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HomeMy WebLinkAboutBuilding Permit #175-14 - Exception 8/26/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: S ' I Date Received Date Issued: IM ANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER CUL)N 7% d"-Y C�v Unit# Print MAP NO: PARCEL. ZONING DISTRICT: Historic District yes no Machine Shop Village yes no 100 year-old structure yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: -z4Fi!!5—mmercial impair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other i .®;Sepicttic, q WeIP rshdtDt -,..- ❑ Water/Sewer � ��t__._-_�__ — - - - - DESCRIPTION OF WORK TO BE PERFORMED: i (Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: --�_670 CONTRACTOR Name: YY -- 44 P6e—V1�J Pho Address: -7c74;- D A S D&y'441z,, Supervisor's Construction License: � Exp. Date: y y JExp. Home Improvement License: l ) � Ex p. Date: / ARCHITECT/ENGINEER ��- Phone: L. Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. opt J% Total Project Cost: $ FEE: $ 9W Check No.: Receipt No.: D NOTE: Persons contracting with regiis red contra ors do not have access to th�garantyLund .. ;Signature of Agent/Owner na _ icon rator� . .. 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 o Workers Comp Affidavit o 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 o Building Permit Application ❑ Certified Surveyed Plot Plan o 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) o Mass check Energy Compliance Report (If Applicable) a 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 El Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses a Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract ❑ Mass check Energy Compliance Report o 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: Doc.Building Permit Revised 2008mi i 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments I Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: r; J Located 384 Osgood Street FIRE DEPARTMENT w Tempr Dempster on site yes no ' F Located at 124 Ma'm5treet 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 2lA—F and G min.$100-$1000 fine R NOTES and DATA— For department use i i I I ❑ Notified for pickup - Date Doc:.Building Permit Revised 2011 June/mi Location65 CSU✓04 jol No. 5 ' / Date —Sk(,/13 • - TOWN OF NORTH ANDOVER r Certificate of Occupancy $ aBuilding/Frame Permit Fee °. � Foundation Permit Fee $ Other Permit Fee TOTAL $ Check# 26776 Building Inspector The Commonwealth of Massachusetts Department o fIndustriglAccidents Office o fInvestigations qu 600 Washington Street Roston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/ContractorsfElectritcians(plumbers _Applicant Information Please Print Ledbly Name(Business/Organization/Individual): Address: -7'1'�- DALE � City/State/Zip: D", IvV , Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have lured the sub-contractors a sole proprietor or partner- listed on the attached sheet. Jf Remodeling ship and'have no employees These sub-contractors have S. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.[]Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.[]Plumbing repairs or additions myself. [Noworkers'comp. c.152,§1(4),and we have no M]Roofrepairs insurance required.] employees.[No workers' comp.insurance required.] 13.❑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 aie 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. .1am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy 4 or Self-ins.Lic.#: ExpirationDate: Yob Site Address.. ` (70 e<C e'f T Po-1,3 i) �FD City/State/Zip: �J, A�,JP0-J C?, NC A . Attach a.copy of the workers'compensation-policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required.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 V50.00 a day against the violator. Do advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I�Izerehy cer fy nde ze pains a penalties ofpeYjury that the informationprovided ab e is tru andcorrect.S . Date: Phone#: �� t���� �C)� Of use only. Ito 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 CIerk 4.EIectrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone 0: Information and ffustruction's , 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 employeY is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a j oint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,associatiop.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 workon 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 ofits 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 beenpresented tothe 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 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 notrequired to carry workers'compensation insurance. If anITLIC or LLP does have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confi nation of insurance coverage, Also be sure to sign and date the affidavit. The affidavit should be retumed 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 andprinted legibly: The D epattm crit 11as 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 Min 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 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 CQmmonwealth of fassa.,chusPtts Dep.aftent offad ustdalAccidents Office of lawtigatiors. 