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Home My WebLink AboutMiscellaneous - 1401 GREAT POND ROAD 4/30/2018 (8) o �� -� . � � 1 �� 1 .� I Date. �':rho TOWN OF NORTH ANDOVER - p PERMIT FORYLUMBING , ,SSACMUS� i This certifies that .,. . ., . `.. has permission to perform .. -.. . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . .-��'.! . . . . . . . . . . . . . . . . . . . . at . . ./. ` ... . . . .-�`I�%. . . 'rte' .A.Fo. . ., North Andover, Mass. Fee. .f�. �Lic. No.� .' ' �. . . . . .� !.�_ 2- . . . . . . . . . . . . . . ,e� PLUMBING INS; TOHe Check # f G -3 8075 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS / 11� Date Building Location �� Owners Name ( � Permit# p r� 9 Amount Type of Occupancy New Renovation Replacement Plans Submitted Yes No FIXTURES ri R4SEU M' 1S>C Hj" 2141 FUM �FIDQt 4M HfM SII3 FIDCR 6M FIOM 7M HM gm FLOCK (Print or type) hec one: rtificate ` Installing Company NameZA ��Corp. Address JJ❑��P"artner. usmes a ep one I Firm/Co. Name of Licensed Plumber. Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy E Other type of indemnity 11 Bond E Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and insta ations performed unde ermit Is ued for this application will be in compliance with all pertinent provisions of the sach e s State Plum 'n e a er 142 of General Laws. By: of Zicensea Type of Plu bing License Title City/Townis n um Master Journeyman APPROVED(OFFICE USE ONLY BUILDING PERMIT ot NORTHtt,6o 16�ti TOWN OF NORTH ANDOVER ?`". '' ` '' '° °� APPLICATION FOR PLAN EXAMINATION 2/ Received— Date Permit NO: Date Received � �SSACHU`�E�� Date Issued 1-0 IM ORTANT:Applicant must complete all items on this page LOCATION l7�/O i f pcwZ) AD rint PROPERTY OWNER_ I9A777�aJAJ ,f l Print MAP NO: PARCEL:- ZONING DISTRICT: Historic District yes: n Alit— Machine Shop Village yes n TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial AI era ion No. of units: Commercial replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: Identification Please Type or Print Clearly) OWNER: Name: )l6n 'ht CC kg2f F Phone: 97,F-,5-60-1,PV/ Address: /yof CgO �6Nl� ,AZA Lliu/T-;fq AJ.4kDOilaA/ 74 CONTRACTOR Name: ,A44 J InAZTIAJO Phone; Address: -17117J 41�Fyy Supervisor's Construction License: (0 3#a Exp. Date: Home Improvement License: Exp. Date: 9 -7 r � ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST,�4SED ON$125.00 PER S.F. Total Project Cost: $ �J`J a FEE: $ Check No.: /,20 Receipt No.:Qk035 ,— NOTE: Persons cont acting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contra or ti 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 NOTE: 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 ❑ 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) ❑ Mass check Energy Compliance Report (If Applicable) ❑ 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 ❑ Certified Proposed Plot Plan ❑ 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 ❑ Mass check Energy Compliance Report ❑ 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 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 21 A—F and G min.$100-$1000 fine NOTES and DATA— (For department use ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 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 Conservation Decision: Comments Water & Sewer Connection/Signature &Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Location/d/ (r'' � a^� � q No. Date �- V- TOWN d /OF NORTH ANDOVER 3: � SOL h 9 Certificate of Occupancy $ ,sS CMUSt. Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # I j Building Inspector NORTH Town of .4 L Andover . No. C% A K E dover, Mass., �- co MIC ME WICK ��' �d ADRATED S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT `L.. . ...................._................... Foundation oun ation has permission to erect............ ..... ................. uildings on ........V/.......05.......�� ....................i.......... Rough to be occupied as .. ... ..�...��,�.. X 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. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final IFos PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTR Cj 10 ART 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. ILSEE REVERSE SIDE Smoke Det. Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR ug Registration; 124961 Expiration 9/17/2009 Tr# 132544 l "I. 11 ."-v;_ Type in,IVidual DARREN MARTINO iti ri=/-' Darren MARTINO 44 ADDISON AVE?EXT rv, METHUEN,MA 01844 Administrator t Gflze 7e"'noMuea ons/la lea Board of Building Regulations andd Standards s Construction Supervisor License w { License: CS 66342 k. Birthdate 8/15/1971 Expiration 8!15/2009 Tr# 2233 M ' Restriction ODS DARREN MARTIN, 44 ADDISON AVE EXT,::' METHUEN,MA 01844 Commissioner I I. The Commonwealth of Massachusetts kj ! Department of Industrial Accidents It . Office of Investigations ii It 600 JMzshington Street ti Boston, MA 02111� www_mass govldia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plambers Applicant Information Please Print Legibly Name (Business/orpniration/individual): N TWO Address: JI L L k- City/state/Zip: 104V Phone#: F2.9 you an employer?Check-the appropriate box: I am a em to er with 4. Fwc l (regniret�:P Y ❑ 1 am a general contractor and Iemployees(full and/arpurt-time).* have hired the sub-contractors constructioni am.a.sole proprietor or partner_ listed on the attached sheet t odelingship and have no employees These sub-contractors have olitionworking for me.in any capacity, workers' comp.insurance.[No workers com . insurance 5. ing additionp Q We are a corporation and itsrequired•) officers have exercised their ical repairs or additions 3.Q I ant a homeowner doing all work right of exemption per MGL ing repairs or additions myself,.[No•workers'comp. c. 152, §1(4),and we have no insurance required.].t 12.Q Roof repairs T�1 ) .employees. [No workers' comp, insurance required.] 13.Q Amer *Any applicant fiat checks boli l mustalso fill out the section below showing their workers'compensation policy information t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new afridavit indicating such. #Contractors that check this box must attached an additional shwrshowir .the name ofth,sub_contn;dors and the irT workers'comp.Fo.r ICj information. t ant an employer that is prouid ng:workerscompensation imurmcefor my enW10yeeL Below is the policy andyob site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: 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$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 cerd under the pains and penalties of pedury that the informadon provided above is true and correct St Date. Phone#: _ v ,�3 ficial use only. Do not write in this area,to be complat�d by city or town ncia[ City or Town: Per•mit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Towa Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: Information a nd Instructions Massachusetts General Laws chapter 152 requires all emp 7 oyers 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 airy two or more of the'foregoing engaged in a joint enterprise,and includiz-ig 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 owneir-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 *o construct buildings in the commonwealth for any applicant who has not produced acceptable evidence..oV compliance with the insurance'coverage required" Additionally, MGL chapter 152,§25C(7)states"Neither tilde 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 pa tn=,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 nusarberfisted below. Self-irisured cornnanies 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 ofthe 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 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 Commonwealth of Massachusetts Departmcrit of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 TeL# 617-727-4900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax#617-727-77491 www.mass.gov/dia