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HomeMy WebLinkAboutBuilding Permit #009-13 - 101 BRUIN HILL ROAD 7/1/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: J J Date Received--4//`I3 Date Issued: IMPORTANT Applicant must complete all items on this page I TF 4 ,.» y:-� -e "v Thi °EA of ":, b Pe cam-`- �''*1X' r '_ —k .- Y�'3� LOCATION ' 7r '�-wY JA;. €::-cam- a°rr,.�i-c -„�'rn�[]�--{r "�'-- �3"`�; yam ` ' �n�.�scs°'•t.'.4.,-+mf.�,�f- Y ,;s a 'PRO�ERT-t,0WNER .PROP dam,rf. , �g ..�,�. �.sg� c- - -.f.r �v -•tea: x � , r _ Pnnt10,0 Y�ea0ldStructure yes no M' d ARCEL Z�� NINGDISTRICTFitor, Distric chi ho TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family El Addition El Two or more family 11 Industrial Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other q�s,`,t.�rt.❑s�Se'pt�i"c. ❑1 Y .r� y ,e'a', a`k,}r'ta�t�«�'°+` ��r `7;3,. S e .:� ` �” �g �fir: eC d Distric_t t Well lain ,❑WaWaterhhtlands * r y DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: � �/ 7;9 'i Phone: Address: O�/ `�� GL / /�/�D vl "�"1�«w• �y -,�„ y71 1-s "',Ar+ .a�A; ���.qt+�e..y, d� -� �ts�-�r.-z .Ra r-.�t�-£ "'Af' �'.�y�"�rY-��71''Cs t`s�rx'.'�jza�"�+�. r.��7 y-�`� ,N. :. y d xr ., Vim- F " M , . .F CNN}TRACTYOR1,Name �� Phone POE X1 �'_ # aAcddres tips e ' y¢ - i^� 'T•. xr ,a �.. Lx.L.w.< Supervisovr s��Constru� ction icense � `+�#c� +ri >X>rwa�y Home ImprovementrLicense ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED-ON$125.00 PER S.F. Total Project Cost: $ � FEE: $ Check ll �- & Receipt No.: " NOTE: Persons contracting with u e iste c Tactors do not have access to the guaranty fund Signature of Agent/Owne Signafure of bontractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans. ❑ 1 i Location� �/ i No.0t!" Date — r i 10 4 i • ' TOWN OF NORTH ANDOVER' Certificate of Occupancy $ h� M Building/Frame Permit Fee t Foundation Permit Fee Other Permit Fee $ TOTAL $ Check# i 6 ` � v Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ 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 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 DPS'Towia Engineer: Signature: Located 384 Osgood Street FIRE DEPARTI ENT -Temp Dumpster on site yes no Located at 124 Mair Street Fire ®epartmert 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 El Notified for pickup - Date Doe.Building Permit Revised 2010 Building Department The fol,,3, wing 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 o 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 that the aprr,al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subWted with the building application Doc: Doc.Buiiding permit Revised 2012 -70 r', 41 711710, :R NNI; fi i Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost 7800.00 m $ - $ 84.00 Plumbing Fee $ 10.50 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 10.50 Total fees collected $ 205.00 101 Bruin Hill Road 009-13 on 7/1/2013 Installation of Attic Bedroom NORTH own of :, . - V.: TO No. 00 _ 1 * - O - LANi h ver, Mass, COCHICHI WICK I�111A. A0gATED S U BOARD OF HEALTH PERMIT L D Food/Kitchen . Septic System II LL BUILDING INSPECTOR THIS CERTIFIES THAT ................ .�..�.y..`. !�.......... ......0. '!�R.I�t......... ..... .......................... s /� , 1• Foundation has permission to erect .......................... build' son �.V. ..... .` ..•.••• I• ••••. •�......•••• Rough tobe occupied as ...... .h.lt. ......A. .. . ..4........ ... ......R..O��......................................... 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 fop UNLESS CONSTRUC ST T S Rough Service ........... ...... ........ .............................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final FIRE DEPARTMENT No Lathing or Dry Wall To Be Done � Burner Until Inspected and Approved by the Building Inspector. Street No. Smoke Det. SEE REVERSE SIDE The Commonwealth ofMassachusetts Department of Industriql Accidents Office ofInvestigations Uf 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information //���` Please Print Leafty Name(Business/OrganizatiorAndividual): t;�111—f10*1 Address: City/State/Zip:Ird le�` !!�e-�� ��P one#: Are you an employer?Check the,appropriate box: Type of project(required): 1.❑ I am a employer with 4. ElI am a general contractor and I ' 6. New construction employees(full and/or part-time).* have hired the sub-contractors ❑ 2.❑ I am a sole proprietor or partner- listed on the attached sheet.# 7• ❑Remodeling ship and'have no employees. These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its equired.] officers have exercised their 10.❑Electrical repairs or additions 3( am 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 box#1 must also fill out the section below showing their workers'compensation policy information. T Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new 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. lam an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job 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 civil penalties 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 ce un ie 1 d alties ofperjury that the information provided abov 's true and correct. � G Signature: •/� Date: Phone#: W `�� 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 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 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 lf-insurance license number on the appropriate line City or Town Officials -Please-be sure-that the-affidavit-is-complete-and printed legibly. Tho Depaitmeht 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 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 Zndustda7 Accidents Office ofInvestigatlons 600 Washington Street Boston,MA.02111 Tel,#617-72.74900 ext 406 or 1-8777MASS.AFB Revised 5-26-05 FaY,#617-727-7749 www.mass.8oV1dia i i i TOMW OF NORTH ANDOVER OFFICE OF y BM DING DEPARTMENT a :'1600 Osgood Street Buildin • .y�Aa aw.a.�p�• � . . . g 20,-Suite 2-36 APROS£��� •North Andover,Massachusetts 01845 Gerald A.Brown Inspector of Buildings Telephone(97g)688_9545 HOMEOWNER'LICENSE EXEMPTION Fax (978)688-9542 BUIDING PERMIT APPLICATION Please print DATE: / JOB LOCATION: 1 Number Street Address Map/Lot HOMEOWNER l U/1�1� Gam/(/ t5 / 3cw �, 6 Name Home Phone Work Phone PRESENT MAILING ADDRESS /_A*771 C tv Tnt Zip Code The current exemption for"homeowners"was extended to ilnclude owner-occupied dwellings to fivo units or less and to allow such homeottrers to engage an iadividual•for hire tiyao does not possess acts as supervisor). State Building (Code Section.108.3.5.7) a license,provided that the owner DEFINITION OFHOMEOWNER Person(s)who Qwns 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-yearperiod shall not e considered a homeowner. The undersigned"homeowner"assumes responsibility for compliances with the State Building Applicable codes,by-laws,rules and regulations, g Code and other The undersigned"homeowner"certifies that he/she understands the Town of Forth Andover Building Department minimum inspection procedures and requirements and that he/s will co ply with'said procedures and requirements, HOMBOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 7.2oo9 Form Homeowners Exemption ''BOARD OF APPEALS 688-9547r ` CO)\rSERZ ATION 688-9530 HEALTH 688-9540 • PLATINING 688-9535 .