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HomeMy WebLinkAboutBuilding Permit #684 - 1601 SALEM STREET 5/7/2010 BUILDING PERMIT of NORTH q TOWN OF NORTH ANDOVER 02 APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: r �/ IMPORTANT: Applicant must complete all items on this page L0CAT ION,�J, _=, s f �� 57,4/E S : Print c PROPERTY OWNER Print MAP 210PARCEL: C2 ZONING DISTRICT: Historic District yes no Machine 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 epair replacement Assessory Bldg Others: emolition Other Septic . Well Floodplain Wetlands Watershed District Water/Sewer II'I q DESCRIPTION OF WORK TO BE PREFORMED: ti0'/ALJ C EdI¢I S �AG/ 4 F Identification Please T,yPeo r Print Clearly) OWNER: Name: Q I A Phone: 17 I/- iK s 8 - 3 Address: 1100 E S i CONTRACTOR -Name: Phone: Address: Supervisor's Construction License: Exp. Date: Herne 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: $ �0©� FEE: $ Check No.: (I/ (� Ur -��c� Receipt No.: NOTE: Persons contracting with unregistered con actors do not have access to the guaranty fund Signature{of^Agent/Ownery/�4 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 HLALTH 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'Os ood Street FIRE DEPARTMENT Temp Dumpster on site yes no Located at 12.4 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 2010 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 L3 Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit- Addition Or Decks o Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) u Engineering Affidavits for Engineered products j NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single e and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan a Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o 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 Revised 2008 i Location�� / T No. Date //v MaRTM TOWN OF NORTH ANDOVER Oft••'o , ,h•C V F y r Certificate of Occupancy $ CHusE`� Building/Frame Permit Fee $ —_a Foundation Permit Fee $ f Other Permit Fee $ TOTAL $ Check 25 i 60 Building Inspector µoRTM TOWN OF NORTH ANDOVER =Ot`."eO �6• 0L OFFICE OF BUILDING DEPARTMENT o ; * 1600 Osgood Street Building 20, Suite 2-36 R •,a , �9A�AATB0�PPay North Andover,Massachusetts 01845 �Ssgc►+uSE� Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE: JOB LOCATION: 16 0/ Number Street Address Map/Lot HOMEOWNER i�P IM ��[ I 'TTI -TS-3- 74/ 3 Name Home Phone Work Phone PRESENT MAILING ADDRESS 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 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 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 id procedures and requirements. HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 The Commonweizlth of Massachusetts Department of industrial Accidents Ogee of Investigations ..600 Washing ton Street Boston, AL4 0211, www•masxgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lesibly NaIl7C (Business/Organizatiou/Irtdividtral f Address: 11.61 S�/ City/State/Zip: l� /� Phone#: FV employer?Check the appropriate boa: employer with 4_ ❑ I am a o7tor TyE f project(required):eneraees(full and/or part-time).* have hired th6 New constructionama sole proprietor or partner- listed on the 7• ❑Remodeling ship and have no employees These sub-contractors have working for me in any capacity. workers' comp.insurance, g' ❑Demol [No workers' comp. insurance 5. ❑ We are a corporation and its 9. ❑Building addition equired.] officers have exercised their 10 ❑Electrical repairs or additions 3. I am a homeowner doing all work right of exemption per MGL 11. Plumbing repairs or additions myself. [No workers'comp. c. I52,§14 , ( ),and we have no 1 ❑ repairs insurance required.] t employees. [No workers' Roof r comp.ins ] I3.�] Other urance r,P quired -^S =_Thcant that check,:box,a1 must aso fill cut the .. `eCCC^_L:LC4.'S.^.C`.',^.;tg homeowners who submitthis affidavit indicating the; are dQ�e al"'wark and then hire aide contractors r.',is. +Contaattach ctors that cheer:this box must ed an additional sheet showing the name of thea sub-csubmit a new affidavit indicating such.onttactots and their workers'comp.policy information. information am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declarationsho age p s ( giving the securepolicy number and expiration date). Failure to sure 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 fine of up to$250.00 a day against the violator. Be advised that a copy of this state Investigations of the DIA for insurance coverage verification ment maybe forwarded to the Office of I do herebyacerWunder t4he pains�andpenaald�cs�ofpc > th4rr the information provided above is true and correct Sisnature: _._ DQr7 _ Phone#: n Official use only. Do not write in this area, to be completed bbl city or town offciaL Cit} or Town: PermitUcense# Issuing Authority(circle one): 1. Board of Health 2.Buildiub Department 3. City/Town Clerk 4.Electrical Inspector 5.PIumbirtd Inspector 6. Other Contact Person: Phone#: Information an- d 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 peon in the service of another under any contract of hire, 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 incluaingthe 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 maim-mance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not be cause 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 alicense 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 of public work until acceptable evidence of compliance with the mcura„ce requirements of this chapter have been presented to the contracting authority.,, Applicants Please fill out the workers' compensation afndavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractors) name(s),address(es) and phone numb er(&)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' comp ensation 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 be&tire to sign and date the affidavit. The affidavit should be returned t0 the city or tOKTi that the apuiicnu�i for the peuxu or Ine �e iS being requested,not the De:7ar-nertt of Industrial Accidents. Should you have any questions regardim g the law or if you are inquired to ob~air.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 ED 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"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 pemMits or licenses. A new affidavit must be filled out each . year.Where a homeowner 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 Investigations would like to than 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 ax_numberThe Commonweala of Massachusetts Department of Industrial Accidents Office of h estieatilons 600 WashmgtQn Street Boston, MA 0.2111 Tel. 617-72.7-4900 ext 406 or 1-8 77-MASSAFE Revised 5-26-05 Fa.), #61-7-727-7 749 VrVrV'-Ma&s._g0V/dna. VkORT Town of Andover . No. 6 0 0 y dover, Mass., 0 LA COCHICHEWICK Pa\ 0'4?ATED BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT.......... BUILDING INSPECTOR -ewbo6 has permission to .. ..................................... ...... ...................... Foundation erect........................................ buildings on../0A0­/`0*_.',�Y*..wobl-�.....441 .......I ..... Rough 4 ............ %' ok • to be occupied as..... jj JNW Chimney is ..........4.t ...................................... a g t provided that the peii'�*WZ&pioion a perm all in every respect conform to the terms of the application an 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 0 PERMITEXPIRES IN 6 MONTHS Final ELECTRICAL INSPECTOR 44P UNLESS CONSTRU N ST TS Rough .................................................................................. Service BUILDING INSPECTOR Final Occupancy Permit Required to Oca4py Building GAS INSPECTOR nal RDisplay in a Conspicuous Place on the Premises — Do Not Remove Fi 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. EE