HomeMy WebLinkAboutBuilding Permit #0761 2017 - 10 PERIWINKLE WAY 2/6/2017 J
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BUILDING PERMIT
um— TOWN OF NORTH ANDOVER f- o
APPLICATION FOR PLAN EXAMINATION
Permit NO:0'4- 7-01-:�L Date Received
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Date Issued: o 9SSACHUS��
IMP RTANT:Applicant must complete all items on this page
LOCATION Q) f&1 W t'in P 7- W11
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PROPERTY OWNER I U &(P dry Oil -Al&,-r
Print
MAP NO: � e PARCEL: ZONING DISTRICT: 93 Historic District yes no
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 F1 h 15W 80'6afYA1
❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District
❑Water/Sewer
Identification Please Type or Print Clearly)
OWNER: Name: Al iq� V�- Phone:
,V qA 11021 r
Address: dovr
CONTRACTOR Name: Phone:
Address:
Supervisor's Construction License: Exp. Date: '
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COSTBASEDON$125.00 PER S.F.
Total Project Cost: $ > Z(208. Ob FEE: $ (/ '"--
Check No.: "Z R2__ Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
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Signature of A eVlOwner Signature of contractor
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TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION °" n
Permit NO: Date Received
Date Issued:
IMPORTANT:Applicant must complete all items on this page
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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
q Septic❑-Well•, �«4 Flood0lain4.�.WQ WetIand�p ❑F Watershed D'tstncf.,. . ;.�. .M F.S. °1 -. _ . -i 41 L J '�'x
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❑Water/Sewer . t r w
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1,1 7 _X11_.DESCRIPTION OF WORK TO BE PERFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
Address:
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Sunervisorr s z onstruction License Date
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14-Horne lmproyement License n_ Exp� Date
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT.-$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
Total Project Cost: $ FEE: $
Check No.: Receipt No.:
DOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
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nature of.A enti.Owner- �atiare::of:.coritractor...
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Plans Submitted 0 Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
Building Department
Tine folowing 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
DOTE: 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
DOTE: 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
o 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
TOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cEis,:s if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the; app-,al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must bf- submitted with the building application
Doc: Doc_Building Permit Revised 2012
i
s
Plans gubrr fitted [IPlans Waived ❑ Certified Plot Plan ElStamped Plan
I
TYPE-OF-SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/MassageBody 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
i
HEALTH Reviewed on Signature
COMMENTS
,,�'ioning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes .
1
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Seger Connection/Signature&Date Driveway Permit
DPW Towi! Engineer: Signature:
Located 384 Osgood Street
FIRE-DEPARTMENT - Temp Dumpster on site yes no
Located at'124 Mair Street
Fire Deliartmefit signature/elate
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
DATER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A-F and G min.$10041000 fine
NOTES and DATA- (f=or department use
B Notified for pickup - Date
Doc.Building Permit Revised 2010
Location fig/
No.,0 Dateoz 7bzel�`
• TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ _
Check# ' �
504 Building Inspector
Enter construction cost for fee cal - North Andover Fee Calculation
Construction Cost
$ 21000.00 m
$ - $ 24.00
Plumbing Fee $ 3.00
Gas Fee 100 comm. $ 100.00
Electrical Fee $ 3.00
Total fees collected $ 130.00
10 Periwinkle Way
761-2017 on 2/6/17
basement
NORT11
Town ofndover
6
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o Lver, Mass, Q
COC NIC Nl WK.1 y1.
�a ADRATED 0�,`�5
S U
BOARD OF HEALTH
Food/Kitchen
P E R !
T L D.
Septic System
THIS CERTIFIES THAT .... �. �N.. BUILDING INSPECTOR
� ... . ... ...................
O%y
0 has permission to erect .................. buildings on Foundation
.�� ......... Rough
'�� .
tobe 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
Rough
VIOLATION of the Zoning or Building Regulations Voids this Permit.
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR-
UNLESS CONST§ 10N
10N S Rough
Service
now
. .... 4UILD41NGli�N�SPEOOER
Final
GAS INSPECTOR
Occupancy Permit Required to Occupy Buildinz 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 ofMassachusetts
_. Department of IndustrialAceldents
r - a 1 Congress Street, Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information /�, Please Print Legib
Aly
Name(Business/Organization4ndividual): V1 W l,o( �'!+_
Address: 1Q P4 v\ w\4k1( uja(4
City/State/Zip: - 0 V fPhone#: '11 g 7114 p Z 1 5
Are you an employer?Check the appropriate box: Type Of project(required):
1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction
2. I am a sole proprietor,or partnership and have no employees working for me in 8. 0 Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 Building addition
4.E�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.E]Plumbing repairs or additions
5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
❑ 13.F]Roof repairs
These sub-contractors have employees and have workers'comp.insivance.1
6.❑We are a corporation and its ofCcers have exercised their right of exemption per MGL c. 14.❑Other
152,§1(4),and we have no.employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
i Homeowners who submif Us affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
lContractors 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 workeis'comp,policy number.
lam an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site
information.
t
! 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 S'T'OP WORK ORDER and a fine of up 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.
Ido hereby ccertiffyn,,under the pains and penalties ofpeijury that the information provided above is true and correct.
JI Si ature\ Vk-y`�": " Date: Z- Q
/ 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#:
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=contractor(s)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 bum 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
Nor+rk TOWN OF NORTH ANDOVER
OFFICE OF
h BUILDING DEPARTMENT
1600 Osgood Street Building 20, Suite 2-36
Arl ;:��',r North Andover,Massachusetts 01845
�ss'%c►+us�
Gerald A.Brown Telephone(978)688-9545
Inspector of Buildings Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
Please print
DATE:-2-1610
JOB LOCATION: d Q 1 UJ 1(01 k�Z UUG�
Number Street Address r, Map/Lot
HOMEOWNER NIccU K , l�al �► � `��1'E'` b l�
Name ome Aone Work Phone
PRESENT MAILING ADDRESS ' (ONVZ
n(r% kAw kkA 61W
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"assumes responsibility for compliances with the 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 that he/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
97
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