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Home My WebLink AboutMiscellaneous - 113 APPLETON STREET 4/30/2018 113 APPLETON STREET 2101037.6-0031-0000.0 PA lst`(�l )c� FORM U - LOT RELEASE FORM °�°� C)(s1�5 INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS APPLICANT G� 0 PHONE 6 14 LOCATION: Assessor's Number PARCE SUBDIVISION LOT (S) STREET 11 r 1;�3 �` S . MBER 113 *************** ICTAL USE ONLY **** CO OF N AGENTS: C NSERVATIO DMINISTRATOR DATE A ROVED DATE REJ TED = lf� 2G�S COMME aky L rk I ��W oK � k ,P,a. CL 0 1, 10NAIL WN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS-SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING ,. . M, rn BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioner/12Wtor of Buildings Date Z SECTION 1-SITE INFORMATION O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: l 1.4 Property Dimensions: 1 c' -0y L Zonm District Pr ed Use Lot Ar s Frontage fl 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide ReWred I Provided ReqWred Provided 3 C �ca341 30Crs�v 1.7 Water Supply M.G.L.C.40. 54) 1.5. Food Zone Infom�ation: 1.8 Sewerage Disposal System: Public Private p Zone Outside Flood Zone JX Municipal On Site Disposal System 0 SECTION 2-PROPERTY OWNERSHIP/AUTHORIZEDAGENT Historic uislrlci: Yes Fic M 2.1 Owner of Record Name(Print) Ad ress for Service: Si re Telephone 2.2 Owner of Record: e Print ) Address for Service: Z M afore Tel hone SECTION 3-CONSTRUCTION SERVICES 3.1 rLq, Construction$up�rviso r: Not Applicable ❑ cul Licensed Construction Supervisor: S761 0 1 13 . License Number mn Addres Expiration Date rgna re Telephone 3.22 Registered Home Improvement Contractor Not Applicable ❑ I a.A.,`a �//('��y Company Name (3 ( l� 7 / m Registration Number f (3 ��IfFY'd� Si �J • fkylpoJ� �/I✓.i., Address ? ��7 )0t Expiration Date /'1 t na re Tele hone V 1 SECTION 4-WORKERS COMPENSATION(NLG.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......0 No.......0 SECTION 5 Description of Proposed Work(check all applicable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) 0 Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Desm'ptionff Proposed Work: CJt nowQ J SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)td be OmCIAI.USE ONLY Completed by permit a licant r 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Za 00 Construction 3 Plumbing p- 'Z—V Building Permit fee tel x(b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZAT TO BE COMPLETED WHEN OWNERS AGENff OR C NTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property q Hereby authorize '� , to act on My behalf,in all att s lative to work authorized By this building permit application. Signal<e of cr Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION as Owner/Authorized Agent of subject pro y Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief �.ftl G Print Nam V Vd SiEture M r-dArQ ent Date NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS Fr 2ND 3RD SPAN DMIENSIONS OF SILLS DMIENSIONS OF POSTS DINIENSIONS OF GHWERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE NJdil f/10FJQ i8; 33 97$685I.99�1 NE. ENGINEERING Sl/C PAGE 02 I 41 (9 MAF 378 InT at JCC_ fXJSTfr;.; 061c�'INt -lAn 4EF�ti:7lCf. KLAN 323; FS0EX "Ok(4 RC6171"v OF J' "LAN rE.FEF?WrE- BOOK 3512, PAGE. W. �36 ; 7sscr hJoRtli RL I$Tk" t7F UE£DS 7N1; PLAN IS rl,R '11c USf 7r 1Na` �+ ?IJLpINC� '-N5Nrr.'t0%t OF T}IE T+CAW Q;: L' RJP1tS AVO:wdP. FUH 1ME. �?UKPUSE O �E.FRMINATCiry JF Z::N;NC- COMPLAICE. 190' A El r PLL OPO' STREET REET PLOT PLAN 1.19 APPLEtON STREET NORTH ANDOVER, N1Am1Causims ASSr$SORy MAP :372, IDT 31 PRFI'AREI) plox W a ti DAVID w, GAIL J., & I.IQYD R, LICCIARDELGC1 NIL sqm ld KtR•IUROP AVE LAXRRNCE, NA 1 -- SCAIX !' = 40' iJATF- MARCH 16, 2004 r- NIP'W FNf,L ND ENGjNFr.RjW0 SEP.V1Cr-4 INC.. GC► III=RCi4Y 000 DRIvE LAIR F+[PTS ANDOVER, 1(A33A01MCWS Bat r, 5 8 la l E F (€lo8) 686-41"E►A NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: /xz�f 0, is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 10A. The debris will be disposed of in: (Location of Facility) *i1a ofPermit Applicant Fire Department Si ff: Sign o Dumpster Permit Date Department of Industrial Accidents Qffiee ofInvestigations 600 Washington Street Boston,MA 01111 www.massgov%dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electridans/Plumbers Applicant Information Please Print Leeibly Name(Business/organization/Individuap:�L�ccoS .0m, Address: 1 13 • h o lf�ro iy gr- IU- OkA�)e!VC-,t 1/00 City/State/Zip: Phone#• ./ Are you an employer?Check the appropriate box: 1.