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HomeMy WebLinkAboutBuilding Permit #1054-15 - 90 LANCASTER ROAD 6/15/2015 L n NORTH < /� �k BUILDING PERMIT 32�y�T�E° TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit Nol:vj— Date Received � '°RATE° / �SSACHU5�4 Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION � Print PROPERTY OWNER /r/�G►��- �a z Print 100 Year Structure yes no MAP ©off-® PARCELP5 ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Re idential Non- Residential ❑ New Building One family El Addition ❑ wo or more family ❑ Industrial Alteration No. of units: ❑ Commercial ❑ epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other [] Septic El Well ❑ Floodplain ❑Wetlands ❑ Watershed District 0_Water/Sewer _ - -1i ESCRIPTION OF WOR T BE PERFORMED: o iJ C of S�(`� cJ L' S t� 9 i 1 F Iden 'fication-Ylease Type or Print Clearly _ g ? 3 OWNER: Name: /(/f o'� P y� Phone: Address: x � Contractor Name: C o Phone: Email: � cx-r Address: �/� 1 Gam'c T7� - fi� C, o� 1 Supervisor's Construction License: C�) -xp. Date: 0 Home Improvement License: l j O Exp. Date: _ 12- -;Z D/ 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 C t: $ ® O ' FEE: $ � G Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the gu ranty fund A.+ 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 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 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 4, 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 I ECC Energy code Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit i 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 i t Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ i TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ i 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 I 1 sCOMMENTS � f r HEALTH Reviewed on Signature COMMENTS Zoning 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 OsgoodStreet FIRE DEPAR�T�MENTt' p - - ,� ��� ;- .��� - ite s �.. Lo ted at 124 MainjSt�e�et Fie Den irtmen_�signature/date COMM'EfVTa L 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) I ® Notified for pickup Call Email Date Time Contact Name Doc.Building Pen-nit Revised 2014 Location &M1,4"rn No. Date • - TOWN OF NORTH ANDOVER . . Certificate of Occupancy $ Building/Frame Permit Fee $ ; .� Foundation Permit Fee $ r Other Permit Fee $ ' TOTAL $ V94L,Check#_ � 8 9,2 uilding Inspector NH ORT own of t E 11, ndover 0 - �: No. h , ver, Mass, A- COCMICHIWICK 7�A0 AT E D P'4�,t'�y 1 S U i BOARD OF HEALTH II Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT ...............A).1.4.vaAft........ ..... V.. ......................................... BUILDING INSPECTOR � (�. Vv4A* � Foundation has permission to erect . ....................... buildings o ........................ . ....... Rou5& Agh to be occupied .... .. .......... ........ .............. ............ Chimney . � `�......... ........0 ..... - 1 provided that the person accepting this permit shall in every respect conform to the ter 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final i PERMIT EXPIRES IN 6 MO TIRt ELECTRICAL INSPECTOR i UNLESS CONSTRUCTIO ARough i 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. PROPOSAL NO. SHEET NO. DATE PROPOSAL SUBMITTED TO: WORK TO BE PERFORMED AT: NAME ADDRESS //v� C(/L ADDRESS DATE OF PLANS PHONE N0. � � �� � , n/ � ARCHITECT We hereby propose to furnish the materials and perform the labor necessary for the completion of ee All material is guaranteed to be as specified,and the above work to be performed in accordance with the drawings and specifications submitted for above work and completed in a substantial workmanlike manner for the sum of Dollars ($ )with payments to be made as follows. Any alteration or deviation from above specifications involving extra costs will be executed only upon written order,and will become an extra charge Respectfully over and above the estimate. All agreements contingent upon strikes, submitted accidents,or delays beyond our control. Per Note—this proposal may be withdrawn by us if not accepted within days. 1 ACCEPTANCE OF PROPOSAL he above prices,specifications,and conditions are satisfactory and are hereby accepted. You are th ' ed to doth ork as s ecified. Payments will be made as 1T� s outlined above. Signature - ~— Date Signature 4&??a&nw D8118 3-12 The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia 07 SV•V Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE'FILED WITH THE PERMITTING AUTHORITY. Please Print Le 'bl A licant Information A' / Name(Business/Organization/Individual): Address: rf�- ��0 1j Cl GL D Kone City/State/Zip: :. . . . . Type of project(required): Are you an employer?Check the appropriate box: 1.❑I am a employer with employees(full and/or part-time).* 7. ❑New'oonstruction 201am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. [ emOlition 3.0 I am a homeowner doing all work myself,.[No workers'comp.insurance required.]t 10[]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11. Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 12,E]Pltltnbing repairs or additions S.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.F1 Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 14 Other 6.❑We are a corporation and its,officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no empldyees.[No workers'comp.insurance required.] *Any applicant that checks boir#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submibthis affidavit indicating they aze 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,they must provide their workers'comp.policy number. Yam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. i Insurance Company Name: Expiration Date: Policy#or Self-ins.Lie.#: / Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(sholin wwing the pocy umber and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a firie 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 certify un#r the pains and penalties of perjury that the information provided above is true and correct. Date: Si ature: Phone#: E[Other only. Do not write in this area,to be completed by city or town official. n: Permit/License# hority(circle one): Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector rson: 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(1)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 certificates)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 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-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia 1W.4Massacfiausetts,•' pt�rtr t'At of�?u#ilk-Sdefy -3 .Roard of.Buildir g Regulations and Stan6rd5'." "t+ t csnstrirctican Supenisol S 1 { y license; CS-087785 � FELIX RAMOS =`� Ir ;18A EVERETT AVE#$° c CHELSEA MA 02150 # fs,�rr � f: .J,�:.. JJ •, Expiration. ` 09114/2015; a ' Cominissi°ner e_ �.r�pr��rn,��zanruea✓l�o�.�/l,�a'tac%rias I 9 f _— Office of Consumer Affairs&Business Regulation t _ OME IMPROVEMENT CONTRACTOR. egistration: '.181206 Type: Expiration: 3/12/2017, DBA RAMOS DRYWALL'y 4 FELIX RAMOSE 26-28 BROADWAY CHELSEA,MA 02150 Undersecretary •