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HomeMy WebLinkAboutMiscellaneous - 153 HIGH STREET 4/30/2018 153 HIGH STREET 210/067.0-003&0000.0 M J . Y ' Location �� r 141 'S No. Y& Date NORT1y TOWN OF NORTH ANDOVER 3? � `. oL h p { Certificate of Occupancy $ �7sS4GMU5'••"•tt�'' Building/Frame Permit Fee $ -� Foundation Permit Fee $ Other Permit Fee $ _ TOTAL $ Check # t �� 17473 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 lP/ / DATE ISSUED: Z D O 7 `" X SIGNATURE: C Building CommissionerhRVEtor of Buildings Date SECTION 1-SITE INFORMATION Z 1.1 Property Address: 1.2 Assessors Map and Parcel Number: O -- � P 1 _ S D , A ,1,n 11 O I j —k Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zonin Distrid Pr osed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Rear Yard Required Provide ��-SideYar! Provided Required Provided j 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private p Zone Outside Flood Zone 0 Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT "'�qi 2.1 Owner of Record I,1 .7 V i fR -5 ` Name(Print) Address for Service: �r NO, 49Z)o VEX Signature NO, 2.2 Owner of Record: a Name Print Address for Service: O Z Signature Telephone M SECTION 3-CONSTRUCTION SERVICES I QO 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor. t O License Number Address aan Signature Telephone Expiration Date ic 3.2 iRegistered Home Improvement Contractor. Not Applicable ❑ AVID CAST 12.0A RE6�' �, 11� Company Name 14 ti �� Q b S U=Q/J 9-r, SU L� -2,.7,ZReglstrahon Number ! '... Address Expiration Date Si nature Tele hone SECTION 4-WORKERS COMPENSATION(KG.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.......❑ SECTION 5 Description of Proposed Work(check_all applicable) New Construction ❑ Existing Building Repair(s) ❑ Alt-rations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: STAI P ,r-- SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be F ,pE'k'ICIAI;USE Com leted by em-tit applicant J 1. Building a . .. . ( ) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)X(b) 4 Mechanical HVAC) �D�-- 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, cat in all matters relative to work authorized by this building permit appliion. Signature of Owner Date i SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1' 124 V/D C_14 S rR tz V E 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 and belief 7� V IP Cl� s7''J21��n>� Prul e „ r �I-L 10v Signature of Owner/Agent Date NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIlVIBERS 1 2 3 SPAN DIMENSIONS OF SII.LS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS � I-IEIGI4'T OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CFMANEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Comm nweaCth of9llassachusetts • ly�� rDepartn=t of IndustnaC,4ccidents Office of Investigations :600 Washington,S'treet (Boston, 9,(A 02111 Workers'Compensation Insurance Affidavit APPLICANT INFORMATION Name: M As Please PRINT Legibly �� ��� �D 1�� Location: 4if L G1 Sr ' i �� e City: /U 7)a .!T N � �,� /� Telephone#: 1 9S 3 ,7 j I am a homeowner performing all work myself. El I am sole proprietor and have no one working'in my capacity lam an employer providing workers' compensation for my employees working on this job Company Name: �n /'t V ITT) (,.AS ,-T , �' b a oFI)V . ¢- Address:—_ 3 K L&7_7_17. 17 I „ A A. City: Ala .Tl/ A/ n V F—ak 'Telephone-#: Insurance Company: S'idJU ALLi/ l LJE Policy#:_ f }� �j 6 � I am(circle one) sole proprietor,general contractor or homeowner and have hired the contractors listed below who have the following workers' compensation policies: Company Name: Address: City: Telephone#: Insurance Company: Policy#: Company Name: Address: City: Telephone#: Insurance Company: Policy#: Attach additional sheet if necessary Failure to secure coverage as required under Section 25A of MGL 15B can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this tatement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby c under th its and nalties of perjury that the information above is true and correct. < n Signature: � 111,�0 b Date:_ 4- Print Name:__ D CA S 7-AC`p�� Phone# 9+7 T Q — �z 4 Official Use ONLY-Do not write in this area City or Town: Permit/License#: o Building Department o Licensing Board j o Selectmen's Office o Check If Immediate response is required ❑Health Department ❑Other j INFORMATION &INSTRUCTIONS Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law" an employee is defined as every person in the service of another under any contract of hire, express or implie4, 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 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 section 25 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, 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 in the workers' compensation affidavit completely, by checking the.box that applies to your situation and supplying company names, address and phone numbers as all affidavits 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 oT 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. City or Towns Please be sure that the affidavit is complete and printed legibly. The Deparfinent 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. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. 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 Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Fax# (617) 727-7749 Telephone # (617) 7274900 ext. 406, 409, or 375 I Town of North Andover NORTH f •q4, t�eo 3�O`�'1' bt6 0 Building Department o 27 Charles Street ~ ' North Andover, Massachusetts 01845 : (978) 688-9545 Fax (978) 688-9542 904 q ° °ww�•,'� 'VS ACHU`� 1 DEBRIS DISPOSAL FORINT In accordance with the provisions of MGL c 40 s 54, and a condition of Building g permit # the debris from resulting � the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, sl 50a. The debris will be disposed of to/at: �., t r j l c�e Facility location Signature of Applicant Date f NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. NORTH ONNM Of 04 (# Z • z o maw 40 LA dover, Mass., COCKICMEWICK RATED P" '9S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System THIS CERTIFIES THAT...... BUILDING INSPECTOR .. . ..�.�.�..5............. ............��..�..�.............................................................. Foundation has permission to erect..... ........ buildings on ....1.5..15..... .` 4................qix!�................. Rough t0 be occupied as........................�M....I..: ..� �........ r. .� rirV�i .......................................... 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 Iain to the Inspect io Alteration and Construction of Buildings in the Town of North Andover. 3 9 44) PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations V lds this Permit.d. Roug h Final PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRUCTION ST ELECTRICAL INSPECTORTS 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.