HomeMy WebLinkAboutBuilding Permit #009-16 - 1145 OSGOOD STREET 6/29/2015 t1oRTy "
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: (,� — / Date Received 17A "
�•9 q�q�reo�Pa�•(9
SSACHUS
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION l S S' oyd
Print T
PROPERTY OWNER 4+�1�� JJGt �1
Print 100 Year Structure yesno
MAP a5l_PARCEL: ZONING DISTRICT: — Historic District ye no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building 7KOne family
)(Addition ❑ Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
El Septic ❑1Nell ❑ Floodplain Wetlands i E].-Watershed Qistnct-
0 Wates/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Identification- Please Type or Print Clearly
OWNER: Name: f�Cd� � h4 CC", rte, Phone: 97e,31 A02,
Address: INS-
Contractor Name: r� Err/ 4 Phone:
Email:
Address:
Supervisor's Construction License: Exp. Date:
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BOLDING PERMIT.$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
Total Project Cost: $ 001 O-V FEE: $ ��vl
Check No.: �Q/ Zi Receipt No.
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
rnvt
au Ain ei nature of.contractor
i
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/Massage/Body Art ❑ Swil ming Pools ❑
well ❑ Tobacco Sales ❑
Food Packaging/Sales ❑
Private(septic tank,etc. ❑ Pennanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF m H FORM
PLANNING & DEVELOPMENT Reviewed On Signature_
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
v
Conservation Decision: Comments
Water& Sewer Connection/Signature& Date Driveway Permit
DPW Town Engineer: Signature:
--_-, - f - - at O _
Located 384 Osgood Street
�,FIREDEPAR TempDumpster
z �on}siteR ;yes
a_
,�,� t t, 4 Mam;iStreet
rt partment�ignature%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 approaral 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 Call Email
Date Time Contact Name
Doc.Building Permit Revised 2014
Building Department
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
4� Building Permit Application
Workers Comp Affidavit
4r Photo Copy Of H.I.C. And/Or C.S.L. Licenses
4, Copy of Contract
Floor Plan Or Proposed Interior Work
Engineering Affidavits for Engineered products
OTE: 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
4. Floor/Cross Section/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 .
OTE: 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
2012 IECC Energy code
Engineering Affidavits for Engineered products
IN OTE: 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:Building Permit Revised 2014
Location
No. V v /' d� Datejt>
. - TOWN OF NORTH ANDOVER
D
Certificate of Occupancy $
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee $
TOTAL $ y
Check#/v/ v
'° e Building Inspector
NORTH
own o s _E ndover
0 Q." . . .
No. IDM 2.0 to
* t ...
- h
Z h ver, Massk3o /
]( .
T O LAKE ��
COC NIG Nl WICK 9V
7,4 p�RwrEo ►•P�,��(5
S U BOARD OF HEALTH
PER T T LD Food/Kitchen
kP
Septic System
THIS CERTIFIES THAT �n .C41!L�.�...... .L CSC. BUILDING INSPECTOR
0o �' Foundation
has permission to erect .......................... buildings on .. ...� . .... Rough
g
to be occupied as ................ .�.. +(... ..................................................... Chimney
.�..�...... ............ �..�.,•r.
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
UNLESS CONSTRUCTIO SiTS 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.
TOWN OYNORM AND OVER
till
01 MCE OF
IIL
w-�^•, - Y A H ..l.)FMT.l,"NT r
600 DBgoad Stroot Buff&g20,-Su te?--36
7 �Rti}�m F4"'��5 - •X6AA.UaDVer,N.Cassachnsetta 01945
RPROS .
rexaId A.Brown - Tole,
ltone(978)688-9:54-5
Inspector ofBuildings _ Fax (978)688-9542
' QV-MRETCENSE EEMPTION ,
' pleaseprin-� '
- • DATE:
JOB LOCAT:ON,, ((V 5-. •
Number Stree Ores& Map)Lot ,
I �a��. F
Mule. dome 1'IioneU Workl'hone .
PRDSENT MAff ING ADDRESS
• zip Cod--
'z he current exemption for"homeow�?ers"was extentted io ilude ownex occtiirzed dftlings to tvo units or less and
fa allow such h0mOm-m rsto engage ank-Oiv;dnal-forbiro who does notpomms a license,provided tliattie owner
acts as sapervisor). SWBv?iding (Code Seotion 108,3.5.1)
DEMMILTION OFHOMEOVMR
Persons)wlzo awns a parcel of lan d on whiol�&elsbe resides or Mends to reside,on M6h there is,oris intended to
bb,aoneortwof'amilysfraGtares. A.person.tvkocomtmots mora t7iatonehomein:atwo-yearperiodshall not'6e
considered abomeowner. .
The undersigned".homeowner"assumes responsibilitg foraompliances witls the StateBuilding Code and other
Applicable codes,by-laws,rules and-xegnlations.
' The undersigned`homeowner"rex Eiftes that helshe understands tTie Town ofNorih AndoverBuilding Depa Gnt
impection procedures and require ends d that helshe will comply witlz,said procedures and
requirements,
HOA MOWN MS SIGNATME G ,
APPROVAL OF J3DMDWG tlF.li'.ICML
Reyised 7.2009 '
?OnuRomeowners.Exemption .
30A'RDOFAPPEAM689-9541 CONSERVA'RON689-9530 BEALTJ3688-9540 PT.AI\J. rcaseea,a�
The Commonwealth of Massachusetts
Department of IndustrialAceidents
a 1 Congress Street,Suite 100
Boston,MA 02114-2017
- ..... www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: (,S�7' d RX
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
I.F-1 I am.a.employer with employees(full and/or part-time).* 7. 0 New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling
any capacity.[No workers'comp.insurance required.]
9. 0 Demolition
3.�I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 0 Building addition
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
- 12.0 Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs
These sub-contractors have employees and have workers'comp.insurance.:
6.F-1We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other
152,§1(4),and we have no.employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
I Homeowners who submit this affidavit indicating they are 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 state whether or not those entities have
employees. If the sub-contraciors 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:
Policy#or Self-ins.Lic.#: l Expiration Date:
Job Site Address: f 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 required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
Ido hereby cert' under th,,a pains and penalties of perjury that the information provided above is true and correct
Signature: �' L Date: 6 L3 b
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
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-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 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 referred 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-inturance 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 Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 02-23-15 www.mass.gov/dia