600 0 Wa bhigtoa Stxeet Aston,MIA 02111 Tol,#617.,727.4900 at 406 or-1-$77-MASSAF13 Revised 5-26-05 Fax#617"727"7749 i r 1 _ NORTl1 �. .. 01, . 0 \A ®ver O z o h ver, Mass COC NIC H!WICK �.QS R4'rE D U BOARD OF HEALTH PERMIT T Food/Kitchen LD Septic System THIS CERTIFIES THAT / y C.Q _ ) IZ ...../....... .......... �; BUILDING INSPECTOR has permission to erect .......................... buildings on ..Soo. .. Foundation 1 . Rough to be occupied as ..... ......... ..� �..... .. ..N��......q.QQ.lti..... ............................. Chimney provided that the person acc pting this permit shall in every respect conform to the terms of thea application pp 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 CONSTRUCTIO TART Rough Service .. ..................................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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. SEE REVERSE SIDE Smoke Det. - - _—- - Department of Public Safety Massachusetts- Regulations and Standards Board of Building en isor Constructian Sun' Ki License License: CS -002685 t)", ;tom• I BERT T GES- RG 0 — '795 II N SSD� 01845 z Expiration 02/24/2014 Commissioner G? a D ROBERT LANGEVIN Building& Remodeling, LLC Homeowner Information Contractor Information Name Company Name C-1-UIg nB wT— �EV1� �flCr Y►?C3J��L1A► � Street Address(do not use a Post Office Box address). Contractor/Salesperson/Owner Name City/Town State Zip Code Business Address(must include a street address) Daytime Phone. Evening Phone City/Town State Zip Code '7 ? X73 ) 7 ry aroo- APb6vr— VV\,A © )FV'S Mailing Address(It different from above) Business Pl d 7, 3 6/61 Federal Employer ID or S.S.Numb _699 j d 9� Home Improvement Contractor Reg.Number Expiration date Law regniros that most home r improvement registration contractors have ` I n valid re istrntion number f( The Contractor agrees to do the following work for the Homeowner: (Describe in detail the work to completed,specifying the type,brand,and grade of materials to be used,use additional sheets if necessary.) Required Permits-The following building permits are required Proposed Start and Completion Schedule-The following schedule will and will be secured by the contractor as the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of .2 5 �} Date when contractor will begin contracted work. MGL chapter 142A.) 2 �3 P Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule / The Contractor agrees to perform the work,furnish the material and labor specified above for the total sum of: Payments will be made according to the following schedule: cs $ pon signing contract-(not to.exceed 1/3 of the-total contract price or the cost-of special order items,whichever is greater) $ � by / / or upon completion of $ �"bq— / / or upon completion of $ 3 upon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) The following material/equipment must be special $ be paid for ordered before the contracted work begins in order to meet the completion schedule.(**) $ e paid for NOTES:(*)Including all finance charges(**)Law requires that any deposit or down-payment required by the contractor before work begins may not exceed the greater of (a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. I Express Warranty-Is an express warranty beine provided by the contractor? 19 No 0 Yes(all terms of the warranty must be attached to the contract) Subcontractors-The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement Contract Acceptance-Upon signing,this document becomes a binding contract under law. Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contract.Take time to read and fully understand it. Ask questions if something is unclear. • Make sure the contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plaza,Room 5170,Boston,MA 02116 or by calling 617-973-8787 or 888-283-3757. • Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage,or ask to see a copy of a"proof of insurance"document. • Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing of this agreement. See the attached notice of cancellation form for an explanation of this right. DO NOT S N THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!! Two identical copies o to contract must be completed and signed. One copy should go to the homeowner. The other copy should be kept by the contractor. Homes Signaturd Contractor's Signature /o /.f --?/� o13 Date Date i Building& Remodeling, LLC 795 Dale Street North Andover, MA 01845 (978)686-3607 HIC#111990 FID#26-0816298 www.LangevinBuilding.com Job Description North Andover Country Club Great Pond Road,North Andover, Ma Replace doorway to rear deck • Provide and install two 3'0 X 6'8 simpson wood doors (cat#F-7015U), one operating and one fixed. These doors feature full divided light thermapane glass • Provide and install panic bar hardware, exterior leverset lock, and door closer in brass finish as shown on literature provided to you • All hardware conforms to handicapped access requirements • The doors also feature conforming low-profile aluminum thresholds. . j • Interior and exterior trim will be replaced or altered as needed • All permits, cleanup, and trash removal j • All painting will be done by others at your expense i V Ir I Contractor's Signature i Date Managers signature Date 7 I i