVEMENT New Building Addition Alteration Repair, acem Demolition PROPOSED USE Residential ne Two or more. family No. of units: Assessory Bldg Other Non- Residential DESCRIPTION OF WORK TO BE PREFORMED: 0 IdentificationPlease Type or Print Clearly) OWNER: Name:_G h rr'S Coi,`n I Industrial Commercial Others: W7JW-/'07 ARCHITECT/ENGINEER Phone: Address: Reg. No:` FEE SCHEDULE: BULDING PERMIT.- $12,00 PIcER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Tota! Project Cost: $_ �, f �6 ✓� dy FEE: $ i Check No.: Receipt No.: 7 7 NOTE: Persons contracting wit1� _ unregistered contractors do not have access r i //I the gcaranty fund 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 (Cep—tic—t4k, etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE 'USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS_ CONSERVATIONReviewed on Si-ghature tCOMINIENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Pinnn in*f3 Roard Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street "E 3Locate,za - 5. n-1 N; . . . . . . . . . . h 3 ime.ni Z191 -NA 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 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) ❑ IVI "'ass 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 ❑ Ce �ified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses Li 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: Building Permit Revised 2008 7 Location _ No. � Date Check # y 3 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $>O° Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 25277 B `ild'i ,g nspector f jo 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: je Zan e is that the debris resulting from this work shall be disposed o 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 OA. The debris will be disposed of in: (Location of Facility) 4igg4naeEo]f�P�ermmiit pp 1z - Date his )ssae- wlj?- clu�,/I,P �.0e-- oeem; 101 Amo o V U vv ;p ac ev W D o 'A CD AmD moa z "INS o 0 `b Goec�v E O L o: z q 4 -'co o U J. O , k O.V O r^ \�= o C. v: SO CD 93 C\ mph m �• o•sZ o U coo o' O CD �CL -40 ~ C, vi CLLU m COD t N C4,2LU O C Z � 5 � CO3 O v •® o m E c FQQ= CO2 a 2 two ���•� � F- S. CL, m :go CD O C O o v z °' CL O H G C CD o, y mm .CO2 O Q7 CL O O i cc o a CL o,a C .o O � Cc Q J .� O� CCL z � V N2 O C C cc d CO2 O ,,aww Y♦ LU U) W W 19 W 0 o L" Cf) v cn o o Cd O G2 O w U G x a o u w aa p w co x a M f3i 0 2 cx Lx. a o. u O—cd w G !L. w w . v GU z V) Q o cn Amo o V U vv ;p ac ev W D o 'A CD AmD moa z "INS o 0 `b Goec�v E O L o: z q 4 -'co o U J. O , k O.V O r^ \�= o C. v: SO CD 93 C\ mph m �• o•sZ o U coo o' O CD �CL -40 ~ C, vi CLLU m COD t N C4,2LU O C Z � 5 � CO3 O v •® o m E c FQQ= CO2 a 2 two ���•� � F- S. CL, m :go CD O C O o v z °' CL O H G C CD o, y mm .CO2 O Q7 CL O O i cc o a CL o,a C .o O � Cc Q J .� O� CCL z � V N2 O C C cc d CO2 O ,,aww Y♦ LU U) W W 19 W 0 j § m `� � �� (� 2 9 m m 2©&. o R « 2 : m � '01 o q q = 2 2 7 , > ) ? R k m a�� m� ' EA■ -r v . yy/ 2 o0 . Me g� k.. o 2 0 _ \ i § CL '/ ! \ ® D . � G j ? 2 \ k C. .■ 3. 2 8 / \ O R \. § k o R ; q > m 2 & q k� k� 22§ m S / �\ c�- % R a g 7 \ � w j § m `� � �� (� 2 9 m m 2©&. o R « 2 : m � '01 o q q = 2 2 7 , > ) ? R k m a�� m� ' EA■ -r v . yy/ 2 o0 . Me g� k.. o 2 0 _ \ i § CL '/ ! \ ® D . ^ The Commonwealth ofMassachusetts • - Department oflndustrigl Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgovIdia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / Please Print Le;;ibly Name (Business/OrganNation/lndividual): �� t/11(�Q f Z_L� C, . Address:_ City/.State/Zip:_ 174 err i /rock k Nk 0.-34SY Phone #: 0y3) 1-?KS- — -2oa 0 Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ T am a general contractor and I 6. [] New construction employees (full and/orpart-time) * 2. ❑ T am a sole proprietor or partner- have lured the sub -contractors listed on the attached sheet. x 7• E] Remodeling ship andno employees These sub -contractors have 8. Demolition El working forme in any capacity. workers' comp. insurance. 5 We are a corporation and its 9. [] Building addition [No workers' comp. insurance required.) officers have exercised their 10.[] Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL 11.[j Plumbing repairs or additions myself. [No workers' comp. c.152, §1(4), and we have no 12.QRoofrepairs insurance required.) "i employees. [No workers' 13.0 Other 5'( a/ V6 comp. insurance required.] 'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation polioy information. T Homeowners who submit this affidavit indicating they ere doing all work and then hire outside contractors must submit anew affidavit indicating such. ?Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. X am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Policy # or S elf -ins. Lic. Job Site Address: Expiration Date: 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 requiredunder 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 civilpenalties 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 DTA for insurance coverage verification. Ido hereby certi# uncle yhepains andpenalties ofperjury that the information pro videdabove is true anti correct. )'hone#• G� %t%S —_)UoZO 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 ofhire,- 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 ofits political subdivisions shall enter into any contract for the performance ofpublic 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 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 fox 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 pennit/licens e 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: Tho Gommonwoalth o assacl?usotts Dgpaftmt of industtial ,A.cczdoats OfAce of100stigatiow • 600 Waslwa&a Sjroet BostonX.A, 02X X 1 TO, # 617-727-4900 ort 406 or 1-87WA.SS.ABB Revised 5-26-05 Fax # 617"727-7749 www.mass,govaa Page No. of Pages l PH. (603) 765-7020 A9 FAX (603) 595-0919 �sto@ Woodworkill ate, PROPOSAL SUBMITTED TO /Z15- COW All PHONE 0 DATE STREET %� / 73 0 % - JOB NAME CITY, STATE and ZIP C DE I IYDvU�►2 � - o , � �s" JOB LOCATION �� PROPOSAL IS VALID UP TO 30 DAYS FROM DATE JOB PHONE We hereby submit specifications and estimates for: VFz fix_! s�7"in!G._ _�_ �_W _-_ b� 6AD' Y7 L //nn nn II AJ e Propose hereby to furnish material and labor — complete in accordance with above specifications, for the Sul u j� o t�C G dollars ($ U47dUavz3 ) Payment to be made as follows: A.� --- --- --- -- -- O-------------------------------------------------------------------------------- ------------------ N�� — All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from .above specifications involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado, and other necessary insurance. All guarantee claims are at contractor' discretion. All decisions are final. All materials are property of contractor until job is paid in full. There is Authorized a $25.00 fee for any return checks. Customer agrees to pay any and all collection +/or Signature legal fees. Customer agrees to pay 15% interest on any balance over 30 days. Note: This proposal may be wltnarawn oy us it not acceptea wltnin (;kra 1tanrB 01 roposal — The above prices, specifications Customer p ^ and conditions are satisfactory and are hereby accepted. You are authorized to Signature do the work as specified. Payment will be made as outlined above. Customer Signature Date of Acceptance: days.