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Home My WebLink AboutMiscellaneous - 13 CONCORD STREET 4/30/2018 I CONCORD STREET ' 210/095.0-001 9_0000.0 Location ` G i No. `� Date NpRTM TOWN OF NORTH ANDOVER 9 Certificate of Occupancy $ yes',"•''<� Building/Frame/Frame Permit Fee $ S� s�C,wst 9 Foundation Permit Fee $ Other Permit Fee $ _ TOTAL $ Check # 134 Building Inspector ' TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: C? os— SIGNATURE: sSIGNATURE: Building Commissioner/IpErctor of Buildings Date Z SECTION 1-SITE INFORMATION O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Pa 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sf) Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided ReqWred Provided v 1.7 Water Supply M.G.L.C.40.11 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public 0 private 0 Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System 0 SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT ' iU i t : Li''� • Y17S M 2.1 Owner of Record �z 1pnp ;a' 4 C-S)L- Name(Print) Address for Se •ce Signature Telephone 2.2 Owner of Record: 1-7 el Warne Print Address for Service: z • m Signature Tel hone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: _ Q License Number M Address Expiration Date 3 Signature Telephone r.. 3.2 Registered Home Improvement Contractor Not Applicable ❑ v Y Name t RA7 Re�tio Number r Address zz �- r — , Lam' 'A. AZ Expiration Ofite /1 Si a ure Tel one V i SECTION 4-WORKERS COMPENSATION(XG.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.......❑ No.......C SECTION 5 Description of Proposed Work check all■ ble New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant 1. Buildingj�j (a) Building Permit Fee 6 / T64) Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge mid belief Pr t arra _. Si ture of er/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2ND3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS f SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Department of Industrial Accidents Office of Invesgigations 600 Washington Street : Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electridans/Plumbers Applicant Information Please Print Legibly Name (Business/organizationAn ividuat): Address: // Y City/StatelZip �/Aa &,W, &Z..?Phone M Z 2 (A,91, Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I on a employer with 4. ❑ I am a general contractor and I employee's(fill]and/or part-time).' have hired the sub-cofactors 6• El New construction 2.C1 am a sole proprietor or partner- listed on the attached sleet.t [:] Remodeling sbip and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. g, ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its . required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a bomeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' comp. insurance required-] 13.❑ Other -Any applicant that checks box#1 mint also fill out dee section below showing their workers' mdon oompen policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new aff davit indicating suck tContracton that check this box mot attached an additional sheet showing am Warne of dee sub-contractors and their women'comp•policy infornutim I am an employer that Is providing workers'compensation Insurance for my employees. Below Is the polky and job site information. Insurance Company Name: �►^r - Policy#or Self-ins.Lic.M 2 7 yRI 10 Expiration Date: / p� Job Site Address: �/�'oellI/ �/; y T X?—� �. City/Statc/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiref under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S 1,500.00 and/or one-yen bVrisonment,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 certify under the palms and penahia of perjury that the Information provided above is true and correct Si lure: Date: Cr� Pbone#: Offlcia/use only. Do not write In this area,to be completed by city or town ofj'lcial, City or Town: Permtt/Liceuse# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cky/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone 0: iniormaliun anu unu utwumiia Massachusetts General Laws chapter152 requires all employers to provide workers' compensation for their employees. Pursuant m 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 at 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, 125C(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 number(s)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 for confirmation of insurance coverage- Also be sure to sip 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 Departrnent at the number listed below. Self-insured companies should enter their self-insurance licensennurnber 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 �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 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 as 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 wwwmm.gov/dia NORTH Town Of over 0 No. 2 C., I dower, Mass., 0 tL- LA E COCHICHEWICK 0RATE BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR 30 THIS CERTIFIES THAT........ .........9 b............................................................................................. Foundation has permission to wept.....;510(A..... buildings on ......z*3...Gw.qd0.V%.&P....... ................ Rough to be occupied as..........*.....R W.ro.e..4 Q) r# J&ioft 41&p Chimney ..... .......... ........ ... ..... ........ .......................................................................................... provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final 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. ys/**v PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION SIART5 Rough Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. j oo 4f 1.1 �wclvjel: —fc,p4-ce ela Sec-(�[On O� �'O�� D� rear �erM� ✓ ree 4re4/1 y �..�.Ftt� HJOtor eft. l72r`n c-a-je_r, , Ill sr /rt?4Ftr r�t�;,,� S roQ►^� A-3 nee rcQ l f