HomeMy WebLinkAboutBuilding Permit #775 - 886 SALEM STREET 4/26/2012Permit N0:
TYPE OF
❑ New Building
❑ Addition
❑ Alteration
;K Repair, replacement
❑ Demolition
/G re—
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
PROPOSED USE
Residential
)tOne family
❑ Two or more family
No. of units:
❑ Assessory Bldg
❑ Other
Non- Residential
❑ Industrial
Q Commercial
❑ Others:
DESCRIPTION OF WORK TO BE PREFORMED:
1'-/'\,l9 6 N,-)erl&t— J C 6 A -
Identification Please Type pr Print Clearly) a U yl _lG ��
OWNER: Name: �y�c�°�- a-Gc,d-/�{,� old u Phone: q75�
Address
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ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED $125.00 PER S.F.
Total Project Cost: $ �, 7� 3 FEE: $ Z
Check No.: / ` Receipt No.: ac a'�
NOTE: Pers�ontracting with unre*stered contractors do not have access to the guaranty fund
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
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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2007
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/Massage/Body Art ❑ Seng 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
PLANNING & DEVELOPMENT ❑
COMMENTS
DATE REJECTED DATE APPROVED
DATE REJECTED DATE PPR VED
CONSERVATION C ❑ ❑ 2
COMMENTS__ Wx,�
t� 10b
HEALTH
COMMENTS
DATE REJECTED DATE APPROVED
❑ ❑
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
Comments
Water & Sewer Connection/Signature &Date Drivewav Permit
Located at 384 Osgood Street
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
NOTES and DATA — (For department use)
❑ Notified for pickup - Date
Doc.Building Permit Revised 2007
Locationy !�/lf �Cyh TJ
No. Date 1
Check #L—?
25238
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee ;A ---
Foundation Permit Fee $
Other Permit Fee 1$
TOTAL $
Building Inspector
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MORT6AGE'INSPECTI0N PLAN
City/Town:No . P ►-+Oovc2 State: M 1 R
-------------------- ---------------------
Date: C�c'f 1��1-t J9fScale: I �'= GoI
------------ ---------------------
Owner: G U p Y___________ Buyer: N R
---------- y --------------------
e�-x No ,
Deed Ref. ---a _ ! -- 5 1 _____ Plan No. 3G50,5
---- -------------------
Drawn per City/Torn of .... ly ------- Tax Assessors Map.
To: c> V �. ice. ►� fa �•►
------------------------------------------------------------------------
I hereby certify that the above Mortgage Inspection - Plan was prepared for use in connection with a new Mortgage and is not
intended or represented to be a property line or land survey. It cannot be used for establishing fence, hedge , walls or building
lines. No responsibility is extended herein to the land owner or occupant. The location of the original building(s) as shown
herein was in compliance with the local applicable zoning bylaws in effect when constructed, with respect to horizontal '
disenr:onal requirements, to lot lines or is exempt from violation enforcement action under Mass G.L. Title VII, Chap. 40A, Sec,
7, unless otherwise shown herein, Subject building(s) lies in:a flood zone designated Zone: G
FIRM sapCossunit -Panel i_ 5 D 0 9 g ------------------------- and shown on
Y 8 ' CSO / d Dated: _�___ Job No. 3_1
JCD, INCORPORATED, LAND USE & DEVELOPMENT CONSULTANTS 4 AUTUMN LANE, METHUEN, MA 01844 508-663-9932
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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 of its 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-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 maybe 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 bum 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 Com oxtwealth of Massachusetts
Department of Zndustrlal Accidents
Office of Investigations
600 wash voa Street
Boston? M A, 02111
TO, # 617-727,4900 at 406 or 1-877:,MA.SS.ABB
Revised 5-26-05 Fax # 617-727-7749
-wwwmass.gov/dia
y The Commonwealth of Massachusetts -
Deparim ent of IndustrigIAccidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass gov1d1a
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): w^ T iT r4 V (r 04 5 AI -V 6 A
Address: c 1 iia lle
City/State/Zip:_ D ra eq �- , "144 Phone #: 9 7�- "� / S V
Are you an employer? Check the appropriate box:
Type of project (required):
1. ❑ 1 am a with employer
4. El am a general contractor and I
6. ❑,�d�construction '
epployees (full and/or part-time). �
2, am a sole proprietor or partner-
have Hired the sub -contractors
listed on the attached sheet. ?
7• E] Remodeling
ship and'have no employees
These sub -contractors have
8. ❑ Demolition
working for mein any capacity.
workers' comp. insurance.
g, ❑Building addition
[No workers' comp. insurance
5. El We are a corporation and its
10. El Electrical repairs or additions
required.]
officers have exercised their
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.] t
employees. [No workers'
-13. ❑ Other
comp. insurance required.]
'Any applicant that checks box #1 must also fill out the section below showirigtheir workers' compensation policy information.
7 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name;
Policy # or Self -ins. Lic. #: Expiration Date:
Job Site Address: 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 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.
X do hereby certo under the pains and penalties of perjury that the information provided above is true and correct
Signature: " �!/ Date: L% - / 3 - / Z�-.
Phone #: % 7 i- a-/ s-- /-/ 9 `/ 3
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/Ucense #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. EIectrical Inspector 5. Plumbing Inspector
6. Other - - -
Contact Person: Phone #: