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HomeMy WebLinkAboutBuilding Permit #180-2016 - 9 CHADWICK STREET 8/10/2015 * NORTH BUILDING PERMIT osLeD ,s�tio TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION a- �X04 ey Permit No#: V !/ Date Received �5���� CH Date Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION 0-61Q IC�— 4, Print PROPERTY OWNER P 'nt 100 Year Structure yes no MAP 06(W 063 ZONING DISTRICT: Historic District yes o 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 ro(Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic []Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: 6 IJ kVO6 7w e�PS 2\Y 100 V, A/4 UD +LAI�,s kw f-Y 1+6CL o/,xi.4, Identification- Pl ase Type or Print Clearly OWNER: Name: + -ALkY/V/itJ Phone: q 7FO8 7- ©64S- Address: C(*kLJ �1� �-. 11�1, 1�}, o�c1r �'k6L 0041' Contractor Name: KLLZ 1 -e s-i-' r/-, Phone: 'qV' Email: Address: t``` Supervisor's Construction License: CS'©a7 1�S Exp. Date: 14 /361 1(e,- Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.-$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ Wpm 66 FEE: $ �� •� Check No.: o�QN Receipt No.: Pe son contracting with unregistered contractors do not have access to the guaranty fund i NORTH BUILDING PERMIT of Js ro 16, TOWN OF NORTH ANDOVER o APPLICATION FOR PLAN EXAMINATION y Permit No#: !/� Date Received �s.Areo 1/ SgCH►15� Date Issued: U J IMPORTANT:: 'Applicant must complete all items on this age LOCATION C, CJS Print PROPERTY OWNER v—M0 P 'nt 100 Year Structure yes no MAP PARCEL: ©63 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: ❑ Demolition ❑ Other DS eptic ❑Well ❑ Floo- an D Wetlands ❑ Watersheds District 0 Water/Sewer- --DESCRIPTION OF WORK TO BE PERFORMED: b'K���� 6 �- , kym roc J,9100v,, A/,euD l��c�cr awl— U Identification- PI ase Type or Print Clearly OWNER: Name: +L iA.YqjvPhone: gi 7E-07 7- 684 ;' Address: 'I C, �c�1CS��-..A), ►RvDcr wo FContractor Name: L e�5 rd�, Phone: '3V- 960 - Gql� Email: Address: Supervisor's Construction License' ��� ©��Is S Exp. Date: �d Home Improvement License: q3 I Exp. Date:.- ARCH ITECT/ENGINEER ate:ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ 1Z •n Check No.: vReceipt No.: '2,- I 1�-!5 Pe son contracting with unregistered contractors do not have access to the guarantyfund Location C ' CIL No. �/" I Date ll a j . - TOWN OF NORTH ANDOVER • e r Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Q Other Permit Fee TOTAL $ Check#� Building Inspector i 11 . . . . ! . • . , ... .- ;. ... . . .. . . .. . .. - . _ _ . .. : 3 ,> _ r . t ocation } C- �1 A 4� . �-tL No. V- b Date 0 a l< - .. ..:p-.-�"....-L..1..,,I.�,.:I....—...�:..�,�.-:�-...:....,�I1....t-...I...I..,.�-"-.I�o,�.,:..,:::..!.:/.�..:....:.�-.,:.,..::�:...-:r,r:..I..I.I...:1�.�.,—�,I�..�:-���.�:I.,...:.-..:...I,I�-.::—I.-..:—�.,....�.I.:..:I I:I..I�.�-I:-...:,T I-I-*..:.I-..,..i—pI.�..,—.,...'I-I-I.�..-.I.,,...-:I...�1— • ' TOWN OF NORTH ANDOVER 7. . D.x was .: • 1 Y5 • 1.- Certificate of Occupancy $ Building/Frame Permit Fee $— Z— Foundation Permit Fee $ - Other Permit Fee $_ _ TOTAL t _ ,Q Check#Ju`� 2r� ffyy s .7 $ Building Inspector ,_ t • - . . - w:, -. . . .. 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 PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zol-ping Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Wafter& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street [FIRE DEPN MENT - Temp Dumpster on site ,yes ne. Located,at 12,4+Main,Street - Fire Department signature/date COMMENTS 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 PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Plaining Board Decision: Comments ti Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FF REDEPzA TRTR MENTA-`TernpDumpste� onzsite, ,yes,. -a til-TA d atil-TA MainjSffeet• FireDepartment�sgratur�e/date r ,-,MM r= 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 Call Email Date Time Contact Name Doc.Building Pennit Revised 2014 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 Call Email Date Time Contact Name Doc.Building Permit 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 4. Building Permit Application ,4.. 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 4 Building Permit Application Certified Surveyed Plot Plan Workers Comp Affidavit .� Photo Copy of H.I.C. And C.S.L. Licenses :rt 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 4. Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses .a< Workers Comp Affidavit .� Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract ,a< 2012 IECC Energy code .