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Home My WebLink AboutBuilding Permit #540-2017 - 128 DALE STREET 11/18/2016 BUILDING PERMIT TOWN OF NORTH ANDOVER ° T APPLICATION FOR PLAN EXAMINATION Permit N0: 5+0Date Received '� °4 • „.. Date Issued: SACHU IMPORTANT: Applicant must complete all items on this page LOCATION 2 �� m_ print PROPERTY OWNER �` \�'"� Qv� ' Print MAP NO: PARCEL ` ZONING DISTRICT: IHistoric District yes ( Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑One family ❑Addition 0 Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial D(Repair, replacement 0 Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands 0 Watershed District ❑Water/Sewer !D Identiifi�caattion Please Type or Print Clearly) OWNER: Name: -5'ejej� Phone: ��• �d� Z� op Address: CONTRACTOR Name: Phone: 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$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ (,o000, ®0 FEE: $ ::?-7Z-- Check No.: Receipt No.: 3 12,1 S NOTE: Persons contracting wi h unregistered contractors do not have access to the guaranty fund AA i nature of Agent/Owner Signature of contractor s •� BUILDING PERMIT f o�"OR �T 6� TOWN OF NORTH ANDOVER APPLICATION FOR.PLAN EXAMINATION 11 1 • 1y Permit No#: Date Received DRITED r4A` RSSACHUS�� Date Issued: EVUORTANT:Applicant must complete all items on this'page .�-�'��, �-Zgtq•�,r3+ i ` 4cyTi. ?"..•�. ,fir ,� :t7 1 ^ .'rJ-/c «r�"MA LOCA�TIQNi a4m S id y f r' i Print � PiROPERMYtOWNER j�w r. e- .r�-�:ate- Year Structure D s tMAP : f iPARCEL ZONING-01S. r, ,.''Hi"stone®istnct y� ,�� yess no ,. r. _; n. t.w .� Ma imine Sh p Village' y s xno 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 0. �_:.. Septic Wel - ❑ Floodplain 0 Wetlands 0 Watershed mstnct- -.. _ O.Water•/Sewer. _ �.:_ _ _ 'y'' - - �`�'�'�'�Ir _ DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly' OWNER: Name: Phone: Address: Contractor Name:,..• _ _. ..._.,:.... . Phone:... _ Supervisors Construction►License: Exp: EX e Date.._ •1.�..,.� _ - Home Improvement License: _ _ - ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON.$925.00 PER S.F. .notal Project Cost: $ FEE: $ Check No.: Receipt No,- - NOTE: Persons contracting with unregistered contractors do not have.access to the guaranty fund Signature of.Agerit/Owher Signature of contractor'' Location No. Date � %� • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Buildin /Fr ame Permit -�- e mit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# U 1215 Building Inspector Plans Submitted ❑ Plans Waived 0 Certified Plot Plan ❑ Stamped Plans ❑ •YYPB'C�F SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swh ing 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 e U FORM I 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 Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT = Temp Dumpster on site yes no Located at 124.Main Street Fire Department signature/date COMMENTSb -imension Number of Stories: Total square feet of floor area, based on Exterior dimensions. I Total land area, sq. ft.: - ELECTRICAL: Movement of Meter location, mast or service dro _ e p_, quires approval of Electrical Inspector lies No ®ANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) i ❑ Notified for pickup Call Email ate 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. r Roofing, Siding, Interior Rehabilitation Permits ❑ _ Building Permit Application ❑ Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o 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 o Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o 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) o Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o Mass check Energy Compliance Report o Engineering Affidavits for Engineered products 40TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit Iu 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 Ily Doc:Building Permit Revised 2014 !r 1 pORTH {-- No. 510 h ver, Mass, A0 Ke coc"Ic"RWKK 1 ��S RATE O P �y I r / C4'Tj Co' ll BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT skleAw% ,,.,.., ' . , ,,. ,, , .. BUILDING INSPECTOR H. 01%.qs................................................ .....I n...... ....86"O'k— Foundation has permission to erect ..........................buildings on ....... 1�_431� �.. I.,..ls� to be occupied as ...1.. .. 1 :��!''. !!`fj... 3�.�. � �.�7�!...��:.�.C1 Chimney u he provided that the person ccepting 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSjRQCTIO T Rough .. .. ............ Finaltoo '4BUIiLD61i�N INSECTOR Service 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. r 1 NORTH w: :. . : : : 0. .c ve' 'o 0 No. LAK I h ver, Mass, its zoj& , COC NICN(WICN ORATED AP�,`'�y U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ...... ... .. ,,,,,,,,,,,,,, ,,,,,,,,,,,, , , , BUILDING INSPECTOR ,57.00%... .rl...S.' ........ ........ . . . ....... Foundation has permission to erect .......................... buildings on .......I ........ s� Rough to be occupied as ... .�.. zI.4r�....'�. �i� . Vierms Pow. .�! chimney provided that the person accepting this permit shy I in every respect conform o of the application 40 Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and11 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 CONS 0 Rough Service .... ........ BUILDING IN ECTO Final 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. of No oT �� TOWN OF NORTH ANDOVER a? .,O0L OFFICE OF . ' A BUILDING DEPARTMENT « 120 Main Street North Andover,Massachusetts 01845 �ss�c►+usE� Donald Belanger Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION Building Permit Application Please print DATE: l i V7 Zc�1 JOB LOCATION: Number Street Address Map/Lot HOMEOWNERS N" W Ct1(8 •0_7'833 t C'78. %09 , _2_q00 Name Home Phone Work Phone PRESENT MAILING ADDRESS City Town State Zip Code The current exemption for"homeowners"was extended to include owner occupied dwellings of one or two family dwellings and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. 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 dwelling,attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner.(780 CMR Section 110.R5.1.2) The undersigned"homeowner"assumes responsibility for compliance with 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 requirements and that he/she will comply with said procedures and requirements. HOMEOWNERS SIGNATURE APPROVAL OF BUILD G OFFICIAL Revised 9/16 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 'he Commonwealth of Massachusetts _ Department of_[ndastrialAccidents .' X Congress,Street,Suite 100 d Sostox�,MA 02XX4 2017 w�rvw rnass.gov/dia �Pa�kers' Compensationlnsurance Affidavit:Builders/Contxaetors/Electxicians/Plnmbers. TO BE PILED WLTHTB]�'PERMrrl,NG AUThCOMTY- Please Print Le 'bl A licaut Information Name(Business!Organizationll-dividual): Address: City/State/Zip: %�r �•N-� Phone `_x� , -. .• -•r. Type o£project(required): Axe you an employer?Check the appropriate box: em to ees full and/orparttime).� 7. ElNew`donsi 6d—Ron 1.0 Tama employer with P y 2.❑1 am a sole proprietor or partnership and have no employees Working£or mein 8. Remo del%iig any capacity.[L`Ioworkers'comp.insurance required.] 9. Demolition 3.0 1 an a homeowner doing all work myself.INo workers'comp.insurance required.] 10 F1 Building addition 4,5'1 am a homeowner and will be hiring contractors to conduct all work on my property. 1w 11.[]Electrical repairs or additions "insure that all contractors either have workers'compensation insurance or are sole bin repairs or additions proprietors with no employees. 12�[]'Blum- g p Roof repairs 5.Q 1 am a general contractor and 1 have hired the sub-contractors listed on the attached sheet 13•.[] These sub-contractors have employees and have workers'comp.insurance.! 14.Ej OtheT 6.F1 We are a corporation and its,ofiicers have exercised their right of'exemption per TvIC c. employees-[No workers'comp.insurance required-1 152,§1(4),and We have no affidavit Any applicantthat cheoks box#1 must also fill out section below showing their workers'compensationPoliinusallcys information I Homeowners who subs this.amfria.atavit acroindi6kingtheyen hire outside contrar nal doing the-work andname o£the sub contractors and state whether or not ihoseentities have !Contractors that check p_policy employees. If the sub-contractors have employees,they must provide their workers'com oli number. X am an employer'that is providingworkers'compensation insurance for°my employees. Below is tliepolicy and jo�i site information. Insurance Company Name: ExpirationDate_ Policy#or Self-ins.Lic.#:. PA Q 1,81q S— 1'Z19 bak, ( - City/State/Zip: �� rob Site Address: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date)- SOO.QO Fail-Luc to secure coverage as required as civil MGL enalties2in the form of criminal OP-violationpunishable ORDERIand tine of p to $250.00 a and/or one-year imprisonment,as w P day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. X do Hereby certify, der the ai andpenalties of perjury that the information provided aha a is true and correct. - Date: /1 1�� Si ature: YV Phone# , , 3 official use only. Do not write in this area,to be completed by city or town official. permit/License# City or Town: issuing Authority(circle one): i 1.Board of health. 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Picone#: Contact Person• Information and InstrTuctions 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 d'ef'ined as"an individual;partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enferprise,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 oftha 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 b6 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 whci 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 au LLC or LLP does have employees,a policy is required. B e advised that this affidavit may be submitted to the Department of Industrial Accidents for confizmation 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 beingnested not the Department o re q � p f IudustrialAccidents. 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. L 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 Iuvestigations 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. II 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-MAASSAFE Fax#617-727-7749 Revised 02-23-15 wwwm.ass.gov/dia