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HomeMy WebLinkAboutBuilding Permit #260 - 267 Brentwood Circle 10/5/2006 f NO DTH 9 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 9SSACNUSE4 . 01 Permit NO: v Date Received: ^� Date Issued: '0G IMPORTANT:Applicant must complete all items on this page �r /,-), LOCATION T � PROPERTY OWNER Print,//�/ (�Ces L Print MAP NO.: PARCEL: ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential ❑New Building P-One family ❑Addition ❑Two or more family ❑Industrial ❑Alteration No.of units: ❑Repair,replacement ❑Assessory Bldg ❑Commercial ❑Demolition ❑Moving(relocation) ❑Other ❑ Others: ❑Foundation only DESCRIPTION OF WORK TO BE PREFORMED Identification Please Type or Print Clearly) OWNER: Name: MR —Phone: Si ature Address: A 6� -3 ©d CONTRACTOR Name: ��, ��GS S�/?S Phone: Address: Supervisor's Construction License: �3L-2 5f L� Exp. Date: Home Improvement License: l �'� Exp. Date: �} ARCHITECT/ENGINEER Name: Phone: Address: Reg.No. FEE SCHEDULE:BOLDING P T:ig PER S"W.000 OF THE TOTAL ESTI ATED COST BgSE'D ON$125.00 PER S.F. Total Project Cost :$ � t=FEE:$ Check No.: Receipt No.: 0657 Page 1 of 4 Location`/ 7 '7f17t�Do�• r ,��- 1` No. Date MORTN TOWN OF NORTH ANDOVER ,ti 0 0 A " + iCertificate of Occupancy $ , a �,SSACMUS t� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # l U rf 19651 Building Inspector i TYPE OF SEWARGE DISPOSAL Swimming Pools ❑ 11Tanning/Massagwmmng Tanning/Massage/Body Art ❑ � Public Sewer Well F1Tobacco Sales ❑ Food Packaging/Sales 11❑ F1 Permanent Dumpster on Site Private(septic tank,etc. NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund o Signature of Agent/Owner Signature of Contract Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped lans ❑ 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 Water&Sewer connection signature&date Temp Dumpster on site yes�/no Fire Department signature/date Building Permit Approved and Issued by: Page 2 of 4 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 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 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 o Building Permit Application o Workers Comp Affidavit a Photo Copy Of H.I.C. And/Or C.S.L. Licenses a Copy of Contract o Floor Plan Or Proposed Interior Work Li 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 o Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses Li Copy Of Contract o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) a 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) o Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract o Mass check Energy Compliance Report a 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:Building Permit Revised 2014 BOARD OF BUILDING REGULATIONS ,,,w a License: CONSTRUCTION SUPERVISOR # Number: CS 022680 F Birthdate:06/09/1939 Expires:06/09/2008 Tr.no: 28249 Restricted: 00 ARTHUR J WALSH JR PLEASANT ST N N ANDOVER, MA 01845 Commissioner "� Huard of Kuilding 12e};nt;tti0ns and Standards HOME IMPROVEMENT CONTRACTOR Registration- 103358 Expiration. 717/2008 Type: Private Corporation Sri& SONS INC St i`J Andavef MA 01845 I)cputy Administrator NORTIy 0VM Of 4 _ 4 over No. LA o �` dover, Mass., /d • r a G IwoCOCHICHEWICK Df' I ` ,p AATED P`PC� S BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT......... .S .... ...�!R..I.................. ...1�..!h!1w—A.... ...................................... BUILDING INSPECTOR """"'• ♦ Foundation has permission to erect........................................ buildings on� . . 4 ........ �Ill�.�..46 .....eft Rough t0 be occupied 83........ .� .... ...T........ .We Chimney ey provided that the person accep g this permit shall in a respect conform to the terms of the application on file in Final i 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 101 *a- PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTR TS ELECTRICAL INSPECTOR Rough .... ............ .................................................. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occztpy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RouFinagh 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. Propool Page# of pages CS # 022680 978-688-6737 HIC# 103358 A. J. Walsh & Sons or 55 Pleasant Street 1-866-AJWALSH North Andover, MA 01845 Proposal Submitted To: Job Name �Job# Address Job Location Date L Date of Plans Phone# (� f.� 1 Fa # (Architect 2,101 ----//1 We hereby s bmlt speclflcat/ions and estimates for . ... AV Leaf , cru ', - J:,A� ��u7-fes Zt�' . ......... .. ............. ................. ....... ......._ rWeopose hey to furnish material and labor—complete in accordance with the above specifications f the sum of: jl� !/ a� $ —� .I � Dollars with payments to be made as follows: Any alteration or deviation from above specifications involving extra costs will be Respectfully executed only upon written order,and will become an extra charge over and submitted above the estimate.All agreements contingent upon strikes,accidents,or delays beyond our control. Note—this proposal may be withdra by us if not acce ed within days. �cce�tance ofro�ogaC The above prices,specifications and conditions are satisfactory and are ignature hereby accepted.You are authorized to do the work as specified. Payments will be made as outlined abov . Date of Acceptance Signature NC3819 MADE IN USA The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Apptiicant Information Please Print Legibly Al Name (Business/Organization/Individual): / •1�- lel 1A6%J /r �D s Address: City/State/Zip: 1W vT����1���. A)�P- Phone #: f;Y—6Lfe 673 7 Are you an employer? Check the appropriate boli Type of project(required): 1.El am a employer with 4. I am a general contractor and I 6. F-1 New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or parader- listed on the attached sheet. $ E] Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. El are a corporation and its officers repairs or additions required.] officers have exercised their 3.El 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 12.0 Roof repairs insurance required.] t 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 are doing all work and then hire outside contractors must submit a new 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: A41Y4 W)N/2 K 626 Policy#or Self-ins.Lic. #: w—®/c/4 Cfk6 16 Expiration Date: job Site Address: 4�q 91?e ry7_6Vo104 011zeZ<1__ CitylState/Zip:1VP1514Woe_ja -,0;i 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 cer7' under the is and penalti s o perjury that the information provided above is true and correct Signature: Date: Phone# ��'� Oficial 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 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,§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 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 permittlicense 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 burn 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 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 www.mass.gov/dia