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Home My WebLink AboutBuilding Permit #064-15 - 171 APPLETON STREET 7/21/2014 NORTF� BUILDING PERMIT of t,ED it, TOWN OF NORTH ANDOVER 02 °off APPLICATION FOR PLAN EXAMINATION '' * _ a � Ago . , . Permit No#: _ Date Received OgAr. PPyq`� �9SS/1CHUS�t Date Issued: --� A—/I O TANT:Applicant must complete all items on this page LOCATI Print PROPERTYOWNEF�k Print 10o Year Structure yes MAR PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes o TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic Q Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name:_ ��,� k) cis q0. Phone: 17� Address: �"� 7 ��oe,\-o\n S� Contractor Name:,__ _ _ Phone:_ Address- _ Supervisor's Construction License: _ Exp. Date Home Improvement License:-,- .--., ,- _ __ _ __ _ . . _ Exp. Date: ARCHITECT/ENGINEER Phone.---- Address: hone: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: $ FEE: $ z�� Check No.: Receipt NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor Location n- s.1 ••-w —2 No. 0(6 Date �T 1 . - TOWN OF NORTH ANDOVER . CD4 e Certificate of Occupancy $ �- Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $' TOTAL $ Check# 27792 Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TY_P_E O.F SEWERA.GE DISP_OSAL— 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 PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS u 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 signaturefdate 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-$1000 fine NOTES and DATA—(For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doe.Building Permit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits o Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks a Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses a Workers Comp Affidavit Li Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doe:Building Permit Revised 2014 Tke Commomalth o,f'Hosa0uset$s ~ Depa�€mer�tofltclu� ic�l Acczclet Qfflce oflnvexstigatIORS 600 Washwgtofi,Street Roston,HA 02111 www.`1ass govlcliu Wpnkexs'Compensation bsurance Affidavit:BilffdersfCon.tractor$AlecirlcxansiThiri�be�,� Anplteant]b ranafton Please.Prim Le itlbzv 'Name(3us1ness1orgadzation&dz`v!duaD: vi 5 e\ - Address: M J--'4 Q R\'�6 0v-' S� Ci.iyowe/dip: T�,��`�r•✓`� �`�� Phone#: �� a�G �� (� • . Axe you an.employer?c&ekthe appropriatebox: Type of project(required): 1.Q I am a employer with__-____. 4. [1 1 am a general contractor and 1 6. [1 New construction. employees(fan andira part time)* have rilredthe sub-contractors 2.LlI am.a sole proprietor or pa taar listed on the attached sheet;� 7• L]Remodeling ship and`have na.employees These sub-contractors have S. ElDemolition. working forme in any capacity. workers'comp.insurance. 9, Building addition PTO workers'comp.insurance S. ❑We aro a corporation audlts 10 ]Blectricalxepairs or additions officers have exercised their 3.�1 X am a b omeovrner doing all Work rj t of exemption perMCTL 11f]1'lumbingxepairs or additions 12.Pmyself[I�o workers'comp. c.152,§l(e)a andwehaveno 12, Roofxe�airs insurancere tired. employees.[No workers' 1311 Otlier comp.insurance required.] :Any applicautthat checks box#S mustatso i?It ouithesection beldwshowingtbeirworkere compensation policy information. Homeownerswho submiithis affiidavitindicatingtliey gra doing aLlworkanflt5enbire outside contractors mustsubm ti anew affidayitindicafing sucI xCostracfors that checkthis bo must attached an additional sheet showingf e,name o£the sub-contractors andtheirworkers'comp,policy information. arm are einployet•treat is providixg wo��texs'coynperzsatian insr�rarzee for ray eivroyees Below i 9a voliey wed joh site ir2fp:�matior�. . Tnsuxanc0 Company Name% policy#or Self-ins.Va.