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Home My WebLink AboutBuilding Permit #640-14 - 120 CAMPION ROAD 4/10/2014 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATI0 Permit NO: ��L Date Received Date Issued: V I O TANT:Applicant must complete all items on this page �LOCATION� - �PRORERTY®INNER - 4, q� t int -� 100 Year®Id#„ Structure;. y4es _o tMAPNOPARCELtZ®NINGDLST,R.ICT #HistoricDlstrrct yes rio, IMach op�illage yes no s TYPE OF IMPROVEMENT- PROPOSED USE Residential Non- Residential ❑ N!ew Building 66ne family ddition ❑Two or more family ❑ Industrial ❑Alt ration No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other --� .y. c , �-,n-__7` ,'.- _ s 1'� �Septic ❑.We11 . fiQ,Floodplarn ❑Wetlands ® Watershed District , DESCRIPTION OF WORK TO BE PERFORMED: c_cr entif cation Plea ere or Print Clearly) OWNER: Name: (7dd Phone: Address: �Ol,lnY\_ �:� �� 1 �Qr ✓� ��j i�•s 'r t.- a .,a. .kf°` . — -# 7s .� CONTR_'QT.)R` Name +!1 _f 4 r- piwq T Address < ItSupervl�sor isConstructlon 4Lhcense p :# �' .._'!.° d'I '0 � X�)C. p $`-a` I'•.Fu.Sf 'i%8T _y. `.M�t L '� .+ i � �� f ,Home�Improvemenkens@ _ � ExpDate ARCHITECT/ENGINEER A A Phone: Address: I/Q-P� A �"'n /�' �— 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: $ 1 �, 0 a _FEE: $ , Check Na.: � �, Receipt No.: 2-1-�)c7A NOTE: Persons contractin un egist red contractors do not have access to the guaranty fund i za - �3 Signature of Agent/Own ,SignafureiofcontrectorT. .4 Plans Submitted Plan v Certified Plot Plan ❑ Stamped Plans ❑ _ _ , .. . - -- —r .� . .- r :. G /0 ; Location 1,�eq/", �';,+ter ,J�, l N 6' I..: - No. figf� `l 4` Date ' i - _.� . . . .. : . I � --.1., .. .� - -t ;. . ( . • ' TOWN OF NORTH ANDOVER f s • iSI ED 76 . - -. -_ * r . I • -- . • , n Certificate of Occupancy $ g Building/Frame Permit Fee $/ V ,.;,d3 �- _ 7 Foundation Permit Fee $ f ` ` �` - - Other Permit Fee $ i. : ` > TOTAL $ ` t> i Check# /I r fi rj ,. / - -- 2 6 .3 � �' Building Inspector i . r _ _ . . ... %... .. _. -. _.. .. .. ...r.., _ --. 'Y: ... :. ... .. _ r __ - Plans Submitted❑ Plans Waived ❑ 7.Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF:SEWERAGEODISPOSAL Public Sewer ❑ Tanning/MassageBodyArt ❑... .Swimming Pools F ;>R WellEl ❑ Tobacco.SalesFood Packaging/Sales ❑ Private,•(septic tanlc,etc._ ❑--. : Permanent D dnpster on Site ❑ -THE-FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM -.:--DATE REJECTED: . DATE.APPROVED - PLANNING & DEVELOPMENT` ❑ 3 ' Y COMMENTS ll WQ �SGIe� l� CSV I W e CONSERVATION Reviewed on ' 7 Sinature " COMMENTS 4- HEALTH Reviewed on Signature COMMENTS t Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes - Planning Board Decision: Comments Conservation Decision: :Comments Water & Sewer ConnectionlSignature& Date Driveway Permit DPW Todv;! Engineer: Signature: Located 384 Osgood Street `:FIRE-DEPARTI!l.ENT.:-Temp Dumpster on.site yes no Located at:.124 MainStreet :Fire ®epar#me►it signata"re/date- I J. COMMENTS 'Di mens tan 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.$10041000:fine NOTES and DATA— For department use J i i j El Notified for pickup - Date Doc.Building Permit Revised 2010 Building Department -` The fol�w ng is''a ii`st of-the required forms to be-filled ou -for-the.appropriate:permit to be obtained. Roofivg, 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 products Affidavits for ❑ Engineering A Engineeredp 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 jl ❑ Copy Of Contract a Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And a 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 i New Construction (Single and Two Family) ti{ ❑ Building Permit Application ❑ Certified Proposed Plot Plan j ❑ 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) j ❑ 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 Perm In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeal that the apwal period is over. The applicant must then get this recorded at the Registry of Deeds. one copy and proof of recordi must be subm.¢ted with the building application Doc: Doc.Building Permit Revised 2012 k Enter construction cost for fee cal- North Andover Fee Calculation Construction Cost 100000.00 m $ - $ 1,200.00 Plumbing Fee $ 150.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 150.00 Total fees collected $ 1,600.00 120 Campion Road 640-14 on 4/10/2014 Replace 2 car garage with 3 car garage with Bedrooms Above Town of ndover. No. LAKI_ h ver, Mass, c3ZIl coCHICKIWICK y1. 'tsi4s A?ATED i%? U BOARD OF HEALTH Food/Kitchen - PERMIT T D Septic System THIS CERTIFIES THAT .............. BUILDING INSPECTOR ..... ...... .......... .......... has permission to erect .......................... buildings on ............................... Foundation Rough to be occupied as ..... .. lVermit'sh'afin . . . ... �G.