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Home My WebLink AboutBuilding Permit #574 - 119 MOODY STREET 3/26/2010 pORTH BUILDING PERMIT oFt ��o ,°gtio TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATIONSM I Permit NO: �zyDate Received 'ls40�NAr �SSACHUSE� Date Issued: IA) IMPORTANT:Applicant must complete all items on this page C� LOCATION 07 No �(S ' t PROPERTY OWNER yl Print MAP 210R� PARCEL:_ ZONING DISTRICT: Historic Districty es Machine Shop Village yes no 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 Septic Well Floodplain Wetlands Watershed District Water/Sewer DES9RIPTION OF"RK TO BE PREFORMED: O O/ Id ntifica ion Please Type or Print Clearly) OWNER: Name: / Phone: S & b 0 Address: / cd V CONTRACTOR Name: Phone: Address: IVW4 -' 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: $3 1 Check No.: Receipt No.: �2-Z I-0 NOTE: Persons contracting with unr gi tered contractors do not have access to the guaranty fund u . Signature of Agent/Owner Signature of contractor Plans Submitted Plans Waived Certified Plot Plan Stamped Plans r 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 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 Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT -Ternp Dumpster on site yes no Located at 124 Main Street Fire Department signatureldate 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) ❑ Notified for pickup - Date ..__..._.............------...._...................................._...._._._..-_._._.....----........---....._...........................-...._..._......................._...._....._...._...................................................._....._..---._... -..._..........................................---_......---............. Doc.Building Permit Revised 2010 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 ❑ 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 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 2008 Location7 1 Y r aD , No. Date ' MORTM TOWN OF NORTH ANDOVER f 1 Certificate of Occupancy $ �,SSAC MUS t� Building/Frame Permit Fee $ � Foundation Permit Fee $ _ ! Other Permit Fee $ TOTAL $ Check # 24 1- c, U Building Inspector V40H RT Town of 4dover 0 No. a- 7y IM A K E dover, Mass., 3• t CD i 0 COCHICHEWICK ADRATE D `S BOARD OF HEALTH Food/Kitchen PERMIT T Septic System BUILDING INSPECTOR THIS CERTIFIES THAT....&.10N.Arli ��V.`1.*M%*................................ Foundation has permission to .............................. buildings on � v � ARough........ -...... K1A � .......... to be occupied as... pf%it..C ........ .... h Chimney provided that the person ac ting this permit shall m every resp t c orm to the tertl:"fiti��Dolication on fi Final this office, and to the provis ons of the Codes and By-Laws relating to the Inspection, Alteration and Constructidymf Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTR N STARTS ELECTRICAL INSPECTOR 31� Rough .. .... ..... .... .........................................:............ Service ING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Burner Street No. SEE REVERSE SIDE Smoke Det. doRTH TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT 1600 Osgood Street Building 20, Suite 2-36 M14 cec:rcne..a.��' �,y gDq�se°•Q°'.ch North Andover,Massachusetts 01845 SSACHUSES Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE: JOB LOCATION: A"goke" umber Street Address Map/Lot HOMEOWNER 5-/65 Name Home Pho �(��Werl�Phone PRESENT MAILING ADDRESS 154my ao �I Alt ou ke -P 4 City Town State Zi^r 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 require me is and th t he/ he will comply with said procedures and requirements. HOMEOWNERS SIGNATURE 0 APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 i FROM FAX NO. :9786860598 Mar. 25 2010 04:42PM Pt DA • Inc,r w�srk Comm= fm vm* bum4moss"' { 190va Iaw Aaside■.} 428 pleasant st. K Andyer *L 0106 gffice 978 M 4797 Emw 978 683 03p'/ Fro% wR 686 OW C"gn g11g 7145 Ifs. License 9 001821 s 1n" * Rme 3 amm 6 120199 D; buildin aoi.cop lLexsoitBian I 1 VoWy at 11 Andover m ZZ,10 Ri and rcvlacc root, ,install now :in(kw,; and siidim. I 6s'tiftted prig V5.Ow.00 Z rthcri d lezian rn d0 the above srn k- I a I i AIN The Commonwealth of Massachusetts Department of Industrial Accidents Office of Fnvestzgations 600 Washington Street Boston, MA 02111 www-1nas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibl Name (Business/Organizatioi ndividual): Address: 91w City/State/Zip: Z2 t Are you an employer?Check the appropriate bog: L❑ I am a employer with 4. Type of project(required): ❑ I am a general contractor and I employees(full and/orpart-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner_ listed on the attached sheet $ 7• ❑Remodeling ship and have no employees These sub-contractors have working for me in any capacity, workers' comp.insurance. 8• Demolition [No workers' comp. insurance 5. ❑ We are a corporation and its 9 ❑Building addition required.] officers have exercised their 10.❑Electrical repairs or additions 3. I am a homeowner doing all work right of exemption per MGL ILEI Plumbing repairs or additions myself. [No workers' comp. C. 152,§1(4),and we have no insurance required.] t employees. [No workers' 12•7 Roof repairs comp.insurance required.] 13.❑ Other t ul,applicant that checks box , must also rill out the Section beloiv saowL-E!Waw wor a s'comp=,!:_�on• 5: ., Homeowners who submit this affidavit indicating they are doing all work and pji�hire outside contractors must.submit a new affida.�: it indicating such. v 'Contractors 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 and 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 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 cerkfy un e i nd penalties of perjury that the information provided above is true and correct Si atur : _J 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.PIumbing 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 apartnents 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 pernait 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 bum 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 Cornmonweal& 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 Revised 5-26-05 Fax#617-727-7749 www.mass..gov/dia