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Home My WebLink AboutBuilding Permit #599-2017 - 16 MEADOW LANE 12/5/2016 11,s/ � NORTy ,9 �w Lr� BUILDING PERMIT 4J- I X-�t TOWN ®F NORTH ANDOVER o APPLICATION FOR PLAN EXAMINATION z }d1y Date Received permit No#: CreHD UrSe��y�4` . pate Issued: I� "� 07��fD - LWORTANT:Applicant must complete all items on this page -m .... s N _m ,xs f tin _ - — t � ` I?,ROFERT�Y'.®WNER a - R _ no 9 -___� 1DD Yearn nuc nn r ' sjHisfoncaDistnct yes ono iPARCEL: . . NINE D C ZO 1STR1 T` _,• . x „w._;r- Machine'Shop Village ` yes n TYPE OF IMPROVEMENT PROPOSED USE Non- Residential Residential ❑ New Building ❑ One family ❑Addition [I Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial K Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other D Septic Well _ ❑ FloodLplain n Wetlands 0 Watershed Distract . ❑Water/Sewer. DESCRIPTION OF WORK TO BE PERFORMED: c1e�iCC W" bws Zs� rlwp i Identification- Please Type or Print Clearly OWNER: Name: �,hrS eS�rl Phone: Address: MCedo w L4,%r- N P/yJgad- rn, Contractor Name: PV IL Phone: Address' a - - ESupevisos+Co — prk Date Home;lmprovement License:_ . :� _ Exp ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 R S.F. Total Project Cost: $ FEE: $__� b Check No.: Receipt No,_ NOTE: Persons contracting w' i unregistered contractors do not have:access to the guaranty fund Signature of_Agent/Owner Signature o of contractr J Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TypF'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 PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS ,,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 FIREDEPARTMENT- - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS t limension 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.yequires approval of Electrical Inspector Yes No ®ANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) i ❑ Notified for pickup Call Email ate Time Contact Name Doc.Building Permit Revised 2014 _. 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 Pp Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Cross Section/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 40TE: 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 V Doe:Building Permit Revised 2014 1 Location iA I-:jD0w LA No. 59 C7 - i}U1 Date • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# Building Inspector NORTH own ® Andover No. _T - _ Olt � � h ver, Mass, � 0 0 LAKG 1 COCNICNtwIC/t V �7S RATED A4p��5 \ U BOARD OF HEALTH PERMIT . Food/Kitchen T LD/� Septic System R THIS CERTIFIES THAT0 BUILDING INSPECTOR has permission to erect .......................... buildings 16...... r. , b�. ..... . ............. Foundation 0F Rough to be occupied as ..... .... M C*#* >�. .......... ®. .i ............�..............PeAw Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in 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 CONSTRUCTIO START Rough Service ........... .. ............................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. Smoke Det. cF tiORT,1ti TOWN OF NORTH ANDOVER 3? O�:f 4•,�6�o� OFFICE OF A BUILDING DEPARTMENT * > 120 Main Street North Andover,Massachusetts 01845 1SSACHus�t Donald Belanger Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION Building Permit Application Please print DATE: a S I(o T JOB LOCATION: Number //��"" Street Address Map/Lot HOMEOWNER ChaL s CSG1> off- LSS-,3 Name Home Phone Work Phone PRESENT MAILING ADDRESS I r'^ie_idbW 1AI)c W MA 61 City Town State Zip Code The current exemption for"homeowners"was extended to include owner occupied dwellings of one or two family dwellings and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. 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 dwelling,attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner. (780 CMR Section I IO.R5.1.2) The undersigned"homeowner"assumes responsibility for compliance with 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 requireyInts and that he/she will comply with said procedures and requirements. HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 9/16 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 The Commonwealth of Massaehusetts _ Department of Indus=trialAceidents M 1 Congress Sheet,suite 100 d T3ostox�,MA 02114 2017 ,c www mass.gov/die Workers, Compensation Insurance Affidavit=B�dexs/C�A a�O s��.�xcians/Piuwbexs. TO SE F - WHH TBE PERIL TIl�T Elease Paint Le 'bl A ' licant Information Name(Business/Orgarvzaiaon/Individual): �� \:�� Address: �. �Ui. m4 0)945 Phone City/State/Zip: Axe you an employer?Gle*the appropriate box: 'Type of project(required): em ( to ees full and/or parE tvne).'�` 7. ❑1�eW`donStriict1071 1,C1 I am a employer with p y 2.01 am a sole proprietor or partnership andhave no employees Working forme in 8. Ej R.emodel.ig any capacity.[Noworkers'comp.insurance required.] 9, ❑DemOMon 3. 1 aa homeowner doing all work myself[No workers'comp.insurance required] m. ' 10❑Building addition 4.F]I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11-E]Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole 4 proprietors withno enigloyees. J2. -Plumbing repaars or additions 5.F]I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 11 0 Roof repairs f/ These sub-contractors have employees andhaveworkers'comp.iosuraace.t 14�ptller 6.E]We area corporation.and its,officers have exercised their right of exemption ger MGL c. 152,§1(4),and$ve have no empldyees.[No workers'comp.insurance required] *Any applicant that chgolts bbk#1 must also fill out the section below showing then workers'compensationpoHcytnformation i Homeowners who su. ..,his a�davrt mdicaimg they are doing all work andthen hire outside contractors must submit a new affidavit indicating such (Contractors that check this tidx must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities,have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. X am an employer that is providing-workers'compensation insurance for my employees- BeZow is the policy and j o.6 site information. Insurance Company Name: ExpirationDate: Policy#or Self-ins.Lic.#:. City/State/Zip: fob Site Address: Attach a copy of the-9vorkexs' co�,.pensation policy declaration page(showing the policy number and expiratiortdate)- to$1,500.00 Pailure to secure coverage as required-wel as z�nalties in the form ofis a criminal STOP WORK ORDER punishable a fine of up to $250.00 a and/or one-yearimprisonment,as P day against the violator.A copy ofthis statement may be forwarded to the Office of Investigations of the DIA fox insurance coverage verification. X do Hereby cer under t epains andTenalties ofperjary that the information provided above is d de ail correct Date. L Si ature: Phone#: Official use only. Do not write in t121s area,to be completed by city or to-wn official. Permit/License# City or Town- issuingAuthoxity(circle one): 1.Board of Health 2.Siding Department 3.City/Tov�n Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Phone#- Contact Person: Information and 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 of hire, express or implied, oral or written." An em ployer is d'efvied 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 receivefor trustee of an individual,partnership,association or other legal entity,employing emplbyees.,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 to cal 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 prod-aced-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 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 certificates)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 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 thepermit 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 permit/license applications in any 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 stamp odor 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.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 burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of IudustrialAccidents 1 Congress Street, Suite 100 Boston,MA 02114.2017 Tel. #617-727-4900 ext.7406 or 1-877-MNSSAFE Fax# 61.7.727-7749 Revised 02-23-15 wwwmass.gov/dia