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Home My WebLink AboutBuilding Permit #665-14 - 112 AMBERVILLE ROAD 3/28/2014 i f NORTH q BUILDING PERMIT 3�e•`'``D_ °•°�°oma TOWN OF NORTH ANDOVER ° APPLICATION FOR PLAN EXAMINATION +1 Permit NO: Date Received DAATOD Date Issued: SSwCHUSE I ORTANT:Applicant must complete all items on this a e LOCATION Z CI L2e- Print PROPERTY OWNER - Print MAP NO:IaL�PARCEL4 ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential ❑ New Building :W One family ❑Addition ❑Two or more family ❑ Industrial A Alteration No. of units: ❑Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑Demolition ❑Other Septic ❑Well Floodplain ❑Wetlands Watershed District Water/Sewer �).. Identification Please Type or Print Clearly) OWNER: Name: ��t-,' at-fl)�"-IJ Phone: W10 -1a 7- /VZ7 Address: l l Z � �Kvt z. � (1, ly&A re ,Q>v� �v 14A p CONTRACTOR Name: Phone: Address: —40 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 COST BASED ON$125.00 PER S.F. Total Project Cost: $ 0-0 0 FEE: $ Check No.: Receipt No.: NOTE: Persons c n ac with unregistere contractors do not have ac ss to Mr-g'tZradyfund ignature of Agent/Owner v Signature of contractor is A .1 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page Sa 4 LOCATION .. Print. . PROPERTY OWNER Rnnt 1.00 Year Old Structure yes + no MAP NO: __ __ PARCEL:_- ZONING DISTRICT __ . flistor'ic!District yes no Machine Shop Village yes. no p TYPE OF IMPROVEMENT. PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family 11 Addition ❑Two or more family [I Industrial ❑Alteration No. of units: ❑ Commercial ❑.Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic Well'. ; ❑ Floodplain g,Wetlands ❑ Watershed District: Ll Water/Sewer. DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: - - _n..r Phone.-, -- �CONTRACTOR�'Name: -_�� z - - - �- — r Address: Supervisor's Construction License _ Exp: Date: Home.lrnprovement.License: _ ___ _ . Exp. Date: ARCHITECT/ENGINEER Phone: 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 with unregistered contractors do not have access to the guaranty fund t 9 Si nature of'coritractor3. _ . Slanatureof A erit/Owner Plans Submitted L Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans Location I 2_ Aw No. r Date o - TOWN OF NORTH ANDOVER . LED Certificate of Occupancy $ Building/Frame Permit Fee $ u Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# —y 733 Building Inspector - Plans'Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ dv :TYPE:OF;SEWERAGEDiSPOEAL Public Sewer ❑ Tanning/Massage/Body Art ❑.. . Swimming Pools ❑ Well ❑ � Tobacco Sales -� Food Packaging/Sales ❑ Private(septic tank -etc:_ _Permanent Dempster on Site El THE.FOLLOWING SECTIONS FOR OFFICE.USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM :.-.,DATE REJECTED DATE APPR-OVED PLANNING &DEVELOPMENTS ❑ ❑ COMMENTS .CONSERVATION Reviewed on " Signature COMMENTS HEALTH Reviewed on Signature . e COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection lS_ignature Date Driveway Permit DPW'Tows! Engineer: Signature: Located 384 Osgood Street FIRE-DEP�iRTt4llr iV1 -Temp Dump'seF on site yes no t Located at 124;Mair-Street a 4� _ y Fire Departure►it=signatu 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 t Docluilding Permit Revised 2010 m r Building Department 4` 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 ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses El Copy of Contract ❑ 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 o Certified Surveyed Plot Plan o Workers Comp Affidavit o 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) Li 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) q Building Permit Application a 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) o Copy of Contract ❑ 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 II q Building Department the fol'S ing is'a list of the required-forms to be.filled out foe.the appropriate.permit to`.be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ B.uilding Permit Application ❑ Workers Comp Affidavit o Photo Copy Of H.I.C. And/O'(C.S.L Licenses o 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 a Building Permit Application o Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract a 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 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 ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior 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 submAted with the building application Doc: Doc.Bui!ding Permit Revised 2012 NORTH Town of 2Andover "t No. - h ver, Mass, 1. �,QCO[NtC Nl wICN y�' S RRT E D U BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System THIS CERTIFIES THAT (A .g..... .. .�..4 ....................................................... BUILDING INSPECTOR ............ .. has-permission to erectg Foundation .......................... buildings ...�..�.2....... �-�-�.t4�4.. ..r.............. Rough to be occupied as ...�: !'41„i'-1%-....C��.....��jZtr.�r/,�..........1'�P.�.d�,5....:. .:................... 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 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIONT 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. i w� 19sgh do,ide FINISHED STAIRS � 84 sqk / 6'ta11 under stain C T w� O � 4 deep V 36"w de T TAL 'HOT door S FT 22 dC WATER 24 sq ft OCTA B sq k 36' UNFINISHED PART 2��' FINISHED 36"wide door 54sgk TOTAL SQ FT 500 I A D•FRAMING,DOOR,DRYWALL,ETC FOR ADDED WALL CONVERT INTO DOOR v PART 1 F NEW FRAMING s 0 FOUNDATION b 0 EXISTING FRAMING ® DOOR ® WINDOW E porrrk TOWN OF NORTH ANDOVER o OFFICE OF BUILDING DEPARTMENT 1600 Osgood Street Building 20,Suite 2-36 North Andover,Massachusetts 01845 ��S�1CNU5� Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION Please print DATE: JOB LOCATION: 117 Q�^'1��V)Zz� �� Number Street Address Map/Lot HOMEOWNER •M-�-J `11 o �yz, 7 z-1 Name Home Phone Work Phone PRESENT MAILING ADDRESS nes� �r�Win— Y✓l <:24 7 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 668-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 i The Commonwealth of Massachusetts Print Form Department of Industrial Accidents Office of Investigations 14 1 Congress Street,Suite 100 Boston,MA 02114=2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information 1 Please Print Legibly Name(Business/Organization/Individual): �� Z3 L�v✓��/ Address: 14 L /Ci 5 � aj City/State/Zip: AJ,�;�-rK A—"b"w - 1 l� 4 Phone#: V IWO yz7iZgZL7 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 employees(full and/or part-time).* have hired the sub-contractors 6. E]New construction. 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. N Remodeling ship and have no employees These sub-contractors have g• ❑Demolition workingfor me in an capacity. employees and have workers' y p �' 9. ❑Building addition [No workers'comp.insurance comp.insurance.* required.] 5. E] We are a corporation and its 10.[1 Electrical repairs or additions 3.Do I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself [No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.0 Other comp.insurance required.] '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. tContractors 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 workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: u�� Policy#or Self-ins.Lic.#: Expiration Date,,:,, / Job Site Address: �7 Z A"-3 6n'j' Z'u � /L iCity/State/Zip: z-rr�q Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under 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 certify under the pains and enalties oftedury that the in ormadon provided above is true and correct. Si ature: Date 3 z S� Phone#: WO yZZ —77Z-7 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." i 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 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Revised 7-2010 Fax#617-727-7749 www.mass.gov/dia