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Home My WebLink AboutBuilding Permit # 4/14/2016 OORTH "°qhs BUILDING PERMIT 0a °� TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION �9ACecN;c ,W ®� /� •- 5' Date Received, gar:o P Permit NO P 5 �Ssgco-aus�`� Date Issued: L1 IMPORTANT: Applicant must complete all items on this page Y 4 LOCATION PROPERTY OWNER -MAP NO: PARCEL: ZONING DISTRICT Historic D"stnct yeso -7-77777 -777, MacClit�e Shap Uil� ge yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 7wo e family ,,rr Llddition or more family Mndustrial VAlteration No. of units: ❑ Commercial epair, replacement ❑ Assessory Bldg ❑ Others: Demolition ❑ Other ❑ peptic ❑Well ❑ Flood in` ❑Wetla Watershednds ❑ Drstncfi ❑VVater/Sewer t Identification Please Type or Print Clearly) OWNER: Name: Phone: Tk OM Address: V CONTRACTOR Name: P ne ho Address: r Ex Date ; Supervisor's Construction icense� ` ' p 2 Home Improvement License: , Exp D ate 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: $ 1 � ) FEE: $ 77 Check No.: 5 ��, Receipt No.: NOTE: Persons contracts with u�r istered contractors do not have ac c s t e c anty fund Signature of Agent/Own r � �� Signature of contractor f Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAF Public Sewer ❑ MassagelSody Art ❑ Swimm.ing PoolsWell ❑ ales ❑ Food Packaging/Saxes [ Private(septic tank,etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF m H FORM PANNING & DEVELOPMENT Reviewed On Signature COMMENTS A CONSERVATION Reviewed on � Si nature` � COMMENTS HEALTH Reviewed on' Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection nature�®ate Driveway Permit ]DPW Town Engineer: Signature: _ Located 384 Osgood Street FIRE4®EP`PtI�T(VIENiT,u Tern Dumpster onks C f , fx o- gra.__:. Located iat;1+r24,,M�ainStree i • � NORTk a " dover Town of 0L_I -a 0 No. o : �Aµ! h ver, ass, COC NICNl WICK V� x,95 RATED PP�,t'�5 U BOARD OF HEALTH Food/Kitchen rFERMIT T Lou �y /�� Septic System THIS CERTIFIES THAT s% � �./V/'f `'`"�°.� fj. ....................... BUILDING INSPECTOR ......................... . .. ..................... .............. has permission to erect buildings on 5kr�'n��1y �fr�� /t1/`� .. Foundation .......................... ...................................................... ................. �i Rough to be occupied aS4r-p'.. f l —� ............ 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 PERMITIN 6 MONTHS ELECTRICAL INSPECTOR LESST TIO TARTS Rough ........ Service .......... ......�.. . . ................................... Final DING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove,. Final No Lathing r Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. The Commonwealth of Massachusetts Department ofIndustfialAccidents I Congress Street, Suite 100 Boston,MA 02114-2017 wwwmass.govIdia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE, PERMTTING AUTHORITY. Apl2licant Information Please Print Legibly Name (Business/Organization/Individual): (7 Address: ro City/State/Zip EA Phone #: f ��; ��SMC ��'`,`� �1 : 1" 66 1 t Are you an employer?Cheel(the appropriate box: Type of project(required): Q:J I am a employer with employees(fill and/or part-time).* 7. F-1 New construction 2.Q I am a sole proprietor or partnership and have no employees working for me in 8. []Remodeling any capacity,tNo workers'comp.insurance required,] 9. El Demolition 3.n I am a homeowner doing all work myself.[No workers'comp,insurance required.]t 10 ❑Building addition 4.[:]1 am a homeowner and will be hiring contractors to conduct all work on my property, lwill el)SLIrC that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees, 12,E]Plumbing repairs or additions 5.F]I am a general contractor and I have hired the sub-contractors listed on the attached sheet, 13.E]Roof repairs These sub-contractors have employees and have workers'comp.instiranceJ 61R We are a corporation and its officers have exercised their right of'exemption per MGL 0, 14,R Other 152,§1(4),and we have no employees.[No workers'comp,insurance required.] IL *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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number, I am an employer that is providing workers'compensation insurance far my employees. Below Is th e policy acrd job site in rination. Insurance Company Name: Policy#or Self-ins.Lie. Expiration Date: Job Site Address: City/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 lip 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. I do hereby certify under thepains andpenalties ofpeijwy that the inforinationprovided above is true and correct. Signature: Date: Phone 4: Official use only. Do not write in this area,to be completed by city or to)P11 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-contractors)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 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 burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia tAORTH TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT o 1600 Osgood Street Building 20, Suite 2-36 It North Andover, Massachusetts 01845 Gerald A. Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION Please print DATE:— JOB LOCATION: Number Street Address Map/Lot HOMEOWNE Name Home Phone Work Phone PRESENT MAILING ADDRESS 4�j City Town State Zip Code The current exemption for"homeowners"was extended to include owner-occupied dwellings to two units or less and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be, a one or two family structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned"homeowner"assurnes responsibility for compliances with the State Building Code and other Applicable codes,by-laws,rules and regulations. The undersigned"hoineowner"certifies t iat he/she understands the Town of North Andover Building Department minimum inspection procedures andjequirenients and that lie/she will comply with said procedures and requirements, HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 10,2005 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535