� .. t''d�............................................. Chimney rovided that the erson acct tin this eve res ect conform to the terms of thea licationP p p g every p pp 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 CONSTRU N ST S 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. � NORT1i Town of : EAndover 0 No. I t o h ver, Mass, c3 Xe COCN1CMtw1CM 1_1• 0RATEO MPp�,�y ll BOARD OF HEALTH Food/Kitchen - PERMIT nn-- Septic System THIS CERTIFIES THAT ................... s� ��1............:. .......................... BUILDING INSPECTOR ................ ........... . ................................. Foundation has permission to erect buildings on .� �. 1 ��` .. ............................... .......................... .... Rough 6 nn to be occupied as ........ ...K.....lt�.. .:F.,...... . . ...�tG. .. .d l�.`.' :........................................... Chimney provided that the person acct tin this ermit shfl in eve respect conform to the terms of the application p p p g p pp 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 CONSTRU7,' N ST40eS 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. The Commonwealth of Massachusetts - Department oflndustriglAccMiks Office oflnvestigations quo 600 Washington Street Boston,MA.02111 www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl r c Name(Business/Organization&(Rvidual): Address: f dv� Ll t 11 City/State/Zip: PJ, D J Phone#: ',�o�"D��3 . Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 4• ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time). have hiredtho sub-contractors 2.❑ I am a sole proprietor or partner listed on the attached sheet. 7• El Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition worldng for me in any capacity. workers'comp.insurance. g• L]Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its officers have exercised their 10.❑Electrical repairs or additions required.] of 3. 1 am a homeowner doing all work right of exemption per MGL ILE]Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.]Roofrepairs insurance required.]7 employees.[No workers' 13.0 Other comp.insurance required.] 'Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. T'Homeowners who submit this affidavit indicating they 2te 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 ofthe 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.UG.#: Expiration Date: Job Site Address: City/State/zip: Attach a copy of the workers'compensation poliey declaration page(showing the policy number and expiration date). Failure to secure coverage as requlredunder Section 25A ofMGL 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. Ido hereby cert&under the pains and penalties ofperjury that the information provided above is true and correct. - Signature: Date: ' Phone#• � f c� � Jy a-a� a 3 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(cycle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.EIectrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: _ Information and Instruction" , 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 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 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: `Z,he CaaxUa 0RW0a1dL Of W-0 ssa c"hwetts - Dopajdmmt ofJadwidal Accidents Ofte Qf1nvesiigatjous 600 W W*gton Reef Boston,,MA.0.21 1 1 TO,#617-7-27-4900 QA 406 ox 1-877, ASS.AFE Revised 5-26-05 FRY O 617-72`-7749 �v�.znass, ov�c�a µasry TIOMIOF NORTH:ANDOVER 0f,7tea r�"S:y - �$ OFFICE OF BUILD NG DEPARTMENT ' ' R4;2e�,,^ :"1600 i0sgood Street Building 20,Suite 2-36 f yqS R,hO Fr��S csusNorthAndoveS,-Massachusetts 01845 �A �. Gerald A.Brown Telephone(978)688-945 TnspectorofBuildings _ Fax (978)688-9542 ' . HOMEOWNER.-LICENSE EXEMPTION BMD1NG PERM T APPLICATION Pleasenrint • DATE: 311YIN `( JOB LOCATION: 1'�t , AA Number tre Address V M Nom. ` Map)Lot TI MEOTNER ( o f -Name, ome Phone Work Phone PRESENT MAILING ADDRESS < C;tsi To.m sfgPe. dip Code The current exemption for`$omeowners"was extended to to allow.5W h horaeo:OTS to engage an a�rcividual•for hire mihoLdoes notpossess a 71cjense,prow ded that the ow.23 an ner rl acts as supervisor). StateDuilding (Code Section 708.3.5.7) DEFINITION OFROMEOWNER PorsOn(s)who awns aparceI of land on which helshe resides or intends to reside,on which there is,oris intended to be,a one or two family structures. A person who constructs more that one home in a i hick there O shall not e considered a homeowner. The undersigned"homeowner"assumes responsibilityf0rcompliances with the State Building Co Applicable codes,by-laws,rde and other rules andregulations. The undersigned"homeowner"certifies That he/sheM'aunderstands the Town of North AndoverBuilding Department equir na inspection procedures and requirements and that he/she will comply with,said procedures and requirements, - HOMEOWNERS SIGNATURE ApP.ROVAL OF BUII.,DING OF IAL Revised 7.2009 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION r CO ATION698-9530 nEALTH688-9540 - PLANNING 688-9535