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Home My WebLink AboutBuilding Permit #747-14 - 16 SAUNDERS STREET 4/24/2014 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit. Date Received Date Issued: /IMPORTANT: Applicant must complete all items on this page LOCATION 1A I.� � S 5 i 11� AJ910 VF J Print. _ PROPERTY OWNER N V JCUy rel'19Y'Vl c �-- Print 100 Year 01d Structure es no MAP NOD- m�PARCEE,e_ZONING DISTRICT: Historic District yes no Machine Shop Village yes no .TYPE OF IMPROVEMENT. PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition 'KTwo or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial A Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: J AT tj Al ( )/gj Phone: �j I Address: P 2 Al- 0 CONTRACTOR Name: Phone: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: _ Exp. Date:- ARCH ITECT/ENG I NEER ate: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: $ 3 sq 0 FEE: $ Check No.: Receipt No.: � NOTE: Persons contracts g with unr istered contractors do not have access to the gu ranty fund Signature of Agent/Owne Sig nature of contractor Plans Submitted E Plans Waive ertified Plot Plan ❑ Stamped Plans ❑ _ Plans Submitted ❑ Plans-Waived ❑.. Certified Plot Plan ❑ Stamped Plans F1 TI'PE-OF:;SE WERAGE-DISP_O,SAL Public Sewer ❑ Tanning/MassageBodyArt ❑_ Swimming Pools ❑ Well ❑_ Tobacco-Sales ElFood Packaging/Sales ❑ P-rivate(septic tank,ete�_ -❑.. ;- -permanent Diunpster on Site - THE..:FOLLOWING SECTIONS FOR-OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF-- U FORM .-:.--DATE REJECTED DATE:APPR=OVED PLANNING & DEVELOPMENT ❑ COMMENTS -CONSERVATION Reviewed on Sidnature 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 Tovv;! Engineer: Signature: _ Located 384 Osgood Street FIRE-OEPARTM,ENT ,Temp Dumpster on site yes no Located-at 124 Mair, Street --Fire Departinerit 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, rust-or service drop requires approval of Electrical Inspector Yes No DANGERZONE LITERATURE: -Yes No MGL.Chapter 166.Section 21A-F and G min.$100=$1000.fine NOTES and DATA— (For department use EJ Notified for pickup - Date Doe.Building Permit Revised 2010 Building Department r -`rhe fohowing is"a=list of the required:forms to be filled outfor the appropriate-permit to.be obtained. Roofh,g, Siding, Interior Rehabilitation Permits D B,ailding Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/OC.S:L: Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work o 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) 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) ❑ 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 cascs if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apu;,al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.?ted with the building application Doc: Doc.Buhding Permit Revised 2012 Location No. Date t • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# Building Inspector y The Commonwealth of Massachusetts Department of 1"ndustriglAceidle is Office oflnvestigations 600 Washington Street Boston,MA 02111 -www.mass gov1d1a Workexrs'Compensation Ynsurance Affidavit:Bufftiers/Cont°actors/Elect rxclanslPZumbers AnAlicanf Information Please Print Legibly Name(Business/Organi'zation/Uid%vzduat): low 1�7-�([ _4) T_}�Jt�17'►�1 Address: 14 S&apell57: City/State/Zip: IV N o(10L( 1�jd Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with. 4. ❑I am a general contractor and I 6. 0 New cOnstruction employees(full and/or part-time).* have nedthe sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet.t 7• ❑Remodeling ship and'have no.employees These sub-contractors have S. ❑Demolition working for me in any capacity. workers'comp.insurance. g, Building addition Wo workers' comp.Insurance 5. ❑ We are a corpora�on and its 10.[1 Electrical repairs or additions required.] officers have exercised.their p ri ht of exemption per MGL 11.[]Plumbing.repairs or additions 3.�$[X am a homeowner doing all work g p myself.[No workers'comp. c.152,§1(4),and wehaveno 12:WRoofrepairs insura-acerequired.]i employees.(No workers' 13.❑Other comp.insurance required.] May applicant that checks box#1 must also fill out the section below showing their Workers?compensation policy information. Homeowners who submitihis affidavit indicatingthey Aire doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that checkthis box must attached as additional sheet showingthe 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 the policy andjoh site information. Insurance Company Name% Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City%State/Zip: Attach,a copy of the workers'compensatlowpoffcy declaration page(showing the policy number and expiration date). Failure to secure coverage.as reguiredunder Section 25A ofMGL o.