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HomeMy WebLinkAboutBuilding Permit #401-15 - 12 LAVENDER CIRCLE 10/28/2014 BUILDING PERMIT o*"OR T"qti E o TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: I Date Received Ar H �gSSAus���� Date Issued: lo- C I/MP R ANT: Applicant must complete all items on this page LOCATION PROPERTY OWNER Print Z 100 Year Structure yes MAP -/ fir PARCEL:_ZONING DISTRICT: Historic District yes Q Machine Shop Village yes 63 TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building P9 One family PYAddition ❑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 _DESCRIPTION OF WORK TO BE PERFORMED: v L2 Identification- Please Type or Print Clearly OWNER: Name: /G Phone: 97eP yfe Address: 12- Contractor Name: Phone: Address: Supervisor's Construction License:. Exp. Date: Home Improvement License: _ Exp. Date: ARCHITECT/ENGINEER -Z1W'L Address:AM�0 0�, �'� 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: $ IL32 •may Check No.: Receipt No.:�� NOTE: Persons contracting with nre red contractors do not have access to the guaranty fund gSi nature of A ent/Owner _i na t-_-.._.-�.�...__,_��_ �g _ _ g ture of contractor i Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ 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 I PLANNING & DEVELOPMENT Reviewed On Signature_ } COMMENTS E CONSERVATION Reviewed on Signature COMMENTS i I 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 Con nection/Siqnature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street FireDepartment signature/date COMMENTS a 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 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 ❑ 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/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 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 Doe:Building Permit Revised 2014 Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost ,000.00 m $ - $ 132.00 Plumbing Fee $ 16.50 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 16.50 Total fees collected $ 265.00 12 Lavender Circle 401-15 on 10/28/2014 10x12 Room Addition ' p4� earf�'Si .IOYYN O.0 I ORTHAND VEp ONCE OF BUffiDINGDEPARTMENT • ' �p •�e :7600 i0sg0od5treet)3Rff ng2Q •Svzte24-36 Plus Noz-thAndo -r,Massachn.setts 41845 �cuu , Gerald A.Frown - Telephone(978)68$-945 Inspector of Buildings - Fax (978)6889542 -. HOMEOWNER•LICENSEEXEMPTION ' BMDWG PFR M- `APPLICATION please�nnt DATE: 4�1� ' JOB LO CA3iOIrT: !Z "vex r492C-Coc 6 to � Number StreetAddress • MaplLot ' 15° °SER 7d:Z/fsd 3l ?.6To a Name HomePltone �J"orkPhone . PRESENT MARING.ADDRESS C; l Lf�f� dip Cod; The cuzxent exemption for"homeowners"was extended to incl zde owner-occupied divellings to t�vo units or;ess an_d to allow$Ubh hDM001"MU8 to engage an i�idividual•for hire acts as supezvisor•. Stafe 3u1d' v7ho does not possess a liemzse,provided that the owner Ing (CodeSeofon 18.3.5,1) DEFINITION OFROMEO'6VN R Person(s)who cwnsfam- lY stm I of ares. on which he/she resides or Intends to reside,on which there is,or is intended to b e,a one or two farnly structures. A person who constructs more that Dne borne in a fwi h thcrO is,O shall not e considered a homeowner. The undersigned".homeowner"assumesresp onsibility forcOMP l-iances with the Sfate BuUding Code and other Applicable codes,by Taws,rules andzegulatiom. The undersigned"homeowner"certfesthat,he/sheimderstauds the TowuofNbrih Andover l3uildangDeliaffmout minimum inspection procedures and requirements an at ate/she comply with,said procedures and xequiremenfs, HOMEOWNERS SIGNATURE A PP,OVAL OF BUEDING OFFICIAL Revised 7.2009 Form.Homeowners Exemption '$OA1tD OF APPEALS 688-9541 CONSER,VAUON 686-9530r s: HEALTH 668-9540 PL&NNNG 688--9535 The Commonwealth of Massachusetts - Department of IndustrialAccidiints 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/OrganizatiorAndividual): 2!5� g . G-d V- Address: 12— 4e"2— Cl•2G G �' City/State/Zip: /I/. ,4. 1AS0Jee Z - Phone#: �17,0p, ��•oy f 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. El Now construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- 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.insg .❑Building addition [No workers'comp.insurance 5. El are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.01 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.E]Roof repairs insurance required.] employees.[No workers' � .] 1311 Other 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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lam an employer that isproviding workers'compensation insurance formy employees. Below is the policy and job site information. Insurance Company Name:. Policy#or Self ins.Lie.#: 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 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 civilpenalties 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. X do lierehy cert der ains a 'es of perjury tliat the information provided aho is tt a and correct. Si afore Date: Phone#: e- •O Official use only. Do not write in this area,to he 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#: I 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 persoris 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 producedacceptable 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 Be. 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. Iu 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 GQmmonwealth of Mfassa.,chwetta Department of Industrial.accidents Office oflayestigafions 600 Waslaila&a Street Boston,MA 021.1.1, Tel,#61.7-72,'x_4900 at 406 ox 1-877- CASSAFE Revised 5-26-05 Fax#617-727-7749 vw.znass,gov/dXa F t%ORTh di Town of 'Andover C, T ver, Mass, &*) �/- coc«ic„ewic« �1 l.�S RArEo P'QP,`'�5 U BOARD OF HEALTH Food/Kitchen PERMIT T , LD Septic System THIS CERTIFIES THAT T�'!«......... BUILDING INSPECTOR has permission to erect ......................... buildings on ....... . . . u ....... Foundation ..� . �. A Rough to be occupied as . ... �. ...... .... . ....... ......... ..�.. ► .... i 1�, � Chimney cn� 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. ' i/ Rough PLUMBING INSPECTOR \ • VIOLATION of the Zoning or Building Regulations Voids this Permit”Tfr � Final PERMIT EXPIRES IN 6 MONT S ELECTRICAL INSPECTOR UNLESS CONSTRUCT S TS 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. � Location / No. .r Date ! o - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check#� 7 2 U U 9 Building Inspector !