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Home My WebLink AboutBuilding Permit #691 - 16 MEADOW LANE 6/11/2009 6 BUILDING PERMIT O` yORTh er-T,ro '9.{. TOWN OF NORTH ANDOVER 0o A APPLICATION FOR PLAN EXAMINATION Permit NO: V Date Received ��SSACHU`�� Date Issued: cot 11101 IMPORTANT: Applicant must complete all items on this page LOCATION_ 16 ff)C Oa0w LG t)c PROPERTY OWNER SRNJr4 �tja m Print Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes o lMachine 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: <-r,,,, I Pao 10bLUL mcm cl Identification Please Type or Print Clearly) OWNER: Name: Sr4vo!'A 12e- ei,4 Phone: Address: 16 rn e_, 44&y LAoL 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: $ /S�ab co FEE: $ - b Check No.: 7.56 0 Receipt No.: 2;1- NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund $ignature of Agent/Owner Signature of contractor 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 1 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 Dumpster on site yes no x 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 ❑ 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 i 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 I Location C4 a/,�,'iti - No. Date NORTH TOWN OF NORTH ANDOVER � 9 • i ; ; Certificate of Occupancy $ Building/Frame Permit Fee $ s�CHus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 22 '1 1 I Building Inspector x4ORTH ® of : tAndover �/ O .r.rR,f�b'• ^..V.r+. .tom t No. - o = SAKE dover, Mass., COCNIC NE WICK y�. ADRATED `s BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System �s� BUILDING INSPECTOR THIS CERTIFIES THAT......... ..... � .. C.l...... .f., ... ........................................ ...................................................... an Found 'on has permission to erect........................................ buildings on . ....`. .. .. a.. . t G�J. lt✓/ ..........:............... Rough Chimney to be occupied as..................��'!��t...... . ..,�.Q�t.... ..o%'.o�r.�lr. ......�..rQdKtihe ................................... y provided that the person accepting this permit shall in eve re t conform to terms oa lication on file inryPP 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 CONSTRUCTIONS ART Rough .. .� ........ :4,.,............................................ Service BUILDING INSPECTOR 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. z a Ro PARCEL 210 / 045.G GRIT oA s r DEED BOOK 5994 MS tt PLAN REF. # 4758 Gy R� Atkinso W I ZONE R4 Ht1rs U g' B gpTE■ _ 1.8,160 SQ. FT K P' CL S tTE� AO AN Holy 125so s �7 a LOCUS 0 N 2� Nit. o �n N.T.S. 3 M t 0 Z 151.80' INN xI' N / F SHOLA #24 MEADOW LANE 1a' 8' 17.3' ADDITIN UNDER CONSORV TON # J6 3r �D NORTH ANDOVER 1os.02! 38-V EXISTING 1 STY 38. +I_ BOARD OF APPEALS GARAGE 1 r a' 2a' N /F WEIER #475 MASS. AVE 311% +I- ORNEWAY 41.7T L=76.67 MEADOW LANE DATE : The Commonwealth of Massachusetts ji Department of Industrial Accidents • ! Offlce of Investigations 600 NTashington Street Boston, K4 02111 �c www_mass.gov/dia . Workers' Compensation Insurance Affidavit. Builders/Contractors/Electricians/Plumbers Applicant information L Please Print Le_albly �,T tVi nlie (Business/Organiza6orAndividual)'_ ,!l{�► S Q��j. Address: l Lo F'Ylr�i� , LA?rile City/state/Zip: &dPhone#: . F,31-J 78reyemployer?Check.the appropriate box: em to er with 4, F17. of project(required): P Y ❑ I tun a general corut<actor and Iees(full and/or part-time).* have hired the sub-contractorsNaw corishvction ole proprietor or partner- listed on the attached sheet,: Remodeling ship and have no employees These sub-contractors have g workin for me in any capacity, workers' comp.insurance. 8. E:Demolition [No workers comp. insurance 5. 9. ❑Building addition ' P ❑ We cue a corporation and its 3.0required.] officers have exercised their 10.[]Electrical repairs or additions I am a homeowner doing all work right of exemption per MOL 11.0 Plumbing repairs or additions myself.[No-workers'comp co 152, §1(4),and-we have no insurance required.].t employees. 12.0 Roof repairs • [No workers' I3. Other- comp. insurance required_] - �� Any applicant final checks bo>L#I must also fill out the section below showing their workers'compensation policy information, t Homeowners who submit this affidavit indicating they ars doing an work and then hire outside contractors must submit a new affidavit indicatiag such. ;Contractors that check this box"justa_rtecb d an additional shawl showing.the name of the sur;-contractors and their wortce 'car--,-.r si��'rSam�ation. I am an en yloyer that is providutg workers'compensation wzsurance or information } v' and Below is the policy ana'job site . Insurance Company Name: ' Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/Stat zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration datze� Failure to secure coverage as required tinder Section 25A of MGL c. 152 can lead to the imposition of criminal pena]tics 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 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 and penalties of perjury,that the ifffffma ion provided above is true and correct Si tore: Date: Phone 9:_ 3b I- �[ Official use only. Do not write in this area,to be completed by mJ'or town o�cid 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 Contact Person• Phone#: Information a nd Instructions Massachusetts General Laws chapter 152 requires all emp Ioyers 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,assvoiation,corporation or other legal entity,or any two or more of the'fbmgoing engaged in a joint enterprise,and including the legal representatives of a decreased employer,or the receiver ortarstee 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 shat not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local Eicensing agency shall withhold the issuance or renewal of it license or permit to operate a business or ito 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 pe rformaQrce 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'ccsrnpensation 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•die 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,northe Department of Industrial Accidents. Should you have any questions regar-ding the law or if you are required to obtain a workers' oompensation policy,please can the Department at the number listed below, Self-insured companies should enter their self insurance license number on the'appropriate tine. 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 w-ilI 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. 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 Investipations 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 Fndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 TeL# 617-7274900 ext 406 or 1-11.77-MASSAFE Fax#617-727-7744 Revised 5-26-US www.mass.gov/dia pORTN TOWN OF NORTH ANDOVER • +_ : o� OFFICE OF BUILDING DEPARTMENT " s + 1600 Osgood Street Building 20, Suite 2-36 ,s A� Stt� North Andover,Massachusetts 01845 Gerald A Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION ease mint DATE: I JOB LOCATION: - I b f f)LaCQ j) Lo Number Street Address Map2ot HOMEOWNER 14 Nd X118 s��I Name Home Phone Work Phone PRESENT MAILING ADDRESS IL j y . A,(Na0l Cr- (A City Town State • Zip Code The currax exemption for-homeowners"was extended to include owner-o=jpied 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 helshe 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 requiremmn. HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Ria 10.2005 Form Homwwnm EmmW400 f3OARDOF \PPE.\I.S iiYR!)S 41 C0NFER\'.1'I'ION—'68M;;0 J4E.II1H 689-9340 PI_.�\�N I\G(M-9535