HomeMy WebLinkAboutBuilding Permit #692 - Exception 6/15/2009Permit NO:
Date Issued:
LOCAT
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
IMPORTANT: Applicant must complete all items on this pale
Front
MAP NO: PARCEL: ZONING DISTRICT: Historic District
Machine Shop
no
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
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
ON 9F WORK TO BE PRPFORMED:
11
Identification Please Type or Print
OWNER: Name: ��4viA w-U-)VAILW �IZy
Phone:
8z 3y07
Address: 6. -1-1-6t .c 'It, c2>
CONTRACTOR Name: 4y i-,--.) M , JW UR/ Phone:�-
Address: M. -o S" _( a-72�n Q I
Supervisor's Construction License: eS 4/d :TJ8 Exp. Date: 2,!/--2,e 1/
Home Improvement License: //0
Date: / t) -- 7 0 -
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: $
�
j
Check No.: '" Receipt No.: Z
NOTE: Persons contracting with unregistered contractors do not have access touar my fund
Signature of Agent/Owner Signature of contractor
Location
No. 7 Date 6, '
ORTN TOWN OF NORTH ANDOVER
0��N.•e ,•'�,{.O
9
_�._.
Certificate of Occupancy $
JwCNUs <� Building/Frame Permit Fee $ ` j �
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # 5—eD
22
Building Inspector
Plans Submitted
Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/Massage/Body Art
Swimming Pools
Well
Tobacco Sales
Food Packaging/Sales
Private (septic tank, etc.
Permanent Dumpster 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 Sianature
COMMENTS
V
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision:
Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
FIRE DEPARTMENT - Temp Dumpster on site yes.
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Located 384 Osgood Street
no
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
NU I t5 ana UAI A — (for aeDartment use
❑ Notified for pickup - Date
Doc.Building Permit Revised 2008
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
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ 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)
❑ 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)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
❑ Mass check Energy Compliance Report
❑ 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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2008
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The Commonwealth of Maswachusefts
z<f Jt Department of Industrial Accidents
Office of Investigations
\ a 600 Tfrashington Street
Boston, MA 02111
www_nMSs gov/dia .
Workers' Compensation Insivance Affidavit. Builders/Contractors/Electricians/Plumbers
Appficant Information
• Pietise Print Leaibl
Nanle (Business/organizatiornndividual):
Address: Sv s
City/State/Zig: Phone #:.
Are you an employer? Cheek.the appropriate box:
I. El I am a employer with 4. ❑ I am a general contractor and I Type of project (required):
ogees (full and/or part-time).* have hired the sub -contractors 6. ❑ New constructionI an .a.sole proprietor or partner_ listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These subcontractors have
working for me in any capacity. workers' comp, insurance. 8. Q Demolition
[No workers' comp, insurance . 5. ❑ We are a corporation and its 9• ❑ Building addition
required.] officers have exercised their 10.0 Electrical repairs or additions
3.0 1 ain a homeowner doing all work right of exemption per MGL 1117 PIumbing repairs or additions
myself. [No -workers' comp, c. t52, § 1(4), and we have no
insurance required.].t employees. [No workers' 12.[] Roof repairs
comp. insurance required_] I3.❑.Other
*Any appiicartt tient checks bends l matt also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work end then hire outside comtactors must submit a new affidavit imdicatiag such
;Coetractors that check this box mustam;c& as additiaaal aheet showing the name of the wb•conmwtors and their workers' cct_� _'
! am an ewloyer that is proviric►rg:workers' co ensakon ' r pc•:c3 ir&nnation.
information, mP ursrrrance for my eMPioyem Below is the pokey andjob site
Insurance Company Nam.. ' -6/6 /L
Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address:
Attach a copy of the workers' compensation l• City/Statezip:
Policy declaration�ge (showing the policy courtier and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can against the violator.ead to the position of criminal penalties of a
fine up to $1,500,00 and/or one-year imprisonimposition na
t
men; as well as civil penalties in the form iof ma STOP WORK ORDERna and a
Of up to $250.00 a day Be advised that a copy of this statement may be forwarded to the Office of Beline
— Investigations of the DIA for insurance coverage verification.
_ .r'-yujl un pains and penalties of perjury C*at the information provided above is true and correct
5i
LBOard
only. Do not write in this area, to he conrleted or town o
bJ'}'cxaL
n:
Permit/License
#
ority (circle one):
Health2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
son
Phone #:
Information a nd Instructions
Massachusetts General Laws chapter 152 requires all emp Ioyers 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 ortrustee of an individual, partnership, associatiorn 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 ite construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence -of compliance with the insurance' coverage required"
Additionally, MOL chapter 152, §25C(7) states "Neither tiie 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 carrtracting 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), addrms(es) mind phone manber(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
empioyees, a policy is required. Be advised that this affidavit may be submitted to the Depar trnent 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'
oompensation policy, please -call the Department at the number listed below. Self-insured companies should entm their
self insurance"iicense 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 applicart.
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
policyinformation (if necessary) and Lader "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 now 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 tike 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 Endustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
TeL # 617-7274900 exit 406 or 1-8.77-MA.SSAFE
Fax # 617-727-7744
Revised 5 -26 -QS www.mass.gov/dia
Proposal
DAVID MORII
AODELING CONTRA
41 Balmoral Street
ANDOVER, MA 018.
(508) 475-2672
Lic. #040898
Page No. of Pages
PROPOSAL SUBMITTED TO _
PHONE
DATE
STREET
JOB NAME
CITY, STATE and ZIP CODE
JOB LOCATION
ARCHITECT
DATE OF PLANS
'
JOB''PHONE
L/
We hereby submit specifications and estimates for:
tl~�Gt 4 _tet' Lair, r ��r"Jj l�_ ri L¢-`"fit�e'Z22�
T v •t �„'<^. ' z .�' � � , _fs �`� -'� �y ,=i�Y' •! 4,v' � �i�� � cr�vG•�!i'i�-%�?if/ "_'
-�,
��'-�-�1-G '' '<�,�,.r��%"-��1-� �` •��.e:J���- � ���"�.--�'�1�f�.l;.i--� G�'i �/T >.r�� f r.
WP PropOSP hereby to furnish material and labor — complete in accordance with above specifications, for the sum of:
dollars
Payment to, be made as follows:
/
All material is guara/nteed to'be as specified. All work to be completed in a workmanlike
manner according to standard practices. Any alteration or deviation from above specifications Authorized
involving extra costs will be executed only upon written orders, and will become an extra Signature
charge over and above the estimate. All agreements contingent upon strikes, accidents
or delays beyond our control. Owner to carry fire, tornado and other necessary insurance. Note: This
Our workers are fully covered by Workman's Compensation Insurance. withdrawn by us if
Arreptattre of Proposal— The above prices, specifications Z 'ITZ,
and conditions are satisfactory and are hereby accepted. You are authorized Signature 4Z�Wll
to do the work as specified. Payment will be made as outlined above.
Date of Acceptance: Signature
may be
d within days.
n