HomeMy WebLinkAboutBuilding Permit #716 - 135 RALEIGH TAVERN LANE 5/17/2010 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: I Date Received /v d
Date Issued:
IMPORTANT: Applicant must complete all items on this page _
LOCATION .: iLiFj �4�►
P-
PROPERTYOWNERR 11
Pnnt u
MAPNO: PARCEL:1 ZONING DISTRICT: -2. His#orc'District Wyss ; no
Machine Shop Village ;yes no
t
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
New Building O—n 6 fame
Addition o or more family . _ Industrial
--------------
Alteration No. of units: Commercial
Repair, replacement Assessory Bldg Others:
Demolition Other _
e` tic UVell Floodplain etlands Watershed District w
.n
ate'r/Sewer.
DESCRIPTION JDF WORK TO
C XI Sto}( of �JE.{'IC �I'O rr BE PERFORME�D:
XWaif �
� K '�
I
Iden ' kation Please Type or Print Clearly) '
OWNER: Name: EiZtK -L DORA SvLW Phone:1"18 2S8 o12
Address: 13-S RALEIAH j Avey,4 Lm
CONTRACTOR Name Phone.
Adaress:
jSupervrsor's Construction License; Exp. :Date:
,H®rne 4mprovement License: Exp. Date: e
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
i
FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.t &4YJ0 --Total Project Cost: $ FEE: $
Check No.: �- Receipt No.: e4 3 1& Z
NOTE: Persons contracti ith unregistered contractors do not have access to the guaranty fund
--�_...�. �A
ignature c A jent/Owner, Signature of contractor y
Plans Submitted Plans ived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer Tanning/Massage/Body Art Swimming Pools
Well Tobacco Sales Food Packaging/Sales
Private(sep ' nk,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 Si nature LA (X
I
COMMENTS 'I-9 U.,LJ
�
� .r
HEALTH Reviewed on y -19 Signature
COMMENTS v (D e-
I
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
j Water & Sewer Connection/Signature & Date Driveway Permit
i
i DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE�DEPARTMENV' Temp Durnps#er on site yes n no a
'L;oda"ted,:at 124 Main�Street - _
Fire.Depart nentsignature/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 21A—F and G min.$100-$1000 fine
NOTES and DATA– (For department use
f
❑ Notified for pickup - Date
._...............__............_..........................._.........__....---............_........_...................._....................._......_......_......_....................................................__._....._...—_. _...................................._._.._........_ _._..........._..._..................._....
_.
Doc:.Building Permit Revised 2008
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
i
Addition Or Decks
❑ Building Permit Application
❑ ' Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
D 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)
L + ❑ 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
I
Doc: Doc.Building Permit Revised 2008
C
i I
--1
Location
No. Date
NaR,M TOWN OF NORTH ANDOVER
3? �
F
. 9 7
Certificate of Occupancy $
cMuS<�' Building/Frame Permit Fee $ '
r
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
23 ,1 6,4
Building Inspector
c NORTH
TONM t - 4 Andover ,
.. 0 ti � .`•i` Ott
No.
�. Co �+ .
L A. o. dover, Mass.,J • 1' d
COCMICMEWICK V^
ADRATED PPS` ��
`s BOARD OF HEALTH
PERM IT T D Food/Kitchen
Septic System
� BUILDING INSPECTOR
THIS CERTIFIES THAT �. .....7.4U.^....................... .
................. .... .,..................................................... Foundation
has permission to erect........................................ buildings on ...var.......1�. . 1%.. i. ......... Rough
to be occupied as...... ......., .....6..............i'4d t.��......�........ R......................
Chimney
provided that the person accepting this permit shall in every respect 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
UNLESS CONSTRU N T ELECTRICAL INSPECTOR.
Rough
........................:..... Service
BUILDING ECTOR
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.
