HomeMy WebLinkAboutMiscellaneous - 56 CIDERPRESS WAY 4/30/2018 (2) `''�,�'�, 5 j`; ;G 1
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TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit N0: Date Received
Date Issued:
IMPORTANT:Applicant must complete all items on this page
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LOCATION SU S7 S 415-6 C'►d(Q- "0 VV Jena d►'lS
Print
PROPERTY OWNER MeeL�I" mcms LUQ Unit# sa S s S'6
Print
MAP NO: /d YC PARCEL: 3 r ZONING DISTRICT: R1 Historic District yes
Machine Shop Village yes no
100 year-old structure yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
)(New Building ❑ One family
0 Addition P(Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
-❑ Demolition _ ❑ Other
®F1'oodpla ❑W t and~� (]J Wers]iedDstncts, '�j�Water/Sewera i &
DESCRIPTION OF WORK TO BE PERFORMED:
,e,w -U u iT r0&u" oU R WAr sn(_C72:/Rdr 0ryD*r1eN 6N ,YT_
enti ication Please Type or Print Clearly)
OWNER: Name: C-C- Phone:117F,4197-Z63.5
Address: 115 Car`Tpe- lev Q , N• Ada r-r.,rA a )acs'
CONTRACTOR Name: t 4 J o-�Y ,DP.\ (on ma&fL�C Phone:q 7�9 f46
Address: /Z S Cq* QL ,, IU.✓ Xw2r. l9' 0 f
Supervisor's Construction License: d S S"y )�Z Exp. Date: q
Home Improvement License: NExp. Date:
ARCHITECT/ENGINEER O'SuirivQIlPcfs Phone: 7Y/-y37- 6/64
Address:_S4�t-h'inSt, Aecr , MJ d)F67 _Reg. No. 60/0
r
FEE SCHEDULE.BULDING PERMIT.$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ FEE: $-2-06. �l�L�d(dit�iq art�v
Check No.: S�2 Receipt No.: �41P2 3
NOTE: Persons co�cting with u registered co Tactors do not have access to the gu ranty fun
.. _ --
Sgnature}ofyA'genUOvvner� Stgnatureloficoriftactor;
Location �Z s�/' SL
No. ya/ 2 Date
NORT1y TOWN OF NORTH ANDOVER
O
Certificate of Occupancy $
�ssCNUsE<�' Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $ f
TOTAL $
Check #
24823 `B d ng Inspector
Plans Submitted 19 Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer Tanning/MassageBody Art ❑ Swimming Pools ❑
Well ❑ Tobacco Sales ❑
Food Packaging/Sales ❑
Private(septic tank,etc. ❑ Permanent Dempster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS N 212A C�. q0t (v,,a Oay.��
CONSERVATION Reviewed on — Si nature
COMMENTS M jk-D,5P 2yZ _ )1)q
ir\ a c.6YA noe W106 C Q,ti,( moxC i�,a S
HEALTH Reviewed on Siqnature
COMMENTS 6,,j4j4r/
go k-ypoc - 406
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Z y2�/ Comments
Vater& Sewer Connection/Si nature& D eDrivewa Permit
r
�FW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp D er on site yes no
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.: 3Q Z. A,(-
ELECTRICAL: Movement f Meter location, mast or service drop requires approval of
Electrical Inspector (\j Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA— For department use
-fd ij.►jDjkrr 10,N P&-RK IT 6)SNY
❑ Notified for pickup - Date
i
Doc:.Building Permit Revised 2011 June/mi
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
o Photo Copy of H.I.C. And/Or C.S.L. Licenses
o Copy of Contract
❑ Floor Plan Or Proposed Interior Work
o 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
Li Certified Surveyed Plot Plan
o Workers Comp Affidavit
o 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)
o Engineering Affidavits for Engineered products
VOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
o Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
Li Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Copy of Contract
o Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
TOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg .Permit
a all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
iat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
lust be submitted with the building application
Doc: Doc.Building Permit Revised 2008mi
NORTH
o
Twn of over
4.
r-
No. `
= o , '� dover, Mass., 4r/
Q - LAKE
COC
HICHEWICK �.
A0RATED
`S BOARD OF HEALTH
PERMIT T D Food/Kitchen_
Septic System
07 BUILDING INSPECTOR
i� .
THIS CERTIFIES THAT.............���-�.* '.......... 6...0e +.Iroc -
........................................ Foundation
has permission to erect........................................ buildings on .. �.�`�-?.,�.5 ,..�` ......�r.G!f�' `fy.. ` '........ Rough
to be occupied as C��W 7to� � / Chimney
1 ..... .................................................................................
provided that the person accepting this permit shall in.e ry 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
PERMIT EXPIRES IN 6 MONTHS
ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION ARTS Rough
PIP
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.
.........
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
,SSAcwUS
This certifies that Ar"Mcvz'
............................ ......S.- .............
has permission to perform S-.ewk:'77�..... -10 d)'M
wiring in the building of.50--.i ...... .................
at North Andover Mass.
Fee Lic.No.....A)712A!D�6....... ....
........... ... ... ....
