HomeMy WebLinkAboutBuilding Permit #445 - 104 BLUE RIDGE ROAD 12/4/2012 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
A
Permit NO: Date Received
Date Issued:
IMPORTANT:Applicant must com lee all items on this page
LOCATION
N
PROPERTY OWNER a Lt l
�}�
Print 100 Year Old Structure yes no
MAP NO:�''-``t�q PARCEL:6\20 ZONING DISTRICT: Historic District yes
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
El Addition El Two or more family El 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:
4I entif at' P e Ty e or Print Clearly)
OWNER: Name: Phone: ) ��2—
Address:
CONTRACTOR Name: Phone:
Address:
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.: Receipt No.:
NOTE: Persons contracting w' unregist d contractors do not have access to the guaranty fund
Signature of Agent/Owner Signature of contractor
Plans Submitted ❑ ;Plans Waived Certified Plot Plan ❑ Stamped Plans ❑
Locatio v ,/ ,
No. — Date
• • TOWN OF NORTH ANDOVER
•
Certificate of Occupancy $
s Building/Frame Permit Fee `$ ftp
Foundation Permit Fee $
k Other Permit Fee $
TOTAL $
Check 4-4�—
26008 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 ❑ ❑ �I
COMMENTS
CONSERVATION Reviewed on f Si natur
COMMENTS /UC7
HEALTH Reviewed on Signature
COMMENTS
� I
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 Osciood 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, roast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$10041000 fine
NOTES and DATA— (For department use
El Notified for pickup - Date
3 �
Doc.Building Permit Revised 2010
Building Department
artment
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
o Building Permit Application
o Workers Comp Affidavit
o Photo Copy Of H.I.C. And/Or C.S.L. Licenses
o Copy of Contract
o Floor Plan Or Proposed Interior Work
o Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
o Building Permit Application
L3 Certified Surveyed Plot Plan
o Workers Comp Affidavit
Li Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Mass check Energy Compliance Report (If Applicable)
o 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)
o Building Permit Application
o Certified Proposed Plot Plan
o Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Copy of Contract
o Mass check Energy Compliance Report
o 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: Doc.Building Permit Revised 2012
1
Town of f E 1, 6 ndover
No. -
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'11,9 p°R�rEo ►Pp,��S
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BOARD OF HEALTH
PERMIT T LD Food/Kitchen
Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT .......
,
has permission to erect ... buildings on ...� 61W..... ............ Foundation
Rough
tobe occupied as ...... a:.gIs...6..`*...,-.................................................................................... 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
100- PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTIO T TS 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
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
SEE REVERSE SIDE
A" NORTHERN ASSOCIATES, INC.
342 N.MAIN S7i9EE7' ANDOVER MA 01810 TEL: (503) 474-4410 FAX.- (508) 474-5067
MORTSASOR• WILLIAN E.6 PAULA J.BRANT DEED REF. 2547 / 87
LOCA TIOAh. 104 BLUE RIDGE ROAD PLAN REF. 10 10099
CITY. STATE: NORM AM OVER MA SCALE: S� 40'
DATE., 6124 / 96 JOB d!• 96/2792
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m Access Easement For Town of
3 North Andover Only
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CERTIFIED T0: IPSWICH SA MOS BANK
This mortgage inspection was prepared in accordance
with the Technical Standards for Mortgage loan
Inspections as adopted by the Massachusetts Hoard of
NOTE: This mortgage inspection was prepared
specifically for mortgage purposes only and M OF Registration of Professional Engineers and Lend
is not to be relied upon as a land or property Surveyors ta CHR that
i
I further state that t in my professional opinion ttrrl
line survey. Building location and offsets CARM N the structures shown
shown are specifically for zoning determination conform with
the local zoning horizontal dimensional setback
only and not to be used to establish property requirements at the time of construction or are
lines. The land shown hereon is based on
referenced information noted and may be subject No.18487 exempt under provisions of M.G.L. CH. 40-A Sec. 7,
to further takings and easements. Northern G Property/House is not in a Flood Hazard.
Associates, Inc. accepts no responsibility for "7faTE*�•( Property/House is in a Flood Hazard Area.
damages resulting from said reliance by anyone sup
other than the said mortgagee and its assigns in 03.Information is insufficient to determine
connection with its proposed mortgage financing Flood Hazard.
Flood Hazard determined from lu est Federal Fiou,l
to said mortgagor. //� <�/�` Insurance Rate Map Pane l 6`
-_ �L.
Town of North Andover Page 1 of 1
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibl
Name (Business/Organization/Individual): r
Address:
City/State/Zip:
/� � Phone#:
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. ❑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. 1 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers' comp.insurance.
9. EJ Building addition
[Noworkers' comp. insurance 5.
❑ We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ I 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 12.0 Roof repairs
insurance required.]t employees. [No workers'
13.❑
comp. Other
insurance required.]q
*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 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 their workers'comp.policy information.
t am an employer that is providing workers'
information. compensation insurance for my employees. Below is the policy and job site
Insurance Company Name:
?olicy#or Self-ins.Lic.#: Expiration Date:
lob Site Address: City/State/Zip:
attach a copy of the workers'compensation policy,declaration page(showing the policy number and expiration date).
,ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
ine 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
)f up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
nvestigations of the DIA for insurance coverage verification.
do hereby ceriVn er the pains d genal s of�p(errjjury that the information provided above is true and correct.
t nature: "�Q/ "'s` Date: I Z
hone#:
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 burn 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 Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 5-26-05
www.mass.gov/dna
=okµu,r a a4o To"OF NORTH
ANDOVER
F
-'° ° OFFICE OF
T
BUILDING DEPARTMENT
'1600 Osgood Street Building 20,-Suite 2-36
North Andover,Massachusetts 01845
Gerald A.Brown
Inspector of Buildings Telephone(978)688-9545
HOMEOWNER-LICENSE EXEIVTPTION Fax (978)688-9542
BUIDING PERMIT APPLICATION
Pleas.eprint •• '
DATE:
JOB LOCATION: /
ber Sheet Address
�U
���7�7aplot
HOMEOWNERName. �
Home Phone Work Phone
PRESENT MAIMNG ADDRESS a `�
Sfi`a+w' Zip Code
The current exemption for"homeowners"was extended to:h1clude owner-occupied dwellings to two units.or less and
to allow subb homeovmors to engage all hadividual.for hire who does not posses
acts as supervisor). State Building (Code Section 108.3.5.1) s a-license,provided That the owner
DEFINITION OFHONMOWNER
Person(s)who Qwns a parcel of land on which he/she resides or intends to reside,on which(here is,oris intended to
be,a one or two farnily structures. A person who constricts more that one home in atwo-year period shall not e
considered a homeowner.
The undersigned"homeowner,,assumes responsibility for compliances with the State Building Co
Applicable codes,by-laws,rules and regulations. do and other
The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Department
minimum inspection procedures and requirements and that he/ will comply with,said procedures and
requirements,
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Revised 7.2009
Form Homeowners Exemption
BOARD OF APPEALS 688-9541
CONSERVATION r
ATION 688-9530
HEALTH 688-9540 PUNNING 685-9535
Town of North Andover (� Page 1 of 1
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Town of North Andover Page 1 of 1
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