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
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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
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Water/8ewer,
DESCRIPTION OF VVUKK I U t5t FtKI-UK[Vlr-U;
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VIM
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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
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