The URL can be used to link to this page

Home My WebLink AboutBuilding Permit #362-15 - 163 HIGH STREET 10/16/2014 NORTH BUILDING PERMIT eo TOWN OF NORTH ANDOVER �� h :,. _ _�. vL o PPLICATION FOR PLAN EXAMINATION _ E Permit No* Date Received Date Issued: I O TANT: Applicant must complete all items on this page LOCATION` S Print .PROPERTY OWNER G�iCtt" CEL Print 100 Year Structure yes no. MAP . .r _ PARCEL: _ ZONING DISTRICT.._ Historic ®istrict yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition P/Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial VRepair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: C Ubl!5& ff Lola / W chio Le .7� Identification- Please Type or Print Clearly 01/n OWNER: Name:&4e,/I& r1'e,/'I a Phone: -0 S _30 �et! Address: i? over- Contractor'Name:__ _ _ _ Phone._ Address: . _ I Supervisor's Construction License: _ _Exp. Date: Home Improvement License: nnL_J _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: $ ' C� d FEE: $ r Check No.: ReceiptNo.: NOTE: Persons co tracting with unregistered contractors do not have access to the guaranty fund LSignature of Agent/Owner _ _ ,Signature of contractor. A 4 ./Jo - 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 o Building Permit Application o Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract o 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 o Building Permit Application o Certified Surveyed Plot Plan ❑ Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o 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) D Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract. o Mass check Energy Compliance Report D 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 2014 ~1r Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE'bF 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 I PLANNING & DEVELOPMENT Reviewed On Signature_ j COMMENTS CONSERVATION Reviewed on Signature I 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 FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124,Main Street Fire Department signature/date- COMMENTS_ i i Dimension Number of Stories: Total square feet of floor area, based on Exterior' dimensions. Total land area, sq. ft.: i 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 i NOTES and DATA— (For department use) I ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 i Location 3 SC7 No. Dat (� a . - TOWN OF NORTH ANDOVERw h1,Lb Certificate of Occupancy $ a Building/Frame Permit Fee $15Q r b Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# r v � i 28141 Building Inspector I l NORTli Town of ndover O 1 to - h 90% /A A. I i AL h ver, Mass, COCHICHEWICK �.9 4404A TE O P•P�`�.(5 S V BOARD OF HEALTH Food/Kitchen Septic System t a di I THIS CERTIFIES THAT .............PERM) T ...................... ........................................... BUILDING INSPECTOR Foundation has permission to erect .......................... buildings on ..'*.3......... ..... .. ........................ Rough to be occupied as .. .... ..�..........SO... .......LN � imney provided that the person accepting this permit shall in every respect confo he ter the application Final on file in this office, and to the provisions cif the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MON HS ELECTRICAL INSPECTOR • UNLESS CONST ON ARTS Rough Service ... .... ...... ....................................................... BUILDING INSPECTOR Final GAS INSPECTOR Occupancy Permit Recruited 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. The Commonwealth of Massachusetts Department ofIndustrlglAccidents Office of Investigations 600 Washington Street Boston,MA 02111 IN www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual):, Address:—z(, City/State/Zip s /9dl cslDvr q Phone#aoe u y-6 g y_j/H _ee 11 U -77/. 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. ❑New construction employees(full and/orpart-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet. �• [v�Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its equired.] officers have exercised their 10.El 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. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]i employees.[No workers' comp.insurance required.] 13.❑Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they ace doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that checkthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. j Insurance Company Name:. Policy#or Self-ins.Lie.M Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby cert under tJie ins and penalties ofperjury that the infarmationprovided above is true andcorrec Si ature: ate: A)ZZ19 Phone#: how e 7 2�'-6V — ?/d�/ Cell �7 L 77/ 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 I, 6.Other - - - Contact Person: Phone#: i i j 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 ofhire,- express or implied,oral or written." An employeiis defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a j oint 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 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 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 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-contractor(s)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 cavy 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 the permit 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 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.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 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 number: The Commonwealth of MfassachvsPtts Department of fndustrial Accidents Qffloe ofIavestigations 600 Washington Street Boston,SIA.02111 Tel,#617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass,govOa °IIrk TQWN OFi'40R ,ggA"OV R. OFFICE OF BUMDWG-DEPARTMENT :1_600 Osgood.StreetBuilding20,.SWte2-35 �S�Rcau5��5 •North Andover,Massachusetts 01845 Gerald A.Brown TuspectorofBi ldings Tv-lep1,one(978)688-9545 . (9 HOMEO ` Fa7- 78)688-9542 �IE�Z.'LICEN�E E�:EMI'TION APPLICATION • Pleasebrinf •' - DATE: ' :JOB LOCATION: 6 Number stye Address - ' 1SOMEoWNER� 1VZap_-ot � .. Name. 1lome Pkone Work P one PIESENT MWiNa ADDPBsl 3 G Ca ty Tovm. , 8L-tc- p Co a ,�o The current exemption for"homeowrzexs"was extended to?nch1de Ow -occupied dwalifi gs to i�vo tmifs ox;es,and to allow su6b homee,vers to engage an in cavi dual.for hire,w.ho do es notposmss a license,provided ulli the owner acts as supervisor). State,3uilding (Code Section 108.3.5.7) that DEEM ITION Oy'RO MEOWNE I?erson(s)who pas aparcel oflan on which he/she resides or iutends to reside,ou Which there' ' bb,a one or two family structures. Apersonwho constructs more that one home in afwa yearperiod sball n f be to Pansidered a Homeowner, The undersigned`°Izonteowner"assumesresponsibilityforcbmpliances ilin Applicable codes,by-laws,rules andxegulations, witlzthe StateBudg Code and other • The nndexsigned"homeownez"cert, that +,;n;,�,uzn inspection procedures and reb elshe understands the Town of North AndoverBuildin Deparfinent quirements requirements, and thaf he/she will comply withtsaid procedures and HOAMOWI$lt8 SIGNATIJItE ' 4 - , ATT.R.OVAL OF BUMDING OFFICIAL Revised 7.2009 �'ozm$omeowners�ixemption - . •13OARD OFAPP,EAM 688-954Ir r r;: COITSER�4 AMN 688-9530 PEALTH 688-954o PLA NNING 688-9531