❑ I am a employer with 4. 14 I am a general contractor and I Type of project(required): employee's(full and/or part-time).* have hired the sub-contractors 6. Q New construction 2.Q I am a sole proprietor or partner- listed on the attached sheet t 7 Q Remodeling ship and have no employees These sub-contractors have 8. Q Demolition working for me in any capacity. workers'comp.insurance. 9, Building addition [No workers'comp.insurance 5. El We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers'comp. C. 152,§1(4),and we have no 12.0 Roofrepairs insurance required.]t employees.[No workers' 13 Q Offer camp.insurance required.] •Any applicant that clndra box#1 taut also 611 out the section below showing ft r wad=,co ilmootiou policy information: t Homeowners cubo submit this affidavit indbcstisg they an doing all wart and then hire outside contractors must subrtdt a new a6•idavit indicating such. =Contractors that chcct this box rraut sttacbed m additional sheet dowing The Wane of de sub-contractors and their wotttera'corm.policy inforntati— I am an employer that is providing workers'compensation lnunwnce for my eMPUY"M Below is the polky scud job spa information. Insurance Company Namc: 1Vcs. kLo,r . Policy#or Self-ins.Lic,M Expiration Date: Job Site Address: _ �F 'T" City/Stat&2ip:k.44 �r Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiTJ 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 ent,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. I do hereby cerci er th Ins and penahies of pedury that the information provided 1 k tna and correct signature Phone#: 6`11 0fflcidl useronly. Do not write in this area,to be completed by cloy or town o,(�IeieL City or Town: Permit/License M Issuing Authority(drele one): L Board of Health I.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone 0: lniormalion UJIM i115L1 u%,LJiVJ1fi0 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 employers. 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 bouse or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,425C(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 ed acceptable evidence of compliance with the insurance coverage required." applicant who has not produc Additionally,MGL chapter 152,§25C( )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 cerdficate(s)of insurance. Limited Liability Companies(LLQ 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 erre to dp 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 mmober listed below. Self-insured companies should enter their self-insurance license number on the 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 pennitllicense 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�been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid a 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>n complete this affidavit The Office of Investigations would bice 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 Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5=26-05 www magg,gov/dia A j 7�� ✓!ie�an�naruuea�.a�✓uaaaac�u�aeka�? Board of Building Regulations and Standards j HOME IMPROVEMENT CONTRACTOR Reglstratiori:_134699. s Expiration: 11712006 p+ Type: Individual iAANU�L A PALACIOS 0ANU L PALACIOS F ?pi#�PPLETOIV, +t 48VEP,6TT,MA 02149 Administrator i � e oft , } BOARD OF BUILDING REGULATIONS Li cens6:`CONSTRUCT fOKSUPERVGSOR" F . Number:'CS 085654 i Birthdate 01.12611`976' Expires 01/2612007 Tr ttq 85654 Restricted 00 MANUELA..PALACIOS �. 9A APPLETON TERM' EVERETT, MA 02149•; Adm¢tl#stratcr