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HomeMy WebLinkAboutBuilding Permit #717-16 - 970 FOREST STREET 12/11/2016J&sv, x ,:-D /a 17- Is— BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: :5� Date Received Date Issued, tip PORTANT: Applicant must complete all items on this page LOCATION Y70 r✓`� ,,��jj�� • Print PROPERTY OWNER //,, Print 100 Year Structure yes MAP[��P.PARCEL: _ ZONING DISTRICT: Historic District yes `` Machine Shop Village yes %AORTM OFtzLe° 32 h0 -Jk 6 C 9 � 1• AV 7a A°Rwreo �PP�'��/ no no no 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 ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District p, Water/Sewer DESGKIP I IUN Ut- VVUKtX I U CSI rr_KrURiviw. , Pri'D -'I n , 1�f /00-� Identification - Please Type or Print Clearly OWNER: Name: Phone: A AA -- Contractor A-r. Contractor Nae: big 4�uro Phone: Email: 44 02-4 Address: 51 Supervisor's Construction Licenser f� Exp. Date: ?// san1 Home improvement License: --j d Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BAS ON $125.00 PER S.F. Total Project Cost: $ / y FEE: $ Check No.: Receipt No.:� NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Location !r // 6i I- No. Date Check #� TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $— Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL. Public Sewer ❑ Tanning/MassageBody 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 m U FORM PLANNING & DEVELOPMENT COMMENTS CONSERVATION ,. COMMENTS. HEALTH COMMENTS Reviewed On Signature. Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comm Conservation Decision: Comments Water & Sewer Con nection/si nature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street - LocatedFIRE DEPARTMENT - Temp►Dumpsfer pn site ,yes . � no, ;at) 24tMain Street - _ Fire -Department signature/date COMMENTS 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.$10041000 fine NOTES and DATA — (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Suilding 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 Certified Surveyed Plot Plan 4. 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 . TOTE: 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 4. 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 TOTE: 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 Doe: Building Permit Revised 2014 . v .a C � cn n 0 �o� 2) r- o Q �' N v� C = c a CD CD 0 CD CD C. o CD CO. C � v 0 CSD Z 0 •�-F 0 70 CD a CD O D O z h CD N O� CQ O CD C C1 O m cn -v CD c0-0 " c ami < r c �• CD 0 m CL0 3 o s s � v, = vi F o 0, CL =r W -a y o CD CD m Q -O N O. O O C CD CQ Q O Vl 0 D) O O OCD �" n CCD CD -0 0 o o� O 7 N -, NZ CD; O 0 C =r rt O U Q. O .n O Q. o O rL CD U) =' CD CL CD 03 CDCO) CUA a7 C rt�o ort CD CD rt N O <D n N aCD C� CU O O Q O N O N O `° N O 'Y Z W C O2L m v o m z TZ7 5' O c S Z �n T 3 N n �j O OGC 7" r m .Z7 o 000 S Ms C Z +n 0 T n 7 ru ;v VOO S T 7 0- m N �. A N 3 T Q \ W v O O D r Cl) O M Z.Vi .�.� Z o a� O o Z -� z cn � C Z z m O D O z h CD N O� CQ O CD C C1 O m cn -v CD c0-0 " c ami < r c �• CD 0 m CL0 3 o s s � v, = vi F o 0, CL =r W -a y o CD CD m Q -O N O. O O C CD CQ Q O Vl 0 D) O O OCD �" n CCD CD -0 0 o o� O 7 N -, NZ CD; O 0 C =r rt O U Q. O .n O Q. o O rL CD U) =' CD CL CD 03 CDCO) CUA a7 C rt�o ort CD CD rt N O <D n N aCD C� CU O O Q O N O N O `° N O 'Y Z W C O2L m v o m z TZ7 5' O c S Z �n T 3 N V1 f7 ro �j O OGC 7" m m D r MM 0 T .Z7 o 000 S Ms C Z +n 0 T n 7 ru ;v VOO S T 7 0- C v M m N �. A N 3 T Q \ W v O O D r 0 c c� jo ! A\Mj log a r•) 0, ., , } ,1— I C"';') , VC), L,-1 -.0 . I . J �fA���' V , • v /l�) / ��� V! 546 PROPOSAL N0. DATE BID NO. ARC ITECT TOE OF PLANS ADDRESS _ �F 1 /a :-r r o r s, WORK TO BE PERFORMED AT: n Q UA r �i✓r : i We here propose to furnish the materials and perform the labor necessary for the completion of Area below for additional description and/or drawings: r All material is guaranteed to be as specified, and the above work to be perf rmed in acc�e with the grawings agd s ifications submitted for above work and completed in a substantial workmanlike manner for the sum of C VI1 - / Dollars ($ b O D zp 00 ) with payments to be m�a a as follows. , ►� �� w� c .S 3 r� s33 . 31 k" if733 ..3?3 Co, of t),-�l ACCEPTANCE OF PROPOSAL The above prices, specifications, and conditions are satisfa;# and rb her by accepted. You are authorized to do the work as specified. Payments will be made as outlined above. , , 4 /-). ;�-' ! Signature L ��S `r 2D/S 1 Date —- � Signature ;,adams NC3818-50 11-12 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE PILED WITH THE PEPMTTING AUTHORITY. Name(Btitsiness/Organization/Individual): M City/State/Zip:. Are -you an employer? Checkthe appropriate box: Phone #: ?