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Home My WebLink AboutBuilding Permit #120-2017 - 87 BUCKINGHAM ROAD 8/8/2016 i \1oRTy 1�lllV///1111�\ 1 " VI BUILDING PERMIT o ,�{.-Eo 16 ti TOWN OF NORTH ANDOVER _' '6 APPLICATION FOR PLAN EXAMINATION - �l - z Permit No#• � Date Received 7 A�RITED .PPy'`c �SSACHUS�� Date Issued:op 0906 IMPORTANT:Applicant must complete all items on this page LOCATION 2 Ck)1bq Pring- �F-- R PROPERTY OWNE D o. �L sig, P /(�ir Print 1 o Year Structure yes MAP v � PARCEL: aZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 'R'One family ❑Addition ❑Two or more family ❑ Industrial XAlteration No. of units: ❑ Commercial 'Repair, replacement- ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ® Septic ' bell '111Wig_ ® Floodplain,` 0 Wetland`s , :, s ® UVatershe D�str - titer/Sewers c )DESCRIPTION OF WORK TQ BE PERFOIM v f �Vv� i� :� ' 81,2 t✓ �� Z CPi Iden ' kation- se Type or Print Clearly OWNER: Name: S Phone: r Address: ?,>\ fRt-CEPpLaJJ 6� Contractor Name: (� ^ ICS � Phone: ``7) ` �T L Email: Address: ' T �-t� Supervisor's Construction License: 10 c( I Exp. Date: Home Improvement License: S 22- Exp. Date: 'ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ �3 , 5D®9 ::�) FEE: $ q-2 ad Check No.: 0 Receipt No.: �Q�0 NOTE: Persons contracting with unregistered contractors do not have access tot uaranty fund Y.'l; k�.14. .RS#§:� +J- �&y -:, -.i -a4Z e f i. .'•s--s•. -A ,Jr r 1_ _ v _.a.,....f.,amnsa=,.a;d..s...�_. mow,.:;:—�2'+ 7 4 �.�Jc.,. .L+t,. �w3i. ......�.�. ..:1 Location � �,i_ .� �-3 GK`.t 1 No. � Date . i TOWN OF NORTH ANDOVER • Certificate of Occupancy Building/Frame.Permit Fee Y Foundation Permit Fee Other Permit Fee TOTAL I i s - Check#—Q — z Building Inspector s' $3 ' i b + � ( _ _----------— '— -- W' Plans Submitted Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DTSPOS Public SewerTannmg/Massa eArt El Swimming Pools ❑ g /Bod y Well ❑ Tobacco Sales ❑ FoodTackaging/Sales ❑ Private(septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF v U FORM PLANNING Cox DEVELOPMENT Reviewed On Signature_ .COMMENTS CONSERVATION Reviewed on Signature COMMENTS I HEALTH Reviewed ori Signature _ COMMENTS F Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes r 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 Dempster.on safe, yes�.� � � �: '_ � 'a NR a 'rc r — c L•ocate�datw124Maitreet m1 , , � :Gi- 'C' { A� � ��r 'r `s'•T� 7 �'�fY" 4 ...x .7. 4 �_ �{ Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ff.: 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 Call Email Date Time Contact Name Doc.Building Pennit Revised 2014 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 Ruilding-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 OTE: 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/Cross Section/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 OTE: 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 2012 IECC Energy code Engineering Affidavits for Engineered products NOTE: All dum sterpermits require sign offrom Fire Departmentprior 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 2014 Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 31500.00 m $ - $ 42.00 Plumbing Fee $ 5.25 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 5.25 Total fees collected $ 152.50 87 Buckingham 120-2017 on 8/8/2016 add shower and laundry room NORTH '9 Town Of aAndover C° h ver, Mass, 00f Ale "fA cocK4caew#CK y7. 7,9 A°R�rEo ►P�` •(y U BOARD OF HEALTH Food/Kitchen P. E IT T LD Septic System THIS CERTIFIES THAT . . ...... .. .............................................. .. Foundation BUILDING INSPECTOR . has permission to erect .......................... buildings on ... ... ... • .��, . .� �. W10 Rough to be occupied as r.. ./,� .L. .. .�.... .... ... . ► .. . . ................ Chimney provided that the person accepting this permit shall in every resp t conform to the erm 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 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU TIO KAT§ Rough Service 01 ......jiPE6TT .... Final BUILDING R GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. Smoke Det. LA IL -411 -�4�9 . , T I f i : The Commonwealth of Massachusetts z Department oflndastrialAccidents 1 Congress Street,Suite 100 r„ .Boston,MA 02114-2017 U . www mass.gov/dia SY• Workers'Compensation Insurance Affidavit:Builders/Contractors/FjegiTicians/Plumbers. TO BE]AILED WITH THE PERMITTING AUTHORITY. Please Print L, Applicant Information • e 'bl Name,(Business/Orgamation/Individual1'e � �C�c�,C L VJ, S,(,_ int fs Address: - u�wc,•.y City/State/Zip: ,rc, ' I Phone#: S`0 9- 9*Z ' 2,6 2`1 Are you an employer?Checktlieapliioprlate box: 'Type of project(required): 1.❑1 am a employerwith employees(full and/or part-time).* 7•• Q New coiistruction 2.�I am'a sole proprietor or partnership and have no employees working for me in 8. [ Remo delirig any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.Q I am a homeowner doing all work myself[No workers'comp..insurance required.]t 10 E]Building addition 4.VI am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.[]Electrical repairs or.additions proprietors with no ein#loyees. ' 12:*lumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13_-Q Roof rep airs These sub-contractors have employees andhaveworkers'comp.insurance.; 14.Q Other 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no.,employees.[No workers'comp.insurance required.] *Any applicant that checks b6x4l must also'fill outthe section below showing theirworkers'compensation policy information. Homeowners who subniittlmis affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such TContractors that check this box must•athached 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,ley must pro-vide,their workers'comp.policy number.• Iain an employer tTzat ispi•ovidingworkerrs'compensation insurancefor my employees'Below is thepolicy andjob site information. Insurance Company Name: Policy#or Self-ins.Lic.#: ExpirationDate: Job Site Address: �� (A &tA City/State/Zip: Attach a copy of the workers' compemsatio policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.A,copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer ti u Get the pains and pen ties ofperyury tlaat the information provided above is true and correct Si ature: C9 Date: )6 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 Infox°mation 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 lure, 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 fd1out-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 p artners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. B e advised that this affidavit may be submitted to the Department of•Industrial Accidents for confin-nation 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 aieference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current polioy 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. Anew affidavit must be filled out each year.Where a homeowner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA.02114-2017 Tel. # 617-727-4900 ext.7406 or 1-877-AIASSAFE Fax#617-727-7749 Revised 02-23-15 wwwmass.gov/dia 1Jassachusetts Deparii;ent of P Board of Budding Regulations Public S ' C��e ai�zo�eoaacaetr/C d.C�/f��caaac�ccleGll afety Reg ns and Standards Office of Consumer Affairs&Business Regulation License: CS-109119 HOME IMPROVEMENT CONTRACTOR Construction Su pervisor ;-, MR., Registration X18.5227Type: LExpiration 5/12!201,8 LLC PATRICK RUSSELL 80 SAILE WAY r I SAINT CHRISTOPHER PRO S, LLC 1 NORTH ANDOVER MA 01845 ti �i ` PATRICK RUSSELL 3 r 231 BROADWAY r METHUEN,MA 01844 Co �' Co Undersecretary lY mmissioner Expiration:. -- Ooiu712019 . 4.. s'Y µ