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Home My WebLink AboutBuilding Permit # 6/9/2015 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATIONS Noerw o m 2 u Permit NO: 7 Date Received a ss � Date Issued: "`"us IMPORTANT:Lk licant must complete all items on this page LOCATION 976 Turnpike St North Andover MA Print PROPERTY OWNER Peg Graveline - JEM Property Group LLC Print MAP NO.: PARCEL: ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential ❑New Building ❑One family ❑Addition ❑Two or more family ❑Industrial ❑Alteration No.of units: ❑Repair,replacement ❑Assessory Bldg ❑Commercial ❑Demolition ❑Moving relocation ❑Other ❑ Others: ❑Foundation onl DESCRIPTION OF WORK TO B FORMED New Kitchen, New Baths, U date E pdate Heating S ste change direction of stairs v 4A ) Identification Please Type or Print Olearly) OWNER: Name: Peg Graveline Phone: 603-493-0992 Address: 14 Chatfield Dr Litchfield NH 03052 CONTRACTOR Name: Vinnie Desiderio Phone: 978-360-6952 Address: 138 River Rd Suite 107 Andover MA 01810 Supervisor's Construction License: d Exp. Date: _1/18 IC;�(L Home Improvement License: Exp. Date: ARCIIITECT/ENGINEER Name: Phone: Address: Reg.No. Total Project COSI:$ OF TOTAL COSTBASED ON$125.00 PER S.F. FEE SCHEDULE:BULDINGPE IT: . $12OOPER$IO$10000 0 THE TOAL ESTI ,,,. x12.00=FEE:$ u Check No.: & Receipt No.: Page lof4 l Ir tkORTH _t own of liduver ® ,'S- ",�. h ver, Mass, . cocwIc„ewicu �.®A0RATE® p,PP��S S U BOARD OF HEALTH Food/Kitchen Pt= RM� IT IF D Septic System THIS CERTIFIES THAT ,,,,, /C-- BUILDING INSPECTOR ......... ............ ........ . 6�z. .. 4.....................I.......... has permission to erect buildings o Foundation Rough to be occupied a )... .. ...t..... .. t. . ...... ....... .... ..�!.:I. .....4:57)3 r4 ® Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in 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 IT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESSIO T S Rough Service ................. .... ........ :.-................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® Occupy Building 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 Approvede Building Inspector. Burner Street No. Smoke Det. TYPE OF SEWERAGE DISPOSAL Tanning/Massage/Body Art ❑ Swimming Pools ❑ Public Sewer ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Well ❑ Permanent Dumpster on Site ❑ Private(septic tank,etc. Electric Meter location to project NOTE: Persons contracti ;nsth reregistered contractors do not have access to the guaranty fund Signature of Agent/Owner gnature of contractor 1! Plans Submitted ❑ Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF-U FORM DATE REJECTED DATE APPROVED PLANNING&DEVELOPMENT ❑ ❑ ❑Water Shed Special Permit ❑ Site Plan Special Permit ❑ Other COMMENTS DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS Zoning Board of Appeals:Variance,Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments i Water&Sewer connection/Signature&Date Driveway Permit Temp Dumpster on site yesno Fire Department signature/date The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers'Compensation Insurance Affidavit Please Print Name: Location: City Phone E-1 am a homeowner performing all work myself. 17--U am a sole proprietor and have no one working in any capacity I -T E-1 I am an employer providing workers'compensation for my employees working on this job. Company name: q)es t' r,e-J C o v,s4y-u --6%, x I /Q Address / 6 S f-�cvA f-� t24 City: Akr-fl-, tVtv Phone#: ;7F- Insurance Co. Policv# Company name: Address City: Phone#: Insurance Co. Policy# Failure to secure coverage as required under Section 25A or MGL 152 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 statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature_ Date - Print name Vil"I c V-il-t e-,-r` 3,0 Phone it Official use only do not write in this area to be completed by city or town official' E] Building Dept M Check if immediate response is required Building Dept F1 Licensing Board [] Selectman's Office Contact person: Phone A [] Health Department F1 Other FORM WORKMAN'S COMPENSATION The Commonwealth of Massachusetts 0- .Department oflndustrialAccidents I Congress Street,Suite 100 Boston,KA 02114-2017 www.mass.govIdia Workers,Compensation insurance Affidavit:Builders/Conti-fictors/Flectricians/Plqmbers- TO BE FILED WITH THE PERMITTING AUTHORITY. Please Print Lep-iblv Ap-olicant Information Name(Business/Organization/Individual): Address: City/State/Zip: 1 V6 1( Phone#: Are you an employer?Check the app.ropriate box: Type of project(required):. 1.[:]I am a employer with 'employees(full and/or part-time).* 7. F1 New'construction 2,g!I am a sole proprietor or partnership and have no employees working for me in 8. F1 Remodeling any capacity.[No workers'comp.insurance required.] 9. F1 Demolition 3,n I am a homeowner doing all work myself.[No workers'comp.insurance required.]t10 0 Building addition 4QI am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have-workers'compensation insurance or are sole 11.El Electrical repairs or additions I proprietors with no employees. 12,F1 Plumbing repairs or additions S.FJ I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.FJ Roof repairs These sub-contractors have employees and have workers'comp.insuranceJ 14.F1 Other___� 6.n We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no employees.[No workers'comp.insurance required.] applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. indicating they are doing all work and then hire outside contractors must submit anew affidavit indicatingsuch. I Homeowners who submit this affidavit tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. ensation insurance my emplbyees. Below is t1lepolicy and job site lam an employer that isprovidingwoficers'canp information. Insurance Company Name: Expiration Date: Policy 4 or Self-ins.Lie. Job Site Address: Citv/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 MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 7�� I I do hereby certfy under thepains andpenalties ofpeijuly that the information provided above is true and correct. D Signature: ate: (, L61 Phone#: 'I T�- .3 6, 0 G 7 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): i 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ;Sa ta�re�� 1,3 i r e p ws e` CS-05,093 VINf� 6 r CENT DE LDE 4 'r k 16 STEWA,RTRD rryG North Readingr� 018zl x is k r af Esu^a 07/28/2016 Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet(991M )of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For DPS Licensing information visit: www.Mass.Gov/DPS