� Engineering Affidavits for Engineered products OTE: 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 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 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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks Building Permit Application ,4. Certified Surveyed Plot Plan Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses 4. Copy Of Contract Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) :a 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 :re 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 OTE: 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 2014 tkORTH Town of o - 1 Zo — t 2-A l Z _ h 5 , ver, Mass, o COC.41 C..l W.CM �1• S fJ BOARD OF HEALTH Food/Kitchen PE Septic System THIS CERTIFIES THAT MITT �4�►�' �� ��� BUILDING INSPECTOR � .. .`..�t� Foundation has permission to erect .......................... buildings on .... ..... .. .. ....... .. ... Rough to be occupied as ..... eimo l ....� ......... t.........&-0Nf&'b........................ ........................... Chimney provided that the person accepting this permit shall in every respect conform to the 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 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI ARTS Rough Service ........... .... ...................... -. Final BUILDING INSPECTOR 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. T4pW OF NORM AND OWR b :titi :�ga OMICR OF - y x.500 I)sgo ad Streeet Bufding 20, 243 6 7 p�R37xn Fps•[5 ••-.LV� � (lQfi`'y J.YJ.`C�sa�'cl�'i�tt�c5'�ii4`PJ'd�`i' ' �41�Rc�u5��' ' Gerald A.Brown Omuv(978)68 8-9545 InspeetorofB iMugs • -fax (978)688-9542 IOE1 ZTCEIE ENtPTION - BM)NG NEP M- T"PLICATION Please p Lm . DATE: SOB LOCA.TfDN., •Number EfzeetA-ddress map/Zot oGWNERio dame. dome done W rkMaone ' )?M-SM-T MA6NG ADDRr3SL CUWt" kJouff , F4�-li T6 - T$e euzzent exempfion for"homeowaaexs"utas exteu&d to include Owner occlip'led dWellings to tuo units.0-T'.'Co-s'and ttt E low subh homomuczsto engage au.L-b.-djv;dual.forhire, Wao does notpossess a lice3lse,pxo�ided tbattlle owner Puts as super sor). 9fate3rilding (Code Section l�&•3.5.I) ' bBMITION O)i`HOMEOVMR Persons)who qwRs aparcel of land on which llobfic resides Dr intends to X-0,gjd%oA YJ�21c�fi�7 ere Ts,oT is 7afeIlded to ��,a one or two far•Qily sfcucfares. .Apexsoxl�tlto eonsfcaefs more friaf.onel�.o�tein atgza yearperxod shall notbe coalsidered aILDMeoWx1er. Tho lmdexsigned wIfh tha StatoBuilding C060 End ofhar .Applicable codes,by lm,xules and-rWiatiow. Tbeundersigned"hozneownex"cext�fies that helslzeuudaxsfiands the Town ofl`7'orth,A.adoverBnzidzng De�atbnent '1luimum impeofim procedures and xaquiramenfs and thathalshe,yell comply with�saidpxocedmes and .requirernenfst I-IOMOWN'ER.S SIGNATUR ' APPROVAL OF 13UMDWG OF'.IIICTAL Zeyised 7.2909 - . 'ozm�SomeownersBxemption ' OARDOFAPI'EA.7-688-9.541 COhrSEuu,Aam6s8-9534 The Commonwealth of.lMlassachusetts zDepartment oflndustrialAccidenfs X Congress Street,Suite 100 - = ' Boston,M4.02114 2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le •bl NaMe(Business//Orgnganization/Tndividual): iou q C Address: U-11 Gy a City/State/Zip: &tvv. (K&,O(N S' Phone#: Areyou an employer?C&c'kthe appropriate box: Type of project(required): 1.❑I am a employerwith employees(fulland/orpart-time).* 7. ❑New construction 2.E]I am a sole proprietor or partnership and have no employees working for me in 8. dRemodeliiig any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3..Q I am a homeowner doing all work myseI£[No workers'comp.insurance required.]t �4.L v I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 E]Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.[]Electrical repairs or additions proprietors with no employees. 12..Q Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers 'comp.insurance.: 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 152,§1(4),and we have nq employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fiu out the section below showing their workers'compensation policy information. I Homeowners who submit#his affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors 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,&1 must provide their workers'comp.policy number. I am an employer that is pioviding workers'compensation insurance for my employees'Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: ExpirationDate: Job Site Address: City/State/Zip: Attach a copy of the workers'cbmpepsation•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 DTA for insurance coverage verification. I do here rtify and the pa';s and penalties ofperjury that the information provided above is true and correct. Signature. Date: 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#: 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 bi'hirel 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 bd 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-contractors)name(s),address(es)and-phone numbers)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 foi•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 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-MA.SSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia