HomeMy WebLinkAboutBuilding Permit #809-14 - 8 Bixby Avenue 5/9/2014BUILDING PERMIT
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TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINA +-
H
Permit NO: Date Received ,�„„„,.„.
Date Issued:
IMPORTANT: Applicant must complete all items on this
LOCATION R /ivt
Print
PROPERTY OWNER ('4I9 -i k RL� ,
Print � �
MAP NO:PARCEL: WI�ZONING DISTRICT: Historic District
Machine Shoo Villa
yes
es no
TYPE OF IMPROVEMENT
PROPOSED USE
Phone
Res' ential
Non- Residential
❑ New Building
WOne family
❑ Addition
NJ TWO or more family
❑ Industrial
❑ Alteration
No. of units: 3
❑ Commercial
❑ Others:
Repair, replacement
❑ Assessory Bldg
❑ Demolition
❑ Other
Address:
❑ Septic ❑ Well
❑ Floodplain ❑ Wetlands
❑ Watershed District
❑Water/Sewer
33 \/VALK,FP RD NDRTft /4 DWPR
e�
° eplate ►MP.wf w i Y44W un;
Identification Please Type or Print Clearly)
OWNER: Name: W K /�:6rtp_
Phone
Address: 20 C 8N9141g(vi Pi
N.00U- 14A
CONTRACTOR Name: mprkt,-
RAMS
Phone:
9) 6&- ti9
_(R” �.c�v�rnu
crt I tZV
Address:
33 \/VALK,FP RD NDRTft /4 DWPR
Supervisor's Construction License:
Exp. Date:
cs - oy30)
Home Improvement License:
Exp. Date.
ARCHITECT/ENGINEER
Address:
Phone:
Reg. No.
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ 3000, 00 FEE: $
Check No.: - ,�f/ Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner .2 Signature of contractor
16
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TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date
IMPORTANT: Applicant must complete all items on this page
LOCATION..-.
Print. .
PROPERTY OWNER,
Print 100 Year Old Structure yes no
MAP NO: PARCEL:4 ZONING DISTRICT: Historic District yes no
Machine Shop Village. yes no
TYPE OF IMPROVEMENT.
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
p Septic ❑ Well
❑ Floodplain ❑ Wetlands
❑ Watershed District
❑ Water/Sewer
DESCRIPTION OF WUMM I U tit rtKruruvitu:
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
A -1-1 ....., .
e .
CONTRACTOR Name: __ 'Phone:
Address:
Supervisor's Construction License: Exp. Date:
Home Improvement License: -
ARCH ITECT/ENGI NEER
icense_
ARCHITECT/ENGINEER
Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $
FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund
nature ofAgent/Owne_ r. Slg afure of contractor ,
Plans Submitted Li R Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans El
rT
Location 8 Ave,
No. UU t` I Lk Date
Check #�422 -
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $�
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
27:59
(`` eluilding Inspector
Plans SubmittedE Plans Waived ❑.: =..Certified Plot Plan ❑ Stamped Plans ❑
-TYPE OF' SI WERAGED3SPOSAL
Public Sewer ❑
Tanning/Massage/Body Art ❑
Swimming Pools ❑
Well ❑
Tobacco.Sales 0
Food Packaging/Sales ❑
Private:(septic tank, etc..El❑.
_Permanent D mpster 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
r'
Pianning Board Decision: Comments
Conservation Decision:
:Comments
Water & Sewer Connection lSignature &Date Driveway Permit
DPW To-wo Engineer: Signature:
Located 384 Osgood Street
FIRE DIE -`NT:.,-' Dump;steron site yes....:. no
Located at �124tMain Street '
Fire Departmeri -signatu'r`e/date ' '' ., s {►
.COMMENTS'' =�
.-Dimension
Number of Stories:
Totat land area; sq. ft.:
Total square feet of floor area, based on Exterior dimensions.
ELECTRICAL: Movement of Meter Location, roast or service drop requires approval of
Electrical Inspector Yes No
DANGER -ZONE LITERATURE:. -Yes No
MGL -.Chapter 166.Section 21A. -F and G min.$10041000,fine
Doc.Building Permit Revised 2010
r—
r—
Building Department
=The fol:wng is'a list of the required:forms to be
out -.for. the. appropriate. permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
U.- B,iailding Permit Application
o Workers Comp Affidavit
a Photo Copy Of H.I.C. And/Or G.S.L Licenses
L, Copy of Contract
u Floor Plan Or Proposed Interior Work
u Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Firer Department prior to issuance of Bldg Permit
Addition Or Decks
o Building Permit Application
a Certified Surveyed Plot Plan
o Workers Comp Affidavit
u Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
Li Mass check Energy Compliance Report (If Applicable)
u 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)
u Building Permit Application
o Certified Proposed Plot Plan
o Photo of H.I.C. And C.S.L. Licenses
Li Workers Comp Affidavit
Li Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
Li Copy of Contract
u Mass check Energy Compliance Report
o 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 apw• al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be subm-tied with the building application
Doc: Doc.Bui?ding Permit Revised 2012
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The Commonwealth of Massachusetts , -
DepartmentoflndustrialAccik% is
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass gov/dia
Workexs' Compensation Ynsurance Affidavit: Builders/Contractors/Electricians/Plumbers
.Applicant Information y,Please Print Legibk
Name (Business/Organization&dividual):
Address: D' W4t-t-W 12l�
City/State/Zip: Ai Aatdw Yui- 0'�'T Phone #• 2A 02" "9Z
Are onan employer? Check the appropriate box:
Type of project (required):
1. 71 am a employer with �_
d• El am a general contractor and I
6. F1 New construction
employees (full and/or part-time).*
2111 am a sole proprietor or partner
have ned the sub -contractors
listed on the attached sheet.
,�,/
`!• ! "1 Remodeling
ship and'have no employees
working for me in any capacity.
These sub -contractors have
workers' comp. insurance.
8. ❑ Demolition
9, [l Building addition
[No workors' comp. insurance
5. ❑ We are a corporation and its
10.❑ Electrical repairs or additions
required.]
3. ❑ I am a homeowner doing all work
officers have exercised.their
right of exemption per MGL
ILE] Plumbing repairs or additions
myself. Mo workers' comp.
c. 152, §1(4), and we have no
12.E]Roofrepairs
insurancere ed
�'. a
employees. [No workers'
1311 other
comp. insurance required.]
'Any applicantthat checks box#1 must also fill outthe section below showingtheir workers' compensatioupolicy information.
t -Homeowners who submit ibis affidavit indicating they kedging allwork and then hire outside contractors must submit anew affidavit indicating such.
tContractors that cheAthis box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
X am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site
information. n
Insurance Company Name: ( t �'
Policy # or Self-in.s. Lic. #: V �I C—1 0 Expiration Date:
Job Site Address:, t7 -L4 City/State/Zip:Ah
Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as re(�uiredunder Section 25A of MOL 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
ofup to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations ofthe DIA- for insurance coverage verification.
X do hereby certify under Aepains eng1ties ofperjury that the information provided above is true and correct. -
Phone #• / %A6 — �0 ) ? ' "C (
Official use orly..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. EIectrical Inspector 5. Plumbing Inspector
6. Other - - -
Contact Person:
Phone
NORTH
O `1. �Eo ,bgti0
°A Town of North Andover
Machine Shop Village Neighborhood Conservation District Commission
1600 Osgood Street North Andover MA 01845
C PPP
SACFHutiS f
Application For EXCLUSION From Certificate to Alter
For Mems 9,10 or 11, provide the following documentation:
Photos/drawings of existing doors, windows or siding, as applicable
Description/Catalog Cuts of proposed materials to be used for doors, windows or siding
Plan and elevation of reconstruction for Item 11
Determination:
This project is determined to be
❑ exempt
❑ not exempt
from review by the Machine Shop Village Neighborhood Conservation District Commission. Projects
that are not exempt must complete the Application for Certificate to Alter, available from the Building
Department and be reviewed by the Commission.
Determination,�nade by:
Signature
Neighborhood Conservation District Commission
Date
MSV NCDC Page 2 Current Chair: Liz Fennessy, 77 Elm Street, lizettafennessv@yahoo.com, 978-688-2915
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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 ofhire,_
express or implied, oral or written."
An employes is defined as "an individual, partnership, association, corporation or other legal entity, or any two ox more
of the foregoing engaged in a j oint enterprise, and including the legal representatives of a• deceased employer, or the
receiver or trdstee of an individual, partnership, associatlon 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 chapterhave beenpresentedto 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 certi.{icate(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 au LLC or LLP does have
employees, a policy is required. Be advised that this affidavit maybe 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 andprinted 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 submitmultiple permit/license applications in. any given year, need only submit one affidavit indicating current
PORGY information (ifnecessary) and under "rob 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. Anew affidavit must be filled out each
year. Where a homeowner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license orpermit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance fox your cooperation and shouldyou have any ciuestions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Corr wawealtlt of M -a ssa chmoits -
DeP.8ximQut ofIndustdal Accidents
Qf e o£IntVestigatloxts
6bG Washing Qn Skeet
Boston} MA, 0.21.11
TO, # 617-72,.7-4900 est 406 ox 1-877� MASS.AF`E
Revised 5-26-05 Fax # 617-727-7749 7749
_v�w.x�ass,govfciia