HomeMy WebLinkAboutBuilding Permit #056-2017 - 10 Longwood Avenue 7/19/2016 (2) BUILDING PERMITOF NORTH q
TOWN OF NORTH ANDOVER - -
APPLICATION FOR PLAN EXAMINATION1-7
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Permit No#:
Date Received
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Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION —/Q L.dkR A I Nb AV9
Print
PROPERTY OWNER TIIIM 67 q RP6&-J
Print 100 Year Structure yes
MAP PARCEL: ZONING DISTRICT: Historic District yes
Machine Shop Village yes
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building 2 One family
❑ Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
0 Repair, replacement:.- ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑ Sept�c.� ❑"Well r -�,Floodplaint �k11Vetlantls ❑<tVl/atersled ®stnct:� 4ffi'
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❑Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Identification- Please Type or Print Clearly
OWNER: Name: Tl rn.o fk. j r- g-1-z Phone:
Address: 6 L0PL 4 IiVC- U�
Contractor Name: Phone:
Email:
Address:
tnAA
Supervisor's Construction License`
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 0125.00 PER S.F.
Total Project Cost: 00 FEE: $
Check No.: 1 ' Receipt No.:_ � �
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
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PERMIT T LD Septic System
THIS CERTIFIES THAT ............�t. �4TY.`.5........,V..R ................................................ BUILDING INSPECTOR
Foundation
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has permission to erect .......................... buildings on ........,r..Q......4.0.��e,�4.1.,r.�®,�....� j
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to be occupied as .. .
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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
I
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONST TION Rough
Service
" Final
BUILDING I CT R
GAS INSPECTOR
Occupancy Permit Required to Occupy Building 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.
Smoke Det.
: The Commonwealth of Massqchusetts
Department ofl"ndustrialAceldents
" 1 Congress Street,Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FH.ED WITH THE PERMITTING AUTHORITY.
Applicant Information • Please Print Legibly
Name(Business/Organizatio&bdividual): l a-. 0 4-A" P tr fl-C-14
Address: 1® fiulf //611,11Y +14Dau"t,
City/State/Zip: NQ 2 TA 4, Nb,4aZ7,PLIM ef Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.Q T am a employer with employees(full and/or part-time).* 7. []New construction
2. 1 am a sole proprietor.or partnership and have no employees working for me in 8. [J Remodeling
any capacity.[No workers'comp.insurance required.]
❑Demolition
3.PI am a homeowner doing all work myself[No workers'comp..insurance required.]t
9.
10❑Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees.
12:[]Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs
These sub-contractors have employees and have workers'comp.insurance.$
6.Q We are a corporation and its officers have exercised their right of'exemption per MGL c. 14.Q Other
152,§1(4),and we have no.employees.[No workers'comp.insurance required.] 7.
*Any applicant that checks box 41 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 mutt 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-coritradors have employees,tliey must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees.'Below is the policy acid job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: 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
in the form of a STOP WORK ORDER and a fine of u
and/or one-year imprisonment,as well as civil penaltiesp 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 the pains andpenalties ofperjury that the information provided above is true and correct.
Signature S Date
Phone#
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#:
1
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 R_'ire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,ox 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-contractor(s)name(s),address(es)and-phone number(s)along with their certificates)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 foi•confirmation of insurance coverage. AIso 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 gou'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-MASS.AFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
1600 Osgood Street,Building 20, Suite 2035
�s. .m North Andc_ , Massachusetts 01845
Gerald A.Brown Telephone(978)688-9545
Inspector of Buildings Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
BUIDING PERMIT APPLICATION
Please print
DATE:
JOB LOCATION:
Number Street Address Map/Lot
HOMEOWNER �I v��� t, 6 83—G�900 1 Z 8 - aG - 2.
Name Home Phone Work Phone
PRESENT MAILING ADDRESS
/V o /L l H AiyneyA, p 1,
City Town State Zip Code
The current exemption for"homeowners"was extended to include owner occupied dwellings of one or two family
dwellings and to allow such homeowners to engage an individual for hire who does not possess a license, provided
that the owner acts as supervisor.
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 dwelling,attached or detached structures accessory to such use and/or farm structures.A
person who constructs more than one home in a two-year period shall not be considered a homeowner. (780 CMR
Section 110.R5.1.2)
The undersigned"homeowner"assumes responsibility for compliance with State Building Code and other applicable
codes,by-laws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Department
minimum inspection procedures and requirements and t he/she will comply with said procedures and
requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Revised 8.2015
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535