The Commonwealth of Massachusetts
Department o f Iradustrial_9ccidents
Office of Investigations
600 Rawzind ton Street
+ g
Boston, MA 02111
www.mitzss gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/EleCtrlcianS/P
ADplicant Information lumbers
y^ PIease Print Legibly
Name (Business/Organization/IndividuLal): R I UB
Address: 13-S 4t L-31t-f
City/State/Zip: `' '�L4Z � ®f Phone#:
Are you an employer?Check the appropriate box:
L❑ I am a employer with q.. ❑ I am a Q Type of project(required):
teneral contractor and I
2•❑ employees(full and/orpart_time).* have hired the sub-contractors 6- ❑New construction
I am a sole proprietor or partner- listed on the attached sheet 1 7• ❑Remodeling
ship and have no employees These sub-contractors have g
working for me in any capacity. workers com ,ins g ❑Demolition
[No workers' comp. insurance 5 P mance. 9, [�Building addition
P ❑ We are a corporation and its
required.] officers have exercised their 10•❑Electrical repairs or additions
3. I am a homeowner doing all work right of ex
emption per MGL 11.0 Plumbing repairs or additions
myself. [No workers' comp. c. 152 14 ,
§ ( 1 and we have no 12.(1 Roof repairs
insurance required.] t employees. [No workers'
comp.insurancerequired] 13.[] Other
`-ny�E--ut that checLs box-1 must also 1U.ou!the sece^^eeiew�����...r
Homeowners who submit this affidavit indicatin€the,are do^ , W �- R or ers eomp " Y ick .
+Contractors that checi:• g aL.vorb and thea hireoutside contractors'Alixt.submit a new affidavit indicating such.
�s box must attached an additional sheet showing the
name of the sub-contractor;and their workers'comp
I am an employer that is providing workers'compensation insurance or m e noiicy information.
information. f y mployees. Below is the policy and job site
Insurance Company Name:
Policy#or Self-ins.Lic.#:
Expiration Date:
Job Site Address:
Attach a copy of the workers'compensation policy declaration age (Showing
the po Zip:
Failure to secure coverage as required under Section 25A of MGL C. 152canlead to the impolicy sition ober criminal matron date).
of
fine up to$1,500.00 and/or one-year imprisonment, as well as _,
Penalties of a
of up to $250.00 a da ag ' Penalties in the form of a STOP WORK ORDER and a fine
y ainst the violator. Be advised that a copy of this statement maybe forwarded to the Office a
Investigations of the DIA for insurance coverage verification
I do hereby c r the Pains and penalties of perjury thQt the formation provided abo
Signature: VC is true and correct
-
Phone .-D.ate:..._
#: �• � � ��
Official use only. Do not write in this area, to be completed by city or town offacurl
Cita 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#:
w
Information an- d 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 oemployer,a deceased em lover, or the
receiver or trustee of an individual,partnership, association ox7 other legal entity,employing employees. However the
owner of a dwelling house having not more than three apart encs and who resides there' o
r the occupant ant
of the
� p
dwelling house of another who employs persons to do mainteyance;construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not,b.cauise of such employment be deemed to be an employer."
MGL chapter 152;§25C(6)also states that"every state or Io,`cal licensing agency shall withhold the Issuance or
renewal of a license or permit to operate a business or to(---on.struct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of co=mpliance with the insurance coverage required."
Additionally,MGL chapter 152, §2:5C(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 instance
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'comp enation 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 wire to sign and date the affidavit The affidavit should
be rct.'uiaed to the city or to,n th t the a ralica-Lion for the perrrut or license iR being rent-,-seed,itch fh--.Depa=---nt 07
Industrial Accidents. Should you have any questions regarding the law or ifyou are re ;iired 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
(Le. 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 than 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 and1axnumber: ..._.
The Commonwealth. of Massachusetts
Department Of Industrial Accidents
Office of Inveatfabatons
600 Washmgton Streit
Boston,AZA 02111
Tel. 617-72.7-4900 e)ft 406 or 1-8 77-MASSAFE
Revised 5-26-05
Fax -617-72.7-7749
`7f'A1W.Mass..a
_ov/dla.
