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Home My WebLink AboutBuilding Permit #074-14 - 1100 SALEM STREET 7/22/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: d� Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page / s APO-) + LOCATION G S-9 L Print PROPERTY°OWNERS - _ Print, 100 Year Old structure yes no MAP NO: PARCEI ZONING'DISTRICT: . Historic District yes nos Machine Shop Village yes, no. TYPE OF IMPROVEMENT PROPOSED USE Resi ntial Non- Residential ❑ New Building One family ElAddition ❑Two or more family El Industrial El Alteration No. of units: ❑ Commercial epair, replacement [IAssessory Bldg ❑ Others: ❑ Demolition ❑ Other _ --- Septic; ❑1Nell_ ❑ Floodplain) ❑.1Netlands ❑ WatershediQistrict [A/Vater/S=ewer, j DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) 9 / , _`` OWNER: Name: �u Phon I[) 7 Address CONS jRAC_� Q:R' Name: _ Phone. -- - Address: Ex Date:. Supe rvisor'stGonstruction License: _ p y Ex pate; Home Improvement;Lic_ense : p. Phone: ARCHITECT/ENGINEER 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: $__c _FEE: $ C� x Check No.: Receipt No. e uaran d NOTE: Persons contracting with unregistered contractors do not have access to h g tYan f ature of contractor Signature`of Agent/O_caner - - Plan Stamped Plans Plans Submitted ❑ 41ansaived F1 Certified Plot ❑ ❑ Building Department list of the required forms to be filled out for the appropriate permit to be obtained. The fol wing is a l Roofii-s Siding, Interior Rehabilitation Permits I ❑ 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 NOTEp All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks i ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract Of Proposed Work With Sprinkler Plan And ❑ FloorlCrossection/Elevation Plan j Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered pro dts 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 o Workers Comp Affidavit o 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 fs r Engineered ffrom Fire Department prior to issuance of Bldg Permit NOTE: All dumpster permits requireg 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 apu,-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submAted with the building application I Doc: Doc.BuiHing Permit Revised 2012 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF.SEWERAGE.DISP.OSAL Public Sewer ❑ Tanning/Massage/BodyArt ❑ 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 Siqnature COMMENTS 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 r Water & Sewer Connection/Signature& Date Driveway Permit DPW Toias: Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT Temp Dumpster on site yes no Located at,124 MainStreet Fire Department-signature/date z COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: o of deter location,ELECTRICAL: ement filV v n, 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 ® Notified for pickup - Date i Doc.Building Permit Revised 2010 Location'�V No. Date ri • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ ` Building/Frame Permit Fee $� Foundation Permit Fee $ r u Other Permit Fee $ TOTAL $ f 6 '. Check# � 1 26647 {1 buil-ding Inspector NORTH own of 20 No. h ver, Mass oL > > COC N.'.2 .' *1. % 7 V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT .... BUILDING INSPECTOR 7:3.. . . P ..... has permission to erect . g9 Foundation ....................... buildings on ....11. -C..... .......s�.........: to be occupied as ...... . .....�. ...f..400I..ko!... ..� ....... ..........4 . ' y&�'........ Chimney Rough e provided that the person accepting this permit shall in every respect con for 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 NTHS ELECTRICAL INSPECTOR 3d` UNLESS CONSTRUCTIOrF TSRough 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 aFP`°or a�sy TOMW OF NORTH ANDOVER E = o VER OFFICE OF BUILDING.DEPARTMENT ' *10M. 1.600 P�,y Osgood Street Building 20,-Suite 2_36 n y�SsarHus�c� •North Andover,Massachusetts 01845 V R+ n►r 5 Gerald A.Brown Telephone(9'7g)688_9545 Inspector of Buildings 10MBOWNER•LICENSE XEWTION Fax (978)688-9542 E BMING.PERMIT APPLICATION Please print DATE: JOB LOCATION: //07) •Ste•(( S Number S freet Address HOYMOWNER `Jl� Map/Lot Name. Home Phone Work Phone PRESENT MAILING.A-DDP,ESS o-() CJ,--v Tn.=m State. zip Coda The current exemption for"homeowners"was extended to L-1olude owner-occupied dwellings to two units or less and to allow subh horneotii�ners to engage an�cividual.for hire who does not possess a license,provided that the owner acts as supervisor). State Building (Code Secfion.108.3.5.i_) DEMNITION OF HOMEOWNER Persons)who awns a parcel of land on which he/she resides or intends to reside,on which(here is,or is intended to be,a one or two fan-uly structures. A person who constructs more that Ane home in a which tarpeis,o shall not e considered a homeowner. The undersigned`.homeowner"assumes responsibility for compliances with the State BuildingCode and o Applicable codes,by-laws,rules and regulations, Cher ' The undersigned`homeowner"certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requ1 nts and that he/she will comply with,said procedures and requirements, - HOMEOWNERS SIGNATUREA14 APPROV AL OF BUILD 1NG OFFI C IAI, Revised 7.2009 Form Homeowners Exemption BOARD OF APPEALS 688-9541r r ` • COl\SER�ATION 688-9530 HEALTH 688-9540 PL&NNING 688-9535 The Commonwealth of Massachusetts Department ofIndustrialAccidents 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 Legibly Name(Business/Organization/Individual): 10S Cp Address:— City/State,/Zip: MDwffl /YA 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,x 7. ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for mein any capacity. workers' comp.insurance. g, ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.) officers have exercised their 10.❑Electrical repairs or additions 3.E] 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.❑Roof repairs insurance required.)t employees.[No workers' comp.insurance required] 13.[i Other Siege *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 tLre doing all work and then hire outside contractors must submit anew affidavit indicating such. TContractors that check this 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 policy andjob site information. Insurance Company Name:-- - - - Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a:copy of the workers'compensationpolicy 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert under the p�ainnss-a'n`d penalties ofperjury that the information provided above is true and correct. - Siature: L i Date: �' 1 Phone Official use only. Do not write in this area,to be completed by city or town official. City or Tow n: Permit/License# Issuing ority(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 ofhire,• 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 j oint 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-contractors)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 license number on the appropriate line. City or Town Officials -Please be sure that-the affidavit is-complete-andprinted legibly: The Deliattiiibnt has provided a space at the boitom' 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 orpermit 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: Tho Cornmonwoaliof:Massarhwofts Department of Zn.dustdal,Aocldepts Ofte of layestigations 600 Wasbingtou Street Boston,SIA,02111 Tel,#617-727-4900 at 406 or 1-$77:M1ASS.AFB Revised 5-26-05 Faze#617-727-7749 'cvWW=ss.goyldia