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HomeMy WebLinkAboutBuilding Permit #671 - 14 INGLEWOOD STREET 6/4/2009 AORTH BUILDING PERMIT TOWN OF NORTH ANDOVER 040-- , t �° op APPLICATION FOR PLAN EXAMINATION # 4 _ + X04V-9.1 Permit NO: Date Received A�gATlO I,PP ,�9 �SSacHus�� Date Issued: �r IMPORTANT: Applicant must complete all items on this page LOCATION � � S77- s= - Print'., PROPERTY OV�/NER, D tf 14d L Print . MAP NO: I mPARCEL-. ZONING DISTRICT. His#oris District ,y, yes no :.MachnehQp Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building X One family Addition Two or more family Industrial Alteration No. of units: Commercial X Repair, replacement Assessory Bldg Others: Demolition Other Septic Well;> Floodplain We#lands 1atershadDisti ict Watt/Sewer DESCRIPTION OF WORK TO BE PREFORMED: 1,�9kCH(7-Sc. SRtNC_&_5s dr,,J 84t 0c-t> 3 ��93 sffry S o� Oc�cra ,� Identification Please Type or Print Clearly) OWNER: Name: J,tnAct_s hdct Phone: 9?&'(o8a-9?3 t Address: ZZ /NC�L9v�eyo S7_ �vo�2J7.e ��beV&L � _ _F CONTRACTOR .Name: Phone: R. T - . Address: . Supervisor's Cor;truction Ljcense H Exp. Date' , Home Improvement License: Exp. 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. Total Project Cost: $ FEE: $ � Check No.: Receipt No.:4aoU 0 NOTE: Persons contracting i4ith unregistered contractors do not have access to the guaranty fund ignature of g nt/Owrier c, Signature Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tan ning/MassageBody 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS k 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, Vires no >' 4 Located at 924 Main Street s _ Fire,Depar#ment signatureIdate 77 n, COMME'NT5 : i 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 . l i NOTES and DATA- For department use E ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 i Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Ii Roofing,,Siding,-interior Rehabilitation Permits Li 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 signofffrom 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/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 i ❑ 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 Location LIJyy 04 No. Date v Ma�TM TOWN OF NORTH ANDOVER 40?O•`t`•o ,•1hOoy • Certificate of Occupancy $ s�CMus t� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check /fir 2208 v Building Inspector NORTH ONM 0 4Andover No. A 71 o �_ LC1t E = dover, Mass., COC HIC HEWICK y�. 7d ADRATED `S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT 1. """""' Foundation has permission to.erect....... ................................ buildings on ..TOL....... ....R................ Rough to be occupied as._ O ! ! .......:.........:.......�..Z... Chimney provided that the person acc Ing this permit shall in every respect onform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating o 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 PENT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONS TR N TARTS Rough ...... .................................................................. Service BUILDING IN R 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 ,Until Inspected and Approved by the Building Inspector. Burner FlRE DEPARTMENT Street No. SEE REVERSE SIDE Smoke Det. f pO11TM TOWN OF NORTH ANDOVER a� •� . °0 OFFICE OF BUILDING DEPARTMENT 1600 Osgood Street Building 20, Suite 2-36 North Andover,Massachusetts 01845 SACNUS Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)_688-9542 HOMEOWNER LICENSE EXEMPTION Please vrint DATE: D rr �^ JOB LOCATION: Number Street Address •. MaP/lat HOMEOWNER Thkis tZcNa-r Name Home Phone Work Phone PRESENT MAILING ADDRESS -2;k A)ice L�-� f ©c &tlS� 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,pmvided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) DEFINITION OF HOMEOWNER Persons)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 shuctures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned"homeowner"assumes responsibiiiiy 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 minimuminspection procedares and requirements and that he/she will comply with said procedures and requirements. HOMEOWNERS SIGNATURE �. w APPROVAL OF BUILDING OFFICIAL Revised 102005 Form Homeownen Exemption ROARDOF 1PPE:V.S6XF-9541 CO SERV.MON6.,FF-9530 14E.0:FIi!;FF-9540 PL.\-\', -9535 The CO"wR ,eafth of Massachusefts kj ! Department of Industrial Accidents Office of Investigations . is 16 i 600 TT-ashington Street Boston, )g4 02111 c www nzass.gov1dia . Workers' Compensation I u' rsnce Affidavit: Builders/Contraetors/Electricians/Plambers APPlicant Information Please Print Legbly Name(Business/Orgmization/Individual): L / l Adt ress: 2 l N&r(_:G-L L)" dD Citystate/Zig: itJ ON i a Z ;.� Phone#: . 7 DtFs-� Are you as employer?Check the appropriate box: I.❑ I am a employer with 4. Type of Pref(regaitep: ❑ I tem a general contractor and I employees(full and/or part-time).* have hired the sub-coacors b. []New construction 2.❑ I am.a.sole proprietor.or partner- listed on•the attached sheet= 7• ❑Remodeling ship and have no employees' These subcontractors have 8. Q Demoiition working for me in any capacity. workers' comp.insurance. [No workers comp. insurance 5. 9. []Building addition ' P ❑ We arc a corporation and i#s required.) officers have exercised their 10.0 Electrical repairs or additions 3. 1 am a homeowner doing all work right of exemption per MGL l I TI Plumbing repairs or additions myself. [Novorkers'comp, c. L52, §1(4),and we have no insurance required.] 12.N Roof repairs � ] .employees. [No workers' COMP. insurance required_] I3.[].Other ;Any applicant that checks bob#t must also fill out the section below showing their workers'compensation policy information t riomeownera who submit this affidavit ituiitsting they are daring an work and then hire outside contractors must submit a new Affidavit indicating such $Contractors that check this box must aneched an additional sheet showing.the nerve ofthesub-contractors and their wori�rs'c,—. it in F ,irtamiation e art an eploper that is pro,vWwg workers'compensation insurance for my employe= Below is the o ' information. p 4 and job site . 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 da>ae� . Failure to secure coverage as required under Section 25A of MGL c. 152 can lead tothe imposition of criminal penalties of a fine up to $1,500..00 and/or one-year imprisonment;as well as civil penalties in the farm 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 c fY under the pains and pen OP erjury Mat the information provided above is trice and coned Si tore:: _ Date: Phone#: r76-0tb6r only, Do not write in tfcis area,to be cotrpleted by city or town oaial Town: Permit/License# ority(circle one): Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector son• Phone#: Information a end I9structions �^ 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 Icgal entity,or any two ormore of the'foregaing 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 worst on such dwelling house or on the grounds or building appurtenant thereto shall not because of sucb employment be-deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall.withbold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealtb 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 i=My 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 comple-tely,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(siof insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)wit.h no employees other than the memb=or partners,are not required to cant'workers'compensation insurance. Ilan 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.returned to the city or town that the.application far 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 can the Department at the nuratber listed below. Self-insured companies should enter their self insumnce'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 wvilI 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 ofthe affidavit that has been officially stEmped or marred by the city or town may be provided to the applicant as proof that a valid afeidavit is on file for future permits or licenses. A new affidavit must be filled out each year. When: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 liilm 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 Commonwealth of Massachusetts Department of Industrial Accidents Office of Lnvestlibations 600 Washington Street Boston, IviA 02111 TeL# 617-7274900 ext 406 or 1-8.77-MASSAFE Fax#617-727-774 Revised 5-26-05 www-mass.gov/dia