--------------------
Scale: 1/8" = 1'0"
Notes:
Proposed Deck extension entirely within
100'of wetlands and is expected to require
approval of Conservation Commission
` Leach
Field
15'x 50'
Septic
T nk
x
Proposed o
Deck Extension
6'Tx27'6"
iv Porch`, r
zo (No Foundation) '
Exiting Deek
4 ------------------
h
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5
<: Existing Dwelling
135 RaleigC Tavern Lane
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Post to Beam
Attachment
2x beams
Footing Cross Simpson DJT14
Section ..a-- or equivalent
galvanized
Simpson ABU44Z U
uplift post base or _
�--- equivalent
galvanized
grade
anchor, 5/8"x 8"
galvanized
Scale: 1"= 1' 0"
Notes:
1) Posts centered on footing
_ 2) 2,500 psi compressive strength concrete
3) footing 36" below grade
4) pre-manufactured post base with anchor for 4"x4" nominal post
x-12" 5) 8-16d galvanized nails as required
2' VERTICAL
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,40RTH TOWN OF NORTH ANDOVER
� OFFICE OF
s BUILDING DEPARTMENT
*wo ^* 1600 Osgood Street Building 20, Suite 2
o -36
g9p�q,��p North Andover,Massachusetts 01845
�SSACHUSE�
Gerald A.Brown Telephone(978)688-9545
Inspector of Buildings Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
BUIDING PERMIT APPLICATION
Please print
DATE: lo 20
JOB LOCATION: R&EIGH IAVE2jj U
Numb°err� Street Address Map/Lot
HOMEOWNER R�it 2s&Q1ZI 4 7& 25CA0
Name Home Phone Work Phone
PRESENT MAILING ADDRESS 135 T6L6J6 N JA\)6 A LN
City Town State Zip 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 requirements and that he/she will comply with said procedures and
requirements.
� r
HOMEOWNERS SIGNATURE
Jr
APPROVAL OF BUILDING OFFICIAL
Revised 7.2009
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
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CONSERVATION DEPARTMENT
CominwiitV Development D]v1S1011
NEGATIVE DETERMINATION OF APPLICABILITY
SPECIAL CONDITIONS
135 Raleigh Tavern Lane, North Andover
At the April 28, 2010 public hearing, the North Andover Conservation Commission (NACC) voted
to issue a Negative Determination of Applicability for the construction of a 160 s.f. deck addition
with the installation of six (6) new 12-inch diameter concrete footings. This work will be conducted
in the Buffer Zone to Bordering Vegetated Wetland(BVW).The closest point of work to the BVW
is approximately 97-feet. Footings will be hand dug. In addition, a 12-foot x 18-foot shed will be
constructed on site approximately 99-feet from the edge of BVW7. All work for the shed will also be
completed by hand. No erosion control is required.
Annlirant• Hril Tulin
rr--- r
135 Raleigh Tavern Lane
North Andover,MA 01845
Wetland Delineation: Norse Environmental, 2009 (Wetland Flags 1a-17a)
Record Documents: Request for Determination of Applicability and Narrative
Dated: April 14, 2010
Record Pians: Certified Plot P Ian, 135 Raleigh Tavern Lane,Norm Andover,MA.
Dated: August 26, 2009 Revised: April 14, 2010
Pre-Construction
❖ The work authorized hereunder shall be completed by November 1, 2010.
❖ The applicant shall install 5 wetland markers evenly spaced along the edge of tree line up-
gradient of the wetland resource area.
During Construction
❖ Excess material and construction debris shall be properly disposed of off site and stockpiled
material shall be stored within the erosion controls.
1600 Oggood Street,Building 20,Stute 2-36,North Andover.Massachusetts 018=4.5
Phone 978.688.9530 Fax 978.688.9;.1'
Web:htrp://�t�atv.tomnoftx>rthando�-er.coin/Pales/N_�tdoter\I_�_ onseiz;itionjiitdes
Post Construction
Immediately following completion of the work, any disturbed areas shall be permanently
stabilized against erosion
Upon completion of all requirements, the Conservation Department shall be contacted to
conduct a final site inspection.
1600 Osgood Street.Buildim-20,Suite 2-36,North_''uidover.�M.is'sachusetts 0184
Phone 978.088.95;(! Fats Q78'.05,)'.9 4'
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Existing beam
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Existing Ledger
Existing
Joists Scale '/2" = 1' 0"