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Home My WebLink AboutBuilding Permit #64 - 10 HEATH CIRCLE 7/22/2009 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: y 2 O IMPORTANT:Applicant must complete all items on this page LOCATION f1VtC P` t PROPERTY OWNER �'n � -fil� Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes 'n 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 Septic Well Floodplain Wetlands Watershed District Water/Sewer' DESCRIPTI N, WORK TO BE PERFORMED: G 7xa G IN 1,7 nficaatio lease T e or Print Clearly) Oti OWNER: Name:_ONIl�Rb - i?� Phone: 27F, 6i2 Frq_ Address: CONTRACTOR Name: Phone: Address: Supervisor's Construction License: Exp. Date: Horne Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: n 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: $b y FEE: $ Ca ____ Check No.: / a � `� Receipt No.: NOTE: Persons contracting with ung^ 'stered c ntractors do not have access to the guaranty fund Signature of Agent/Owner° n re of contractor Plans Submitted Plans Waived Certified Plot Plan Stamped Plans Ai 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 rte`— Sig nature Ida trA COMMENTS nd, t�1 V v jq D o� Ll E 0 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.$100-$1000 fine NOTES and DATA— (For department 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 Ithat 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: Doc.Building Permit Revised 2008 i Location No. �,� Date 2 If 011 NORTA# TOWN OF NORTH ANDOVER O 41 Certificate of Occupancy $ Building/Frame Permit Fee $ ( s�c►ws yd Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # lJ 222oo Building Inspector t%0RT#j Town of t 4Andover 0 No. *y C% _;_= dover, Mass., Z't•`� T 0 LAKE COCHICHEWICK V 7,p ARRA TE O P'P�\ �� 7`s BOARD OF HEALTH PERMIT. T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT 6........... �. .. ..�`�� ................... ............................. Foundation has permission to erect.,...................................... buildings on �� ..... .... /. .... Rough ... .............. .. ... ... to be occupied as a.. �� ......... ..... .� ............................................... Chimney e provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the InspectioAlteration and Construction of f Buildings in the Town of North Andover. ��f �� pw k .4 ,� PLUMBING INSPECTOR , ab VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final 3� PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTR STARTS Rough ...... ........................................................................................................ Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final 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. The Commonwealth of Massachusetts f Department of Industrial Accidents tl Q�ce of Investi;ations 600 Nfashin tun Street ''!sa Boston, MA 02111 {'? www nzass.gov/dia . Workers' Compensation Insurance Affidavit: Builders!Contractors/Eiectricisus/piQmbers A licant Information Please Print Lm-'bl Name (Business/Drganiration4ndividual): Address: l/ City/State/Zig: (�,C� — Phone g Fm employer?Cbeek.the appropriate box: m to er with 4, Type of project(required):P Y ❑ J asn a ge�rterai contractor and Iees(fu0 andlar part-time).' have hired rho sut3-contractors 6. ❑waw construction .ole proprietor ar partner- listed ori the attached sheet ? 7. Remodeling ship and have no employees'. These sub-contractors have workin for me in 8• Q Demolition g . airy capacity. workers' comp.insurance. [No workers'comp.insurance 5. 9• []Building addition ❑ We are a corporation and its required] officers have exercised their 1 Q•Q Electrical repairs or additions 3 I am a homeowner doing all work right of exemption per MGL 11. Plumbin m sel£ ❑ g repairs or additions y [Tre required.] comp, c 152, §1(4),'and we have no 12. Roof .. insurance aired. t ❑ t'epaira m9 ] •employees. [No workers' ' camp• insurance required_] 13.❑.Other ��+nY apPiicant tient checks bo>"ai l most also fill out the section below Showing their workers'bompensstion Policy information. ;Any who submit this affitiavh indicating they are doing an work end then hie outside contractors chmust submit a new affidavit indicating s„ t $Contractors that check this box rtrostrtt dmd an additional sheat show' . +ag the nsrrrc of the sub-cormracfin's and their work=,ce„gyp• r:-. r Pc••��irfnm�adon. 1 arrt.�t eWloyer that is provilfing:wor'kers'compensation insurance or e infornradon. f m1' nrployeet� Below is the po&ey and job site . . Insurance Company Name: ' Policy#or Self-ins.Lie.