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HomeMy WebLinkAboutBuilding Permit #464-15 - 10 DUNCAN DRIVE 11/12/2013 BUILDING PERMIT o`"ORT 6�ti TOWN OF NORTH ANDOVER a2 �°� APPLICATION FOR PLAN EXAMINATION '' Permit No#: ri� Date Received �RQ°RATED cy* gSSAC HUS�� Date Issued: I ORTANT:Applicant must complete all items on this page LOCATION .t i vc- Print ( PROPERTY OWNER �t c-k ?1 i C� i Print 100 Year Structure yes nno MAP PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ne 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 DESCRIPTION OF WORK TO BE PERFORMED: Iden tificatio Ple a ype or Print Clearly OWNER: Name: arc �� X74 Phone: ¢t7� za ?j G Address: Contractor Name: 4hone: Address: 1 Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: 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.: au _- Receipt No.: a6ras7$ NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owne Signature of contrac Location 4b DyNc,—, Dr-4J No.AVDate 2 o - TOWN OF NORTH ANDOVER s o Certificate of Occupancy $ Building/Frame Permit Fee $� .� } •° ` Foundation Permit Fee $ Other Permit Fee $ 'Azct ` TOTAL $ Check# r 1 I �r Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPEOF 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 PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature 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/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS 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.$10o-$1000 fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email i 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 ❑ 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/Cross Section/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:Building Permit Revised 2014 The Commonwealth of Massachusetts - Department of Industrigl Accidents Office of Investigations 600 Washington Street Boston,MA.02111 www.mass.govIdia Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information l _/ Please Print Legibly Naha (Business/Organization/Cndividual): Address: 10 irk c ah c: vt City/State/Zip: N orUl �� ovc s- �A D�g� hone#: 173 Z 5ri - 7 Z G � Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I ' . 6. F1 Now construction employees(fall and/or part-time).* have Hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.1 7• ❑Remodeling ship and'have no employees These sub-contractors have S. ❑Demolition 'comp.working forme in any capacity, workersp insurance. ` 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3.h2lam 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.[]Roofrepairs insurance required.]t employees.[No workers' comp.insurance required.] 13.❑✓ Other 'Any applicant that checks box41 must also fill out the section be16w showing their workers'compensation policy information. T-Homeowners who submit this affidavit indicating they a're doing all work and then hue outside contractors must submit anew affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. Iam an employer that isproviding workers'compensation insuranceformy employees. Below is thepolicy andjob site _ information. 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 requiredunder 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 civilpenalties 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 certIAL under the pains aijpenaftie4 of perjury that the information provided above is true and correct. Sipmafore: Date: 1 1, Phone#: `�7 2 8 S 7 Z !.G 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): 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 ire,-express or implied,oral or.written." An employeiis 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 employes." 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 producedacceptable 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 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 retumed 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 pelf-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(ifnecessary)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 bum 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: Tho Cox onweaM off-assachweatts Department ofZnduMal Accidents Office of blvcstigatiton:% - 600 washing on kcQe t Boston,MA 02111 Tei,#617-727-4900 oyd 406 or 1-877-MASSAM Revised 5-26-05 Fax#617-727-7749 www-mass,gov/dja TOWN OF jVORM ANDO'4 EP, - o ,�` ,• rK��J(y�/�,T �v�■O�YITIyC{�E OF tin E'x�7TT • ' R �•� .1600i0sgoodStreetBuitding20,-Surte2-36 7�SSR�uus�c�� .North Andover,Massachusetts 01845 Gerald A.Brown - - - 'Ielepbone(978)68$-9545 InspeetorofBuiIdings Fax (978)689-9542 HOMEOWNER ZTCENSE EXEMPTION B D IO 'E lVEC' .L'YLCO.ATION Mraseprinf , DATE: YQB LOCAffON: l oVe- t A d d r e s -tAddress Il�Iap/Zot IXOMMOWNER o�/c(' 7 g- 2AZZ 6Y9 ' MameHome Phone W ork 2?hone S C S -'RESENT MAILING ADDRESS dam`^.moi Tn�r± - �f.3fw• - . lip Cods The current exemption for"homeowners"teas extended to?nclude owner occripied fo allow stx�Tn homeot vers to engage aa,_,divadsal.forhire tvno does notpossess a.icjense,provided thattthe,oyrnar 1 acts as snpervisor). ,$iatoDuilding (Code Seojion DEFINITION OFRONMOWNER, Person(s)who awns aparceI ofland on bewhich.he/she resides or intends to reside,on which there is,or is intended to ,a one or two fa y sfruetures. A person who constricts more that-one,home in.a two yearpmiod shall not be carisidered ahomeowner. Ab.e undersigned°`homedwnee,assumes responsibilityBorcompliances with the State Building Code and other Applicable codes,by laws,zWes audzegoations. • The undersigned"homeownaz"cerE;fies that he/she tmderstands the Town of Nbrth AadoverBuilding Department Minunum.inspecfion procedures and requirements andthat he/she wi11 comply wzth;sazd pxocedures and requirements, , HOMEOWN13RS SIGNATME APPROVAL OF BMDING OFFICIAL Revised 7.2009 Form Homeowners Bxempfion . '3OARDOFAPPBAM-688-954] r r • COI�SBR�4 A'T.10N 688-9530 PIEt3.L'Hi'688-9540 PLkNNWG 688 9535 NORTH own of O .... Z4tq No. °;�S*._._ h " ver, Mass, f i I Z 113 �!- COCKICMIWICK s U BOARD OF HEALTH Food/Kitchen PERMIT . T LD Septic System THIS CERTIFIES THAT ..................................................... BUILDING INSPECTOR ........................:k: .. ..........a......o.d -�— R,✓ Foundation has permission to erect .......................... buildings on J)..... .✓.. ..... ..:............................ r—� Rough rrAA 11 to be occupied as ... ....... ...... ! ............... 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 JD. . PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION A S Rough Service ................................................................................ Final BUILDING INSPECTOR GAS INSPECTOR Y Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final T No Lathing or Dry Wall o Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det.