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Home My WebLink AboutBuilding Permit #411-14 - 11 COLUMBIA ROAD 11/5/2013 TOWN OF NORTH ANDOVER 9—W APPLICATION FOR PLAN EXAMINATION Permit N0: Date Received Date Issued: IMPORTANT:Applicant must complete all items on this age LOCATION_ °�1 _a _ :< al�;Y_t Print . PROPERTY OWNER . �TYL( Q/h Pri , 100 Year Old Structure yes, n MAP NO: PARCEL ZONINGDIST-RICT Historic District yes rbMachine Shop Village _ yes 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 El Septic El-Well ❑ Flgo_dplain Wetlands , ' ❑ Watershed District' 0 Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: CONTRACTOR Name:.._ Phone: ,. Address: Supervisor's Construction License.-__, _ . __ __ . _-Exp Date _ p _ Exp. Date: .Home Im roverr�ent Lice _� .. ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED QN$125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: t,-0 Receipt No 7 . NOTE: Persons contractin w'th unregis' retractors do not have access to the guarantyfund Signature of Agent/O�wn:; Sig-ature.,of'contractor Plans Submitted Li a{ns Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Location No. ^� Date t V ® - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ �, TOTAL $ Check# 27072.. Building Inspector Plans Submitted-[] Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE_OR-SEWERAGEDiSROSAL 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 DATEAPPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Si nature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes 9 Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Tow;! Engineer: Signature: Located 384 Osgood Street FIRE DEPARTME TTemp Dumpster on site yes no Located at 124;Mair. Street - '`` 3 CO11 MMENTS j 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 Ll Notified for pickup - Date S Doe.Building Permit Revised 2010 Building Department -`rhe folrswing is-a-list of the required.forms to be filled out for the appropriate.permit to be obtained. Roofhig, 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 that the apw-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.tted with the building application Doc: Doc.Buhding Permit Revised 2012 . TO"OF i�TOR TH ANDOVER 6'`° • ° OFFICE OF - BUILDING.IDEPARTARNT ' a :"1600 Osgood• ,, g Street$wilding 20,-Suite 2-36 North Andover, �Ac�tus� 1Vlassachusetts 01845 Gerald A.Brown Inspector ofB@1dings Telephone(978)688-945 •� HOMEMNER-LICENSEEXEMPTION Fax (978)688-9542 DDID]NG PERM T APPLICATION Pleas- eynnE DATE: JOB LO CATION: e.I Number Jf � . Street Address MaplLot • IJOYMO�R �9"; . I -•fru . . Name. HoinePhone Work Phone PRESENT MAILING.ADDRESS 'itv To,zn, etatP zip Cod, The current exemption for"•homeowners" was extended to?-chide owner-occupied dwellings to Uvo units-or less and to allow subh homeovimers to engage an Lk, dividual•for hire who does notpossess a license,provided that the owner acts as supervisor). State3uilding (Code Section 708.3.5.7) DEFINITION OFHOMEOWNER Persons)who Awns a parcel of land on which he/she resides or intends to reside,on which there is,oris intended to be,a one or two family structures. A person who constructs more considered a homeowner, that one home in a two-year period shall not be The undersigned"homedwner"assumes responsibility for compliances with the State Building Applicable codes,by-laws,rules and regulations, g Code t and other The undersigned`homeowner"certifies that he/she derstands the Town of North Andover Building Department equ rem inspection procedures equirements d that he e_will comply with,said procedures and requirements, HONMOWrl$RS SIGNAT APPROVAL OF BUILDING OFFIG Revised 7.2009 Form Homeowners Exemption BOARD OF APPEALS 688-954] CONSERVATION r ` ATlON 688-9530 HEALTH 688-9540 . . PLANNING 688-9531 NORTH Town of tAndover O - 0 No. 411. K h ver, Mass, .. COC IC"IWICK X1,9 AERATED APp,`�(� S U BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT ....................... ... �.1! !c .... r. r.0.0...... 11 Foundation has permission to erect ............. ........... buildings on .... .�..........C.Q..L.... .1. ..................... ... Rough to be occupied as .................. ...... ... ...�ia�r......... .. .. .O ....... T9�� Chimney provided that the person accepting this ermit shall in every respe onform 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 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIOM A Rough Service ................. .... ... ........... Final ILDI G INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz Rough Display in a Conspicuous Place on the Premises — Do Not Remove Fina' 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 The Commonwealth of Massachusetts - Department of IhdustdglAccidents Office of Investigations 600 Washington Street Boston,MA.02111 www.masss gov1d1a Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Orgaaiz(a�tion/lndi/vidual): Address.-41 City/State/Zip: �J )C) U 61'�, Phone#: 4-9 d 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 liircdthe sub-contractors 2.El am a soleproprietor orpartner- listed on the attached sheet, �• Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g. Building addition [No workers'comp.insurance 5. 0 We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their e doin allwork right of exemption per MGL 11.[]Plumbing repairs or additions 3X. I am a homeown r g myself.[No workers'comp. c.152,§1(4),and we have no 12ARoofrepairs required.]� employees.[No workers' insurance re ] q comp.insurance required.] 13.❑Other *Any applicant that checks box#f must also fill out the section below showingtheir workers'compensation policy information. 7 Homeowners who submit this affidavit indicating they a're doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that checkthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees Below is the,polley ant 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 requiredunder Section 25A ofMGL 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 e i under the andpenaldes ofper'ury that the information provided above is true and correct. Signatu 9 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 - ti. PbnnP fi- 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 employeY 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 ofpublic 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-contractors)name(s),address(es)and phonenumber(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 notrequired to carry workers'compensation insurance. If an LL C 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 whichwill 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(ifnecessary)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 fila 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 aad should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: Tho Comm wealtl of Massa hvsetts - ZDepartwelit Qfhadustdal.Accidents OfRoe ofInyestigatim 6W Want ngtoj�Stxeet Bostona MA 021 Z 1 Tel,#617-727-4900 ext 406 o.r 1-877-MASSAF Revised 5-26-05 Fax#617-727-7749