/ 0 — ZL_ P"e 72 O J.n I am a employer with employees (full and/or part-time).4- 2. I am'a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] I ❑ I am a homeowner doing all work myself [No workers' comp. insurance required.] t 4. ❑ I 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 proprietors withno employers: - -- 5. F1 I am a general contractor and I Kaye hired the sub-coiitractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6. Q We are a corporation and ifs offieers have exercised their right of exemption per MGL c. 152, §1(4), andwehavon4employees. [No workers' comp. insurance required.] Type of project (Oquired): 7. [] New construction 8. [] Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.0 Electrical repairs or additions -12: [j Plumbing repairs or additions 13.10 Roof repairs 14. ❑ Other *Any applicant that checks box#1 must also rill outtho section below showing their workers' compensation policy information. 1 Homeowners who subriiiti ibis affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. tContrmtors 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-conlracfors have employees, klieg const provide their workeis' comp. policy number. X am an employer that is pidviding worTkers' compensation insurance for my employees' Below is the policy and jo/i site information. Insurance Company Policy # or Self -ins, Lic. Expiration Date: fob Site Address: City/State/Zip: Attach a copy of the workers' compepsation 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. f do hereby penalties ofpetjary that the information provided�a}bove zs true ana�c0JTe z Official use only. Do notwrite in this area, to be completed by city op town official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical. Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone M Z'he Commonwealth ofMassa*seits Department of Industrial.Aceldents I Congress Street, Suite 100 ' Boston, MA 02114-2017 V9t www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE PILED WITH THE PEPMTTING AUTHORITY. Name(Btitsiness/Organization/Individual): M City/State/Zip:. Are -you an employer? Checkthe appropriate box: Phone #: ?/ 0 — ZL_ P"e 72 O J.n I am a employer with employees (full and/or part-time).4- 2. I am'a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] I ❑ I am a homeowner doing all work myself [No workers' comp. insurance required.] t 4. ❑ I 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 proprietors withno employers: - -- 5. F1 I am a general contractor and I Kaye hired the sub-coiitractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6. Q We are a corporation and ifs offieers have exercised their right of exemption per MGL c. 152, §1(4), andwehavon4employees. [No workers' comp. insurance required.] Type of project (Oquired): 7. [] New construction 8. [] Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.0 Electrical repairs or additions -12: [j Plumbing repairs or additions 13.10 Roof repairs 14. ❑ Other *Any applicant that checks box#1 must also rill outtho section below showing their workers' compensation policy information. 1 Homeowners who subriiiti ibis affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. tContrmtors 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-conlracfors have employees, klieg const provide their workeis' comp. policy number. X am an employer that is pidviding worTkers' compensation insurance for my employees' Below is the policy and jo/i site information. Insurance Company Policy # or Self -ins, Lic. Expiration Date: fob Site Address: City/State/Zip: Attach a copy of the workers' compepsation 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. f do hereby penalties ofpetjary that the information provided�a}bove zs true ana�c0JTe z Official use only. Do notwrite in this area, to be completed by city op town official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical. Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone M Infor.m.ation 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, expres's or implied, oral or written." An, employer is defined as "an individual, partnership, association, corporation or other legal entity, ox any two or more of the foregoing engaged in a joint enferprise, 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 ofthe 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 !be -boxes that apply to your situation and, if necessary, supply sub'con-tractoz(s) name(s), address(es) and -phone numbers) along with their certificate(s) of insurance: Limited Liability Companies -(L -LC) or Limited Liability Partnerships (LLP) -with no empldydes otTfer than the members or partners, are notrequired to carry workers' compensation insurance. If an LLC orLLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for con:fumation ofinsurance 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 requosted, not the Department of Industrial Accidents. Should you have any questions regarding the law ox if yo'u•are requked to obtain a workers' compensation, policy, please call the Department at the number listed below. Self iii'sured 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. Anew 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 f dustrialAccidants 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 ri `M ., ? § $ � \ - { . . \ \ j & / / > / o m 2 ©i � . _d » § / \ k [ m } r R / o m 9: -0c: b . « ' / / / ? <� q ) } . \ 33 \ . 2�mz , o @ ti �} ri