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Home My WebLink AboutBuilding Permit #400 - 16 FERRY STREET 12/17/2008 9 OORTf/ BUILDING PERMIT Oltttteo ,6'9q. d o TOWN OF NORTH ANDOVER F p APPLICATION FOR PLAN EXAMINATION : e� Permit NO: Date Received gO,,,To'pP��g /f �SSACHU`-+�� Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION L' ,S-r NJORAn irk Je PROPERTY OWNER_ f),S WCM0 PrnLNkQ�cla Print MAP NO: PARCEL:—/—ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Buildingne mily Addition wo or more family Industrial Alteration No. of units: Commercial Repai eplacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: O� d2z)A no Cd ne� r t j Identification Pleas Type or Print Clearly) OWNER: Name: 05 W0.\ dO *l, k9-Cd(x Phone: Address: Bb 'o n C( —s+ A4® ` )o 4 . 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: $ IZ)oo FEE: $ Check No.: �� Receipt No.: �C NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owne Signature of.contractor Location /1 No. Vol Date f „OR,M TOWN OF NORTH ANDOVER 3? ° SOL Certificate of Occupancy $ ItJMUBuilding/Frame Permit Fee $ AG S Foundation Permit Fee $ Other Permit Fee $ Y, TOTAL $ Check # s / _ 2 : � UJ Building Inspector r -r 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 R 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 signatureldate 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 f� 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 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:Building Permit Application Revised 2.2008 NORTH Town of . , - Andover No. 4/#v dover, Maw., l ' J`4 ` p T O LA COCHICHEMCK 7� ORATED `s BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING .INSPECTOR THISCERTIFIES THAT......... .. f ........... ........................................................................................................................ Foundation tom. has permission to erect........................................ buildings on .c(o....:.....F: ......_.....I........8............................................ Rough pi OZ "ilLFll!. ...�.......I�,Q . ...... ......... ....�-..a...f?� ..ao..o. Chimney to be occupied as.......... provided that the person accepting this permit shall Wayjry 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 C PERMIT EXPIRES IN 6 MONTHS Final ELECTRICAL INSPECTOR UNLESS CONSTRUT TS Rough .............::......... Service BUILDING INSPECTOR 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. + pORTIi TOWN OF NORTH ANDOVER �+ •',r_ * '•°� OFFICE OF BUILDING DEPARTMENT { ; + 1600 Osgood 20, Suite 2-36 ood Street Building �.,5�,..• �{� North Andover,Massachusetts 01845 swcNuse Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION plemaipt DATE: JZI 16 08 JOB LOCATION: �' Fe C- Ir Y ST �J. knc�a V( !r Number Street Addressp/I,� HOMEOWNER %ujcki 6 0 . Name Home Phone Work phone PRESENT MAILING ADDRESS g 6 ?D'1 C( S t �401 6rn0P tA+ 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 borueowmm. 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. `.,,HONWWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revind 101005 Form Homeowners Exemption 1.30,\RDOF \PPEALS(00-951[ CONSERt'_1'I'IO\rgg-95;o IiE.U.111689-9540 PL.L\-N.G(K8-9535 - The Commonwealth of Massachusetts i >^y Department o �(dl -f Ind ustrial Accidents n Office o f.investigations 600 Washingto n Street ' Boston MA 02111 ` :- WWrv.rnasS.gOV�dia Workers, Compensation Insurance.A€f idaviit: guilders/Contractors/Elect ricians/Plumbers A. licant Information Please Print LeQibIv Name (Business/Organization/individual): V S I Address: T nn . S- City/State/Zip: o0V, Phone#: del— R — 63 416 Lf Are you an employer?Check the appropriate box: F2,h am a employer with 4. ❑ I am a genet al contractor and I TYPe of project(required): mployees(full and/or part-time).* have hired the sub-contractors 6' ❑ New construction 1 am a sole proprietor or partner- listed on the attached sheet 1 ?• ❑ Remodeling ship and have no employees These sub-contractors have working for me in an capacity. workers g ❑ Demolition Y P t}'� ' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its 9' ❑ Building addition 3.❑ required-] officers have exercised.their 10.0 Electrical repairs or additions I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No.workers' comp. c. 152, §1(4),and we have no insurance required.] t employees. [No.workers' 12•❑ Roof repairs comp. insurance required.] 13.17 Other *Anv applicant.that checks box#1.must also fill out the section below showing ttw it workers'compensation polis} information. ;•homeowners who submit this a-1;,1davit indicatiq alae att duine e E v:;a ;�tnon workers' hiroutside a pcns;torn policy y infor a new affidavit lContractors that chcci:this box must attached an additional sheet showing the nam P tube;. mday.t mdixring such. m_o. b-cont=tors and their workers'comp.I am an.employer that is providing workers'coensation i P"policy infannatio n. information nsuranee for nF employees. Below is the policy and job site insurance Company Name: Policy#or Self-.ins. Lic,r: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration datel. .Failure to secure coverage as required under Section 25A of MGL c. 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 fin-- of up to 5250.00 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 under the pains and penalties of-perjury that the information provided above is tragi and correct S i Qnature: Phone#: Official use only. Do not write in this area, to be completed by city or town officiaL City 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 p b Contact Person Phone Information C .nd 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 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 shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state o r local licensing agency shall withhold the issuance or renewal of a license or permitto operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence mf 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 compl-etely,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 cern-ficate(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 nr LLP does have _ employees, a policy is required. Be advised that this affid>-avit 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 re"a,—rding the lay, or if you are required to obtain a workers' compensation policy,please call the Department at the na-r-�ber:listed belo;v. Sell=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/icense number which will be used as a reference number. In addition,an applicant that must submit multiple permit/iieense applications in arty _given year,need only submit one affidavit indicating current policy information(if necessary)and under".lob Site Address"the applicant should write"all locations in (city or town)." A copy of the affidavit that has been officially starnped 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. VWhere 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 burnleaves etc.) said person is NOT required to complete this affidavit. The Office of investigations 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 numb--: The Commonwealth of Massachusetts Department of Industrial Accidents Off-ice of Investigations 600 Rustington Street Briton, MA 02111 Tel 4 617-727-4900 exit 406 or 1-877-MASSAFE Revised 5-2645 Fax 4 617-727-7749 www.mass.aovldia