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Home My WebLink AboutBuilding Permit #619 - 141 MARIAN DRIVE 5/15/2009 BUILDING PERMIT of "°oT" qti TOWN OF NORTH ANDOVER c? 't<,, -hb*° o°^, APPLICATION FOR PLAN EXAMINATION �O 1eb Permit NO: Date Received QAo gArno Date Issued: IMPORTANT: Applicant must complete all items on this page tt1 � J LOCATION t 71 !y 1 n� A K D �1� ri PROPERTY OWNER PP' Print MAP NO] 4- PARCEL: ZONING DISTRICT: Historic District yeso Machine Shop Village „yes no 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 Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK_TO BE PREFORMED: E - S �n16c a �►y SQA Identification Please Type or Print Clearly) .OWNER: Name: , Phone: ,9 g,�-2 �s� Address: s CONTRACTOR Name: Phone: Address: Supervisor's Construction License: 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.: '3& !(;f Receipt No. (�_U 3 NOTE: Persons contracting with unregistered contractors do not have access to th guaranty fund Signature of V 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 ❑ 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 I 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 DEPARTMENTMFORM07 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 THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature h L - <. COMMENTS HEALTH Reviewed on Signature COMMENTS I 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-Durnpster on site yes no Located at 124 Main Street 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,t on, 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 I I I. ❑ Notified for pickup - Date I Doc.Building Permit Revised 2008 pORTM TOWN OF NORTH ANDOVER • '- °� OFFICE OF BUILDING DEPARTMENT 1600 Osgood Street Building 20, Suite 2-36 re si . North Andover, Massachusetts 01845 CWU Gerald A Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION Please zipt DATE: aObj JOB LOCATION: I q I 6 Number Street Address Map/Lat HOMEOWNER , Name Home work Phone PRESENT MAILING ADDRESS J MA SIA N City Town State Zip Code The current exemption for"homeowners"was extended to include owner homeowners to '0��dwellings to two units or less and to allow such hom engage an individual for hire who does not possess a hoense, vided owner acts as supervisor). State Building (Code Section 108.3.5.1) PT0 that the DEFINITION OF HOMEOWNER Persons)who owns a parcel of land on which helshe resides or intends to reside,on which there is,or is intended to be,a one or two family struchires. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned"homeowner"assumes responsrbilily for compliances with the State Building Code and other Applicable codes,by-laws,rules and regulations. The undersigned"homevwnel"certifies that he/she understands the Town of North Andover Buil ding minimum inspection procedures and requirements and that he/she will comply with said proce&=and Department requirements. HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 10.2005 Fam Homaw wn En=ptiw ROS RD OF 1PPE.V.S6-39,)5L1 C0.NSERVXF10'%F88-9530 NE.1L'T13 688-9540 PLANNING 688--9535 The Commonwealth of Massachusetts kj j! Department of Industria!Accidents 1' ! Office of Investigations . ilial% 600 Nlashington Street Boston, MA 02111 www nzass gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information. Please Print Legibl Name (Business/prganizaEion/Individual): kL ^r� Address: Citystate/Zip: 0� Phone#: . Are you an employer?Check the appropriate box: I.❑ I am a employer with 4 Type of Project(requires: ❑ I am�agZenerzl contractor and Iemployees(full andlorp0rt-time).* have d the sub-contractors d ❑New canstructiat, 2.❑ I am.a:sole proprietor or partner_ listedn the attached sheet.i 7• ❑Remodeling ship and have no employeesThese subcontractors have working for me.in an capacity, workers' comp.insurance. 8. Q Demolition y 9. Building[No workers'camp. insurance 5. ❑ We are a corporation and its ❑ ng addition required.] officers have exercised their 10.0 Electrical repairs oradditions 3. i am a homeowner doing all work right of exemption per MGL I I.❑ plumbing repairs or additions yseIf.[No workers'comp. c. 152, §1(4),and we have no insurance.required.]t 12.❑ Roof repairs . .employees. [No workers' comp. insurance required.] 13.[]Other `Any applicam that checks bob#t must 9190 fill out the section below showing their workers'compensation policy in t Homeowners who submit this affidavit indicating they are doing all work end then hire outside contractors must submit a new affidavit indicating such 4Crnrtractors that check this box must�neehed an additional sheat showing the name of the sub-contactors and their workers'temp-pclicl infomuuion. Oman employer that is promding:wa information. rkers'conepensadon insurance for my EM1010yem Below is7hePolicp and job site . . Insurance Company Name: ' Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address; Attach , City/State/Zi P 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 fine up to$1,500.00 and/or one-year impenaP of criminal penalties of a of up to$250.00 a day against the violators Be advised that a copyof this statement may be forn the form of a ward dOto the ffic of RK ORDER d a fine Investigations of the DIA for insurance coverage verification. I do hereby cert under the pains and pen 'es of pEdury that the Information provitfed oge e and correct . Si toe: Date: S 6 a Phone#: 7 F7H only. Do not.write in this area,to be completed by cit} or town officio[ n: Permit/License# ority(circle one): ealth 2.Building Department 3.City/Town Clerk4. Electrical Inspector 5. Plumbing lncpector son• Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all emp f oyers 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 t3he commonwealth nor any of its political subdivisions shall enter into any contract for the perfonsrance 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 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 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 numberlisted below, Self-insured companies should enter their self insurance'Iicense 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 A ill 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 futare permits or licenses. A new affidavit must be Med 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 bum leaves etc.)said person is NOT required to complete this affidavit The Office of lnvestigiations 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. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investiations 600 Washington Street Boston, MA 02111 TeL # 617-7274900 ext 406 or 1-8.77-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia v,oRr#i Town of : 1. _ 4Andover . 0 �= A K E - dover, Mass., o �. COCKI C MEWICK V A0R47ED `S BOARD OF HEALTH PERMIT D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT........A.6A............ ..... ........... ....................................................................................... Foundation has permission to erect.................................. buildings on ......1 . .. ........MotUAK....DLFM... g ......... Rough to be occupied as � !�i... .....Is.� Chimney ....."a�c��c�ep ... .............. .... ...................... provided that the perg 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 ELECTRICAL INSPECTOR UNLESS CONS TR STARTS Rough ...... .. .................... ............................... Service BUILDI1qM4WSPECTOR Final Occupancy Permit Required to Ocmpy 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. Location l 7I I��-� r4?1 y No. Date �y �oRTM TOWN OF NORTH ANDOVER ' Certificate of Occupancy $ '•^°'Eta Building/Frame Permit Fee $ 11 sAcHus Foundation Permit Fee $ Other Permit Fee $ TOTAL "i Check # 2 2 U Building Inspector