#: Expixatiort Data:-.. Job Site Address: CitylStatel7ip: .A.ttach a copy oftheworkers'coxnpeneaika polley declaration page(showing-the policy mmber and expiration.date). Failure to secures coverage as xequixedimder Section25A.ofMOL o.152 can lead to the imposition of crbinalpenalties of a fine up to$1,500.00 and/017 one-year Nprisozment,as welt as clvilpenalties in the form of a STOP-WORK ORDER and a tine ofup to$250.00 a day against the:vio oto B,advised that a copy ofthis statem ent may be forwarded to the Office of 7nyestigations of;the DlA.fox insurance coverage verification. it do Hereby cert uride�trie�iairas fwd v allies of pe�jury treat flte it2 0imati0n pPOVictec�ai`iOYe zr1true and COrxeC - Si afore• Data: Phone 9 t Oficial use anly. .Do not write in tresis area,to he coNVIeted by city or tow671011 City or Town: Perminicense# fssuizagAtnthority(circle ORO: 1.Board of Health 17.Building)jepartntend 3.CilylxownClerk 4.Electrical Inspector S.]PlttrgbingJ[ttspector F.Other Information and Instructions Massachusetts General Laws chapter 152 requires alt employers to provide workers'compensation,fox their ernployees, Pnrsuamitto this statute,amu e>��layeeis defiuedas",..evexypersoniri the service o£anotherundexany coritxact ohixe, express orkap]1 d,oral o-mitten." An wTfoy_e�is deim ed as"an individual,partnership,assoclafloxt,coxporaUOu or otherlegal entity,or anytwo oxxnoxe ofthe oxegoingengaged inajoinieuteglise,andincludingthelegalxepresenfativesofadecoasedemployex,.orthe xedeiver or ttzisfee ofm individual,partnership,ass owf ou or other legal enfity,employing employees. Mwevex the owner of a dwelling househavingnotmoxe thantbree apartments audwhoxesidosthcrolnoxthe occupant ofthe dwelling house of axtnther who employs persons to do maintenance,construction orropair work on such dwelling house ox onthe grounds oxbuilding appurtenantthereto shallnot because of such employmentbe deemedto be an employer." MGL chapter 152,§25C(6)also states that"every state or Ideal ycensing agency sTiau withhold the issuance ox renewal of a license or permit to operate a business or to construct buildings in the Commonwealth for•any applicant who has not pro duced.aceeptable evidence of compliance with the iusuxauce coverage required." Additionally,MCL chapter 152,§25C(7)states'Naitherthe commonwealfhnor any of political subdivisions shall enter Into arty contract for theperformance ofpnblicwo&until acceptable evidence of compliance WMthe insurance requirements offfiis chapterhave beenpresentodta the cQatractiug authority," Applicants Please fill out;the workers'compens4on affidavit completely,by checking the boxes that apply to your situation and,ii necessary,supply sub-contractor(s)name(s),addresses)andphonenumber(s)alongwith their cerUcate(s)of insurance• Limited Liability Companies(LLC)orLimNdl iabjlityPartnerships(LTX)V&hno employees otfierthamrthe members orparhrers,arenotrequiredto canyworkers'compensation iusurance. IsranLLC orLLP deeshave employees,a policy is required. Be advisedfhatfbis affidavit may be submittedto the Department of 7ndmtdal Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit 'he affidavit should be xetumddtc the city ar townthatthe applicationforthepermit or licensees beingrequdted,-tot theDebartment of 7ndustdal Accidents. Sheuldyou:have any questions regarding the law orifi you are xepted to obtain•avroxkers' compensationpol4cy,please call the Departmentattlieuumber listed below. Self insured companies should cute rfheir self-e HUMCe license number on she appropriate lino. City or Town OfEcials Please be sure that the afirdavit is complete andpxi ated legibly. The Department fres provided a space at the bottom, oftheaffidavit for you to aoutintTieevent&eOfIffceofTnvestlgafionsbastocontactyouregardingtlteapplicaut: Please be-sure to fill in the permit/jicense number wllieb.will be used as a reference number, Tit addition,an,applicant thatmnust submit-Multiple pemmit/liceme applications is any given