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisopmment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of- Investigations fInvestigations of the DIA for insurance coverage verification. X do Hereby cert&under the pains and penalties q?fperjug that the information provided above is true and correct. - Si 4 Date: c7ld Phone#• Oficial 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.EIectrical Inspector 5.Plumbing Inspector 6.Other - - - IContact Person: Phone#: Information and Instruction. s . 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 orimpH4 oral orwxittem,' 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 ox trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having notmore 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 fox any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required." Additionally,MGI,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 necegsary,supply sub-contractor(s)name(s),addresses)aadphonenumber(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 fox confirmation of insurance coverage. Also be sure to sign and date the affidavit. 11a affidavit should be returned to the city or town that the application for the parmit 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 thatthe affidavit is complete andprinted 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/Rcense number which will be used as a reference number. In addition,an applicant thatmust submitmultiple 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)".Acopy of the affidavit that has b een officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on Erle for future permits or licenses. .A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license ox permit not related to any business or commercial venture (i.e.a dog license orliermit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations wouldMo to thank you in advance fox your cooperation and shquld you have any ciuestlons, please do not hesitate to give us a call. The Department's address,telephone aitd fax number: The Co moawa&hofM.asSachv.: Ptf - Dopa put of JhJuMal E cc dcnl Office offAvestigatio= 6QG Wasbi:qg m Sfxeet Boston.,MA0211 . TOL 6IM-21.7,4.900 eA406 or 1-577.:- SS _ Revised 5-26-05 Fax#617-727-7749 Www.Mm%&Qvfctia NORTH Town of "' Andover O .yr. No. * t - �o h Y ver, Mass, coc.41c«[w1c" 1. RATED U BOARD OF HEALTH Food/Kitchen PERMIT T Septic System THIS CERTIFIES THAT ......... �l�!1.�..... .. .�.... .S. �, BUILDING INSPECTOR ,0 ................. ........... ... � ............ Foundation has permission to erect ......... ........... buildings on J.&.........�o .. !�......t.... . .!ceptin :. .�. ./�.A. Rough to be occupied as .-........ .. .... ....... ..................................... Chimney provided that the person his permit shall in every respect con m 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 CONSTRUCTIORT Rough Service ..................t.. ...... ..................................... BUILDING INSPECTOR.. Final GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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. TO"OFNORM AND OVER. • ` °� OFRCE OF DsgOod Street Building 20,•Suite 2-36 �S�scuus��5 No thAudover,Massachusetts 01845 - Gerald A.Brown - Telephone(978)688-945 Inspector oP$uliildings Fax (978)689-9542 HQMEOWNBR LICENSE En &TION BTI�Il�1 G PR)M. T A'BLZCAUoN ' please�rint . DATE: T JOB LOCATION: I Number StreetAddress Map/Lot IMnDWNER Name• . Homo Phone ' Work Phone -PRESENT MAU WG ADDRESS r�?S ill( V'-7 ✓�l } f lip Cod; The current exemption for"•homeowners"was extended to iMILI e owner-occupied dwellings to i�vo unify ox less and as as S Silbh hO�eOy;rerS to engage an individual•forhire-who does notpossess a license,provided that the owner acts as suparvisor). S-iateBuildiag (Code Section.71)8.3.5.7) DBFINITION OFHOMBOWNBR. POMOn(S)who Qwns aparcel ofland on which he/she resides or intends to reside,on wbiclz there is,or is intended to , be,s one or two feown structures. A person who constructs more that Rue home in.a twoyearperiod shall not be considered a hameownez. The lmdersigned"homeowner"assumes responsibility for compliances wifh the State Building Code and other Applicable codes,by-laws,rules and regulations, The•undersigned"homeowne?certifies that he/she&dergtands the Town Of North AndoverBuilding Department rniniraum inspection procedures and requirements and that lie/she will comply with,said procedures and requirements, , HOMfiOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeovmers Exempfion . 'EOAR.D OF APPEALS 688-9541 CONSERVATION 688-9530r HEALTH 688-9540 PLANNING 688-9535