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Home My WebLink AboutBuilding Permit #895 - 126 HIGH STREET 6/13/2012 BUILDING PERMIT ofNo oT",��. TOWN OF NORTH ANDOVER oG a / APPLICATION FOR PLAN EXAMINATION A Permit NO: Date Received �q RATED ' �J f �/ SSACHUS Date Issued: I v I ORTANT:Applicant must complete all items on this page LOCATION / �= 5 . Pnnt PROPERTY OWNER ' Pnnt 'MAP NO: Histon District ist ictDye n�no r Machine Shop Village, yes. TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building < One amiI Addition Two or more family Industrial . Alteration No. of units: Commercial Replacement Assessory Bldg Others: Re air r emolition Other Septic Wel Floodplain WetlandsWatershed District Water%Sewer ESCRIPTION OF WORK TO BE PREFORMED: • 1 Identification Please Type or Print Clearly) OWNER: Name: - �y Phone: E? kza,�� Address: CONTRACTOR Name ji .Phone Address: `Ex Date:_ Supervisor's Construction:License y-_: _. _ ,. �z- _ � p. Home Improvement-License- Ex 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. 1, ` Total Project Cost: $ d ®� FEE: $ Check No.: t Receipt No.: y4 NOTE: Persons contrac ing with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor. 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 r ❑ 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 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 I THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Si nature,. \' ;z COMMENTS HEALTH Reviewed on Signature COMMENTS I '. , e,--) Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments fi Conservation Decision: Comments Water & Sewer Connection/Signature &Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT, TempDumpster on site yes no .y Located.at-124Main StQeet Fire Department signature/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 approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 2 1 A—F and G min.$100-$1000 fine NOTES and DATA— For department use) i ❑ Notified for pickup - Date E Doc.Building Permit Revised 2008 Location No. Date !2- • ' TOWN OF NORTH ANDOVER w, e ry Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ " Other Permit Fee $ TOTAL $ Check# ' 25408 130161 g Inspector x40RTH ® Of 2 - Andover 0 0dover Mass.,— Y O t- LAKE 1 COCKICMEWICK �I SRATED P '�C U BOARD OF HEALTH 'v Food/Kitchen .PEHMIT TU D Septic System BUILDING INSPECTOR THISCERTIFIES THAT....... . .. ...... .................................................................................................................................. Foundation .......................... buildings on ../�� has permission to erect.......... ... s g ...... ... ...��.(7........&...................................... Rough to be occupied as G%`�l=- o ... V.C. 11_, Chimney ...................................................... provided that the person accepting this permit shall in eve aspect conform to the terms of the application on file in Final- 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 CONSTRUCTION k)TARTS Rough ............................. ......................... ..�,�-�,..... Service .. . . ...................... BUILDING 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 FIRE-DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. 2.0� �or 6 6No TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPART MENT y* ,1600 Osgood Street Building 20,-Suite 2-36 sSACHus�c North Andover,Massachusetts 01845 Gerald A.Brown Inspector of Buildings Telephone(978)688-9545 HOMEOWNER-LICENSE EXEIVIPTION Fax (978) 688-9542 "'DING PERMIT APPLICATION Please print DATE: JOB LOCATION: Number Street Address Map/Lot Name - .. Home Phone Work Phone PRESENT MAILING ADDRESS /,z , S+„+e. Zip Code The current exemption for"homeowners"was extended to include owner-occupied dwellings to f4vo units o 1 to allow such homeots�ners to engage an individual-for hire who cloes not possess a license,provided that the owner r1 acts as supervisor). State Building (Code Section 108.3.5.1) DEFINITION OF HOMEOWNER Person(s)who.9wns a parcel of land on which he/she resides or intends to reside,on which there is,oris intend be,a one or two family structures. A person who constructs more that one home in a hick there oriod shall note to considered a homeowner. The undersigned"homeowner"assumes responsibility for compliances with the State Building Co Applicable codes,by-laws,rules and regulations. de and other The undersigned`homeowner"certifies that he/she understands the Town of - North Andover Building Department inspection procedures and requirements and that comply withsaid procedures andre requirements, • HOMEOWNERS SIGNATURE - - APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption 'BOARD OF APPEALS 688-9541 CONSERVATION 688-9530A HEALTH 688.9540 PLANNING 688-9535 The Commonwealth of Massachusetts Department of Industrial Accidents Offce ofInvestigations ..600 Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Prmt Le�><bly • ' Name(Business/Organization/individual): - - • Address: ' - .- –– — City/State/Zip:��G� Femployees employer?Check the appropriate bozo employer with 4. ❑ I am a general contractor and IType of project(required):' (full and/or part-time).*' have hired thesub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet.t [7. ❑Remodeling ship and have no employees These sub-:contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. [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 11.0 Plumbing repairs or additions myself. [No workers'comp, c. 152,§1(4),and we have no required.)t 12.❑Roof repairs insurance re ] em q ployees. [No workers' comp.insurance required.] 13.❑Other *Ary FP licaw.that cheLks box*1 must also fill out the section be?ov..,seo:=,i^b mei;wo l:�'coWPe saiion policy infozmaficn. T 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 - showing the name of the sub-contractors and their workers'comp,policy information. I am an employer that is providing workers'compensation insurance far my 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 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 penalties ofperjurjr that the information provided above is true and correct � Date. Phone#: ,.7p — _ FFOther only. Do not write in this area,to be completed by city or town official n: Permit/License# hority(circle one): Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing, PInspector son: 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 6r 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' another-who employspersons to slo.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 chpter 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),addresses)and phone number(s)along with their certificates)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 retr.ued to the city or town that the apphioa ion.,for the pe:alt o: +nas�yY a P9tln rSP�i 4P' 4 nP TIT L1i 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 m 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 homeowner 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'Iike to thank you in advance f6r 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 IndusErial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-8.77-M.ASSAFE Revised 5-26-OS Fax#6.17-72,7-7749