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HomeMy WebLinkAboutBuilding Permit #995-13 - 166 HIGH STREET 1/7/2013Permit NO: 4q Date Issueds- TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 'ANT: pplicant must P"RO P E R4TtY,'QW N EA MAP'NE),"-:-' pl- E L -- --NI Date Received all items on this page Machine, $hop., Village-, yes,, TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Building 0 One family El Addition $Jwo or more famil El Industrial L'qAlteration No. of units: El Commercial D Repair, replacement D Assessory Bldg El Others: El Demolition El Other J A5,pptic. ETWO-lb DIFM ' 0 W, oo& laim p d. VV- i6tshed 4' firicV: 0Q Water/8ewer, DESCRIPTION OF VVUKK I U t5t FtKI-UK[Vlr-U; 2 tq P� - f" VIM -3 r / — V -6n C) �a OWNER: Name: Hb Type or Print Clearly) Phone: 0/7f - Address: L ff---/ff- ceq(� - ---------- p� Dc H. om&lm, provement'.1d Ex ate" ARCH ITECT/ENG I NEER Phone: Address: Reg. No. FEE SCHEDULE.-BULDING PERWT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost. -_ FEE: $. D�2— — Check No.: �2-4 Receipt No.: Q -(a NOTE: Persons con cting with u7n1regis4teedd contractors do not have access to the guarantyfund ion -t— ntrkqtc a ure�q�, tractOn"..a natW� ri, Plans Submitted U Plans Waived'E] Certified Plot Plan U Stamped Plans Building Department The foHowing 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 Ei Photo Copy Of H.I.C. And/Or C.S.L. Licenses u Copy of Contract ci Floor Plan Or Proposed Interior Work u 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 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 submAted with the building application Doc: Doc.Building Perinit Revised 2012 Plans Submitted D Plans Waived 11 Certified Plot Plan El Stamped Plans TYPE -OF SEWERAGE DISPOSAL Public Sewer El Tanning/Massage/Body Art E] Swimming Pools El Well El Tobacco Sales E] Food Packaging/Sales El Private (septic tank, etc. El Permanent Dumpster on Site El THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS DATE REJECTED El DATE APPROVED CONSERVATION Reviewed on Signature COMMENTS HEi:�LTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Com Water & Sewer Connection/Signature & Date Driveway Permit DPW Towp- Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT Temp Dumpster on site yes -_no Lqc.a.ted' at'1'2'4.Mairl Str6.et Fire-1360i-tffi Og 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 N o MGL Chapter 166 Section 21 A —F and G min.$100-$1000 fine NOTES and DATA — (For department use) El Notified for pickup - Date Doc.Building Permit Revised 20 10 Locatio-j6c' Date No. I I-- Check#A?�- 26065 TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee TOTAL X�? jl�f- v Building Inspector The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (13usiness/Organization/Individual): L Address: City/State/zip:plrmdkV� W6/rlrPhone, Are you an employer? Check the appropriate box: -El I am a employer with 4. 1 am a general contractor and I employees (fall and/or part-time).* have hired the sub -contractors I am a sole proprietor or partner- listed on the attached sheet. t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. We are a corporation and its I required.] officers have exercised their LW I am a homeowner doing all work right of exemption per MGL ')nyself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. n New construction 7. Remodeling 8. Demolition 9. Building addition 10. F1 Electrical repairs or additions 11. EJ Plumbing repairs or additions 12.EJ Roof repairs 13T] Other .ny applicant that checks box# 1 must also fill out the section below showing their workers' compensation policy information. lomeowners,who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ontractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. tm an employer that isproviding workers'compensation insurancefor my employees. Below is thepolicy andjop site formation. surance Company Name: ,licy # or Self -ins. Lid. #:— - . Expiration Date: b Site Address City/State/Zip: lach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a Le 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 up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of vestigations of the DIA for insurance coverage verification. !o hereby certify under th Pains aWpenallies ofperjury that the information provided abovf is trite andcorrect. Y.nature: Date: 7 1 Official use only. Do not write in'this area, to be completed by c4 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 6. Other Contact Person: Phone ft: 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 employer is defined as "an individual, partnership, association, corporation or other legal entit�, 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 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 carry workers' compensation 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 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 permithicense 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 bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advatice 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 Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1,877-MASSAFE Fax # 617-727�7749 Gerald A. Brown * InsPector of Buildings TOMW OFNJORTH ANDOVER OFFICE OF IRMDING DEPARTMENT Oskood Street Building 20, -Suite 2-'36 Xorth Andover, Massachusetts 0 1845 Telephone (97�) 688-9545 Fa_X fO'7 4-00 110MEOWNER-LI(IENSE P XEW 'U10MG PERMIT APPLICATION heaseprin DATE:-.. J0.13 LOCA-NbN: 16f Number Street Address 'JOMEOVWR Natne. PRESENT MAILING ADDp ESS_ C 'tY To U! - 3 . rqFL. clvror Map[Lot WorkPhone zin coal, The current exemption for'ihomeo"ers,, was r to allow such horneormers to engage a- xtenaed to L'Include Owner-occlipied ,1 in , C acts as supervisor). ivjdual. d"Vol"At-s to UVO units 'Or less and for hire who cloes not Possess a provided that the, ovmer State,Duilding (Code Sect, on 1 0S.3.5. 1) DEFINITION OFROMEOWNER Persc"'(s) who _qw-us a parcel of land on which he/she resiaes or intends to reside, on which there is, be, a oneor two fanulY structures. A Person who constructs more thatone, Or is intended to con . sidered.a homeowner. home in a two-year peri6d shaH not be The undersigned "homec'wnee'assumes responsibility fOr compliances with the State Building Co Applicable codes, by-laws, rules andreguIations, de and other The undersigned "homeownee, certifies that he/sh(-, 11*nderstands the To* minimum inspection Procedures and requirem wn of North Andover Building Department requirements, ents and that he/she will comply With,said Procedures and 11OMEOWN'ERS SIGNATUPX - APPROVAL OF BUILDING Revised 7.2009 IrOn" -Homeowners Exernption BOARD . OF APPEALS 688-9541 CONISERVATION 688-9530 HEALTH 698-9540 PLANNING 688-9535 0 0 qN rA rA cl Cc 0 2,0 wo CD CA r_ (D cm r O -E 0 CL) d6: X I Ing 1 in) 4) r cc dft 0 0 .1, �s -um > (A 0 E%- 0 0 z (r.DL . 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