year,need only submit one affidavit indicating current policy information(ifnecessary)and under"J'ob Site Address"fire applicant shouldwrite"all locations:h (cety or tom').".A:copy O&o Mae&that has been officially stainped or marked by the city or town may be provided to time applicant asProof`$atavalidafdavit.rearfilefoxiufuxepemmifsorlicemyses, Anew az�davitmustbe�lledouteach year.VJltere"home owner or citizen is obtaining allcense oxpennitnotrelatedto auybusiness or commercial venture (i.e.a dog license crpermit to burn leaves etc.)said person is NOTxequimd to complete this affidavit. The Office of Tnvost gatlons would Me to thank you in advance for your cooperation and shouldyomx have any questions, please do not hesitate to give us a call. The Depaxtmeat's address,telephone atA fax numb er: no QMM011wadth Of U-Machme"tfI DtrpaftegttdulaXccxc� tse • t�f�ce o�Tn,�e�ti�a�a..��. 6Q0 WaWn Revised 5-26-OS Fax#617-727-7749 wvzaa�,s,gQ��dia TOWN OF i'MRMU ANDOV:E+R. ' BUMDNG DEPARTMENT • ' Q � . sgood Street$wilding 20, 76000 Suite 2-36 7�s�RN 5 �5 NozfhAndover,Massachusetts 01845 Gerald A.Brown Telephone(978)6$8-9545 Inspector oi:Buildings - Fax (978)688-952 80100MR•LICENSE tnE& IOI�I B�TID►BrtG PFPMT•YPPLICATZON please print DATE: -11 LOCATION: Number SkeetAddress Nlap/I,ot �TONMOWNERAv �a��s 2-70 Y 70- Name Home Phone Work Rhone 'RESENT MAHiNG ADDRESS ' �3tw• zip Nje The current exemption for"•homeowners"was extended to ed to allow suite 120MM MQ S to engage an i,idzvadual-for hire tiynoi does satposseI a 71c1v'lli,p0 to provided units that the owner d arts as supezvisor). Sfafe3uilding (Code Section DEER Yff ION OFHONIBOWNER PaTsOn(S)who gwns aparcel ofland on which he/she resides or intends to reside,on which there is,or is intended to bb,a one or two family stzuctures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned"homedwner"assumes responsibility f0roompliances with the State Building Code and other Applicable codes,by laws,rules andzegalations, c The undersigned"homeowner"cezfihes that helshe,understands the Town ofNorth Andover Building Delartmant minimum inspection Procedures and requirements and that hefshe will comply with,said procedures and requirements, HONMOWNBRS SIGNAMB .APPROVAL OF BUILD)NG OFFICTAL Revised 7.2009 Form Homeowners Exemption . 130ARD OF APPEALS 688-9541 CONSERVAT70N 688-9530 HEALTff 688-9540 PL.AWNG 689-9595 NORTi Town o2Andover O •�1• �'Y No. 4z oh ver, Mass, o� COC NICNl W.CN �q. rep PIV S V BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System THIS CERTIFIES THAT ....... .. BUILDING INSPECTOR has permission to erect .......................... buildings on ......� 1..... Opne -ixi ... e ............... Foundation �. 1 ' / � /�,- ,f� Rough to be occupied as ....� ...........X.� ...........WARL Y.`'Y?:'....... .............................................. Chimney provided that the person accepting this mit shall in every respect conform 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCT I ST RTS Rough Service ............. . ....... ........ .................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required 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. � �.1pRT11 Town of No. � 1 h ver, Mass, o� A- C OC NICMl C. S V, BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ........ V BUILDING INSPECTOR has permission to erect ... buildings on ............... Foundation Rough to be occupied as ....I.4J............1(.� .............} !.�! .I�P�.Q.K. z.......r.............................................. Chimney provided that the person accepting this mit shall in every respect conform 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 CONSTRUCT I ST RTS Rough Service ............. . ....... ........ .................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Fina' No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det.