CA
..ALEC� L INSPRe
Check #
0730
A -
- Commonwealth of Massachusetts Official Use only -
a
Department of Fire Services PerrnitNo._ j D736
BOARD OF FIRE PREVENTION REGULATIONS [Rev.07)yandFeeChecked
(leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code C),527 CMR 12.00
(PLEASE PRINT)N INK OR TYPE ALL.INFORMATION) Date:---, I u /f, Z
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) S Z—s S C rl
Owner or Tenant
Owner's Address r , .t,jZ� (titA o a
Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box)
Purpose of Building $t�� � � � � Utility Authorization No. 1 2,4 f Z 7 7,97
Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters
New Service XQ--0 Amps 110/ Z t&olts Overhead❑ Undgrd ER' No.of Meters ,
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
QJ ( C
Com letion o the ollowfn table may be waived by the Ins ector o Wires.
No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o mergency ig ng
rnd. rnd. BatteLy Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of zones
No.of Switches No.of Gas Burners No.of Detection and
Initiating Devices
No,of Ranges No.of Air Cond. TotaTonal No.of Alerting Devices
No.of Waste Disposers Heat Pump Number Tons n KV4' No.of Self-Contained
r Totals: '-'""'�""
Detection/Alerting Devices
No,of Dishwashers Space/Area Heating KW Local❑ Municipal
Connection ❑ Other
No.of Dryers Heating Appliances , Security Systems:x
No.of Water No.of Devices or E uivalent
No.of No.of Data Wiring:
Heaters signs Ballasts No.OfDev'cesorE uivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
No.of Devices ox E uivalent
OTHER:
'311Attach additional detail 1f desired,or as required by the Inspector of Wires.
Estimated Value ofElec4rical Work: 5'0C)DW (When required by municipal policy.)
Work to Start: 3 Z► I 12s Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The
undersigned certifies that such c,�o�v,�er ism force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE L`� BOND ❑ OTHER ❑ (Specify:)
I certify,under the pains andpenalties ofperjury,that the information on this application is true and cor,piece.
FIRM NAME: A -<, (C LTC.NO.-/4,(_Jul
Licensee: kl LkAA tests ,, c ignatur LTC.NO.: Z7 b pS
(Ifapplicable ente "exempt"in the licens number line.) $us. e.No.• 3 3 Z- 2 q
Address: �- J. yq S .. „L`, � �,�5 ib.✓ .+�
^� Alt.Tel.No.: `I
*Per M.G.L c. 147,s.57-61,secu ty work requires Department ofPublic Safety"S"License: Lic.No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner
Owner/Agent ❑owner's a ent.
Signature Telephone No. PERMITTEE;$S�(7
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- _ ME+M&ALy��[;?2.�'•(T�►ryR-�16�y5•j'�1.'eyl.�l�O. _ µ'��/•T p�� _�iT��`7t' + ® T }'� �
_ �.1U.VVSJf..W.+i-Ct��.L'f V.+.®.L0. • .. ._ r • S_ R
.ROVO .3 N-SP)g ON,,
. 7��sset�s[ � _- +'ailed--[ J fie-inspection z'equzzec�($�0.00)�[ j
�nspectpxs'comzne�uts:
+ ir.
• p y h•1 i
(I•nspeetore Signature-)ao inifials) Pate
2.JEJCNAz,TN�`P�C'3C'TOI�7; -
Passea--[ } +ailed--[ e inspection xec uixec�($50.00} [
Inspector's,comments:
(.C�ispectozs'Signature•-no initials) date
pDIIRO
ed paned—[ � �2e-insp ectzon xegnixe�l($ 0.00)�[ ]
omment I
(hgectoxs'Signature-no initials) Date
4. WSPECTfON—SE3rqC,:
rrffi,li CAL -RD WAT+ONAI;G 3101 D. JV Alt j
Passed-- Nailed--[ ] �e-iuspectionxequired($50A0) -[ }
pnspect�xs'eoxnme��ts:
3- 22K
(Cusp ectors',signature-io I 'als) Ibate
'assed--[ } paned--[ }_ Etc-inspectionxequSxecl($50.00)�[ J
aspectoxs'coxum.ents:
AL1 spectoxs'Signature no initials) Bate
D 0 O TAGN-AFY,TO BE ED 0-1jr AND EEET ON BITE-W TE APXA TO BE INRECTED 79 NOT
•A.CCESMLE AND•A.BE WBRECTION OF 550,00 INTO 33Y,CMRGED. '
y The Commonwealth of Massachusetts
Department oflndustritrlAccidents
Office of Investigations
U1 600 Washington Street
Boston,MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): �eit^t (—G- c-T-yt,
Address:__3 PLy
City/State/Zip: `>T-o.0{N 1-S 031sq$Phone#: 7 C6-
Are y�-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 hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet.# 7• ❑Remodeling
ti ship and'have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. E]Building addition
[No workers'comp.insurance 5. El We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3.E] I am a homeowner 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.]r employees.[No workers' 13.❑Other
comp.insurance required.]
*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 Aire 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.
I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name:. %(� �,��p )
Policy#or Self-ins.Lie.#: Expiration Date:
Job Site Address:_S__0 City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(s wing the policy number and expiration date).
Failure to secure coverage as requiredunder 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 cerci under the pains and penalties ofperjury that the information provided above is rue and correct. -
Simature: Q Date: .3 l�
Phone#:
Official use only. Do 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 Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#'
Information and Instructions
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 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,§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 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 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 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 number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials ,
Y
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 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 ofMassachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 0.2111
Tel,#617-727-4900 ext 406 or 1.-877rMASSAFE
Revised 5-26-05 Fax#617-727.7749
Www,m.ass,govfdia