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Home My WebLink AboutBuilding Permit #907 - 149 COTUIT STREET 6/18/2012 BUILDING PERMIT pORTh q tt.lD 16 12 6 TOWN OF NORTH ANDOVER C m APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received2^� " "'Qq�RAT6o/,PPS.(5 Date Issued: i �.z �SSACHIIS IMPORTANT:Applicant must complete all items on this page LOCATION Print PROPERTY OWNERIC \ ' Print 'MAP NO: PARCEL: ZONING DISTRICT: Historic District yeno Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Al 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 PREFORMS : ,, c, 1 Identification Please Ty or Print Clearly) OWNER: Name: ��.,.` J Phone: Address: `t L 0-�-� -� �`� ( ct�-� ,✓� 6 `� 5 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: $— 4L16 FEE: $ Check No.: 02� Receipt No.: �y NOTE: Persons contra ting it unregistered ltractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor Location t � � i �#7 No.96 Date • - TOWN OF NORTH ANDOVER _ Certificate of Occupancy $ Building/Frame Permit Fee -�' Foundation Permit Fee $ ,k , r Other Permit Fee $ TOTAL $ Check# �� 254255 Building Inspector ■ 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 COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes r 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 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, 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) ❑ 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 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 ❑ Building Permit Application ❑ Certified Surveyed Plot Plan o Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ 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 ❑ 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) o Copy of Contract ❑ Mass check Energy Compliance Report Li 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 ^ The Commonwealth ofMassachusetts . - Department oflndustriglAccidents Office of Invesfigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeObly Name(Business/Organization/Tndividual): Address: �-- City/State/Zip:_ Phone#: L! Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ 1 am a general contractor and I � 6. F1 New construction employees(full and/orpart-time).• have hired the sub-contractors 2.❑ T am a sole proprietor or partner- listed on the attached sheet.x 7• El Remodeling ship and'have no employees These sub-contractors have El8. Demolition working forme in any capacity. workers'comp.insurance. 9. ❑Building addition [[No workers'comp.insurance 5. ❑ We are a corporation and its 10.f]Electrical repairs or additions equired.] officers have exercised their 3. X am a homeowner doing all work right of exemption per MGL ILEI Plumbing repairs or additions myself.[No workers'comp, c.152,§1(4),and we have no 12,❑Roof repairs insurance required.] employees.[No workers' •13.❑Other comp.insurance required.] ?Any applicant that checks box#1 must also fill outthe section below showing their workers'compensation policy information. T Homeowners who submit this affidavit indicating they ke doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. X am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy anrljob site information. Insurance Company Name:. Policy#or Self-ins.Lic.#: Expiration Date: n Job Site Address: 1�� C v 6`�" `� City/State/Zip: 11VA"r,14Vw_9,1 Q c ev 5 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL o.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 ofup to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DTA.for insurance rverage verification. X do Hereby cer fy artier tlns�an enrdties of perjury that flte information provided above is true anrlcorrect. - I Signature: �' Date: t Phone#: Official use only. Do not write in this area,to be completer)by city or town offrcial. City or Town: . Permit/Ucense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector 6.Other - - - Contact Person: Phone#: Information and iustructi®u8 ' Massachusetts General Laws cha Pursuant to this statute,an empter 152 requires all employers to provide workers'compensation for their employees. ployee is defined as"...every person in the service of another under any contract ofhire,- 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 shallnot 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 the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic 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. B e advised that this affidavit maybe 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 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 permittlicense applications in any given year,need only submit one affidavit indicating current policy information(ifnecessary)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 ii on file for future permits or licenses. Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a license o permit not related to any business or commercial venture (i.e.a dog license orpermit to burn leaves etc.)said person is NOT xequired to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and shquld you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The commonwealtl ofM-amachum"tts Mp.aftc,at ofJhdustdal,A.ccxdants . ()�'f�:ee of 7��estiga�ious 600 wa$l b&a Street Boston?MA,02111 Tol,#617-727,4900 ext 406 or 1-877WA.SSA`E Revised 5-26-05 Fay,#617"727-7749 www-mass,gov dia a�tK°or 6 atio TOWN OF NORTH AND °�, OFFICE OF a BUILDING DEPARTMENT iL i� ,r° ':,1600 Osgood Street Building 20, Suite 2-36 cmus North Andover,Massachusetts 01845 Gerald A.Brown Inspector of Buildings Telephone(978)688-9545 HOMEOWNEKLICENSE EXEMPTION Fax (978)688-9542 BUIDING PERMIT APPLICATION Please print DATE: JOB LOCATION: �j rr--- Number Street A dress `f i Map/Lot 1JM4EOWNER J Name Home Phone Work Phone PRESENT MAILING ADDRESS _. C. To?=m Mate Zip Code The current exemption for"homeowners,,was extended to include owner-occupied dwellings to two units or less and to allow such bomeovrDers to ell age an individual.for hire who does not possess a license,provided that the owner acts as supervisor). State Building (Code Section 108.3.5.T) DEFINITION OF HOMEOWNER Person(s)who Awns a parcel of land on which he/she resides or intends to reside,on which there is,oris intended to considered a homeowner. be,a one or two family structures. A person who constructs more that one home in a two-year period shall not be The undersigned"homedwner"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 Townof Forth Andover Building Department minimum inspection procedures and requirements and that he/she will c pIy with,said procedures and requirements, HOMEOWNERS SIGNATURE C . APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVAT10N 688-9530r HEALTH 688-9540 PLANNING 688-9535