#: Expiration Bate: Job Site Address: City/StateJZip: Attach a copy of the workery.compensation policy d Failure to eclaration page(showing the policy number and expiration date). secure coverage as required under Section 25A of MGL C. 152 can lead to the imposition of criminal penahies of a fine up to$1,500 d and/or one Year imprisonment,as well ELS civil penalties in the form of a STOP WORK 4RD£R and a fine of up to$250.00 a day against the violator. Be advised that ac Of this copy statement ma be f Investigations of the DIA for insurance co Y orwarded to the Office of verage verification. I do hereiry send under the iru fPerjury that the info?»ration provided abo is true eonrd Si Date: Phone#: E0ffwzaDv use Only. Do not write in tftis area,to be completed bi,C or town.off ciaL n; Permit/License # hority(circle one): Hearth L Sulldi on„Department 3.City]Town Cierk 4. Electrical ins estor 5.P Plumbing inspector on: Phone#: Information a nd Instructions ' Massachusetts General Laws chapter 152 requires all emp Ioyms 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 twoor more of the1bregoing engaged in a joint enterprise,and includirzg the legal representatives of a deceased employer,or the receiver err trustee-of an individual,partnership,associatiorn or other legal entity,employing employees.'Howe=the owner of a dwelling house having not more than three apaort ments and who resides therein,or the occupant of the dwelling house of another who employs persons to do mairrteaance,construction or repair wcirlt on such dwelling house or on the grounds or building appurter t 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 perfonee of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presmrhed to the cortbacting authority." Applicants Please fill out the workers'compensation.affidavit compi,--tely,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 certific�(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not requiredto carry workers'ca-rnpensafion insurance. If an LLC orLLP 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 theapplication 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 roquired to obtain a workers' oompensation policy,please-call the Department at the number listed balow. Self-insured coanpanies should enter their self-instuancelicense number on the'approprtate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department hes 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 sura to fill in the permit/license number which A-0 be used as a reference number. In addition,an applicant that must submit multiple permit/Jicense applications in any given year,need only submit one affidavit indicating-current olicy'informafion(if necessary),and under"Job Site Address"the applicant should write"all 1 P &?') app orations in (city or town),"A copy of�the affidavit that has bmt 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 fai=e 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 poison 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 Aa6dents Office of Lnvesti afions 600 Washington Street Bosfon, MA 02111 TeL #617-7274900 ext 406 or 1-8.77-MASSAFE Fax#617-727-7749 Revised 5-26-QS www,mass.gov/dia f MORTM TOWN OF NORTH ANDOVER •, _ °� OFFICE OF y BUILDING DEPARTMENT " + 1600 Osgood Street Building 20, Suite 2-36 '��s''•.,.:.�'"�, North Andover, Massachusetts 01845 swc„us� Gerald A Brown Telephone X978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION Please print DATE: 7 0 JOB LOCATION: '0 +' ��` �[ r Number Street Address HOMEOWNER 1 l�f'� o - `7 (gal 17Nam Q 3 Home Phone work Phone PRESENT MAMING ADDRESS �J rcZ City Town State Zip Code . The cine mon for"homeowners"was 10 dude o-.r "-r—=p ed dweninp to tws in=or less and to allow anal homeowners to engage an individual for hire who does not possess a Iim m,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 winch there is,or is intended to be,a one or two family structures. A person who constructs mme that one home in a two-year period shall not be considered a homeowner. The undersigned"homeowner"assumes responsibility fur COmpliances with the State Building Code and other Applicable ,by-laws,riles and regulabons. The undersigned"homeowner"certifies that helshe undo she the Town ofNorth Andover Building Deparft m minimum inspection procedures and=Xk ments and He/she will comply with said procedures and HOMEOWNERS SIGNATURE a APPROVAL,OF BUILDING OFFICIAL. Revised 10.2005 Form Homeowners Enmpgon BOARD OF �PPE:ILS 698-9511 CO.NSERN'xr[ON 688-9530 diL.ILTH 08-9540 PL.I.NNING(;88-9535 ■� slow lo, all aim •,� ■ i� I r 5t P - 71 f Door- 761 r� t • y ch S / i t i C. 2 - I. 10 i �" --�-�- r J P j 6 F Y 71- Y f'LAN /-`i NU./ /U f1t C.Z>NJ/UtKtU AN ALTA/A CSM LAND TITLE SURVEY. ' 1�) 4" RUQ 2) BUILDING OFFSETS ARE TO WOOD CORNER BOARD. 252'28 � rD � FLUSH _ o FD•) 114" I ROD F usH F QUINN r z & ELIZN A5BE18s56#,36 PLAN MICNAN'E'RD � o 7 O PROPOSED 12 X15' CO VERED PORCH z OLE, (FD') 28'(C) -Zo uA z , Q1 Q DRILL H 259 50�(R) o p"Z3 m H = l?>� ✓0 X15 Cr� 0` 1 ol o r PROPOSED ~ x ADDI TION h w co 93'1- O ^ 00 v (30' MIN.) N a 108'1- 29.3' ^ k rh (30' MIN.) 118.4STOR I'1'OOD p m . N PROPOSED 5'x12' DECK GARAGE 29.4 DECK 2 7•g' ZEV15�� j SHED �y- GROUND o w w POOL LOT 19 to N 36, 086E S.F.(C) � _ 34, 178.1- S.F.(R) M z �k11�o1C,6�� g