HomeMy WebLinkAboutBuilding Permit #537 - 88 SAUNDERS STREET 2/7/2007Permit NO:
Date Issued:
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION -
Date Received_42Lt'y 9
IMPORTANT: Applicant must complete all items on this page I
LOCATION
Print
PROPERTY OWNER PeIZ!- :/ l054 �
Print
MAP NO.:1'155'`0 PARCEL:_
a1( -Or
TIVDW A AM ITOF MW RiTY[ MIN(:
ZONING DISTRICT: '/C'
mgTnRIC nISTRTCT YES ❑
a as ar
TYPE OF IMPROVEMENT
- _ -____ _ _ -
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ Addition
❑ Alteration
❑ One family
CEJ-T-wo or more'family
No. of units:yZ�
❑ Industrial
epair, replacement
❑ Demolition
❑ Assessory Bldg
❑ Commercial
❑ Moving relocation
❑ Other
❑ Others:
❑ Foundation only
DESCRIPTION OF WORK TO BE PREFORMED
Identification Please Type or Print Clearly)
OWNER: Name: Pe3l�,4- i`'Ly Phone•F�l-8'Ul-/
Address: ??' --
CONTRACTOR
2e/
Address:, -2 ? 0
Supervisor's Construction License: CS 083ol `j Exp. Date:
Home Improvement License: i3 E Exp. Date: % 7
FEE SCHEDULE. BOLDING PERMIT.• $1200 PER x1000.00 OF THE TOTAL ESTIMATED COST BASED ON 5125.00 PERS F.
Total Project Cost :$ 1 ��DO �- FEE:$ aa10
Check No.: �b ,ice Receipt No.: Z9 I
Page ]of 4
TYPE OF SEWERAGE DISPOSAL
,_,/
Tanning/Massage/Body Art E]g
Swimming Pools ❑
Public Sewer LI
Well ElTobacco
Sales ElFood
Packaging/Sales El
❑
Permanent Dumpster on Site
ElPrivate
(septic tank. etc.
Electric Meter location to
project
NOTE;: Persons contracting with unregistered contractors do not have access to the gaarantyfund
SignatureCfAgen %1+il Signature of contracto
Plans Submitted Plans Waived ❑ Certified Plot Plan ❑ Stamped Pl s ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
DATE REJECTED DATE APPROVED
CONSERVATION ❑ ❑
COMMENTS
DATE REJECTED DATE APPROVED
HEALTH ❑ ❑
COMMENTS
R
FIRE DEPARTMENT - Temp Dumpstejoneyes no
Fire Department signature/date 1/ .. — —70
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
Building Setback ft.
Front Yard
Side Yard Rear Yard
Required
Provided
Required Provides Required
Provided
Dimension
Number of Stories:_ Total square feet of floor area, based on Exterior dimensions. 9-
3��
Total land area, sq. I: /i ,�
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
Addition Or Decks
❑ Building Permit Application
❑ 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)
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
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
Dec: INSPECTIONAL SERVICES DEPARTMENT:81'FORM05
Page 4 of 4
Location A- (T <
No. 15 3 Date
MO^Th TOWN OF NORTH ANDOVER
9
Certificate of Occupancy $
Building/Frame Permit Fee $
�CHUS
i
Foundation Permit Fee $
Other Permit Fee $ '
TOTAL $
Check # DL
1991 -�
Building Inspector
s
The Commonwealth of Massachusetts
Department of Fire ServiceS
Office of the State Fire Marshal
P. O. Bo- 1025 State Road Stow MA 01775
PERMIT Date: oz o/
North Andover permit No
( City of Town) (If Applicable) Dig Safe Num er
In accordance with the provisions of M. G.L_14 8 Chap.ter10L as provided in section U ? 7 (,.MR 34
Stag Date
This Permit is granted to: 14
Full name of person, Firm or Corporation
Permissionto locate dumpster for construction/renovation/demolition of building.
Comments: dumpster must be. 25' from structure if unable to place with required
Restrictions: cleara�ncie dumpster must becoveredwith plywood or tarp end of work day
,I
at
( Give location by street and no., or describe in such mance//r as_W provied adequate identification of location)
Fee Paid$ 50.00 Fire Chief
This Permit wi11 expire ?-CZ-OZ (Signature of offical granting permit) Offical granting permit ( Title )
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I - )(-IQ ,
Rich Gaffney
27 Longwood Ave
Woburn, MA 01801
(781) 424-2217
CUSTOMER NAME & ADDRESS:
5% ,
16-1 poi -- y/ 7
DATE
C
RICK GAFFNEY
RICHARD GAFFNEY
27 LONGWOOD AVE
WOBURN, MA 01801
DESCRIPTION
,administrator
BALANCE
T y 3e 0 C-.) , —
50
/
THANK YOU FOR YOUR BUSINESS PLEASE PAY THIS AMOUNT /
JftC V07IY/ILM2l!/PC7/Gf2 0�,b3QC121G1E
BOARD OF BUILDING REGULATIOI
License: CONSTRUCTION SUPERVISOI
Number: CS 083817
Birthdate: 08/31/1961
' Expires: 08/31/2008 Tr. no: 141
Restricted: 00
RICHARD GAFFNEY
27 LONGWOOD AVE
,
Board of Building Regulations and Standards
='
HOME IMPROVEMENT CONTRACTOR
Registration: 139961
Expiration: 9/8/2007
Type: Individual
RICK GAFFNEY
RICHARD GAFFNEY
27 LONGWOOD AVE
WOBURN, MA 01801
DESCRIPTION
,administrator
BALANCE
T y 3e 0 C-.) , —
50
/
THANK YOU FOR YOUR BUSINESS PLEASE PAY THIS AMOUNT /
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 Legibly
Name (Business/Organization/Individual):
Address: )7 AV`e -
City/State/Zip: (A)015u'l`V 0 M Phone.#:
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
gniployees (full and/or part-time).*
have hired the sub -contractors
2. 211 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.
employees and have workers'
[No workers' comp, insurance
comp. insurance.#
5. ❑ We are a corporation and its
required.]
3. ❑ I am a homeowner doing all work
officers have exercised their
myself. [No workers' comp.
right of exemption per MGL
insurance required.] t
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):,
6. ❑ New construction
7. bleemodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13. [1 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.
tContractors that check this box must attached 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, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance. for my employee Below is the policy and job site
information.
Insurance Comnanu-Alar�e: `
Policy # or Self -ins. Lic. #:
Job Site
City/State/Zip:
Attach a copy of thewotr.,
' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coy rageasequired 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 may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains andpenaldes ofperjury that the information provided above is true and correct
Sienature: 1f . bate. 7
_;T/
use only. Do not write in this area, to be completed by city or town ofjiciaL
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. # 617-727-4900 ext.406 or 1-877-MASSAFE
- Fax # 617=727=7749---- - - -- ---- --- ---- -
Revised 11-22-06 www.mass.gov/dia