HomeMy WebLinkAboutBuilding Permit #717 - 171 PLEASANT STREET 6/22/2009BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: -7 / 'J Date Received
Date Issued: 6,7,7, --of
IMPORTANT: Applicant must complete all items on this pate
LOCATION
Print '
PROPERTY OWNERS �C LS C L�
MAP NO-)
` Print
PARCEL- ZONING DISTRICT: Historic District yes no
Machine Shop Villaae ves no
-. �--07A
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 Well
Floodplain Wetlands
Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
Ct-AOV- �� �GA� LS P�a-,U C-
D
D 12 y w L N
Identification Please Type or Print Clearly) \ t
OW R: Name: 13-0 V c c- (Z L_S z- / . Phone: 6
Address:
CONTRACTOR Name: ( Phone: ' ..
Address:
Supervisor's Construction 'License: Exp. Date:
Home improvement License:
. Date:
ARCHITECT/ENGINEER (—) r P 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: $ O c FEE: $
Check No.: IMP— Receipt No.: Lg
NOTE: Persons contracting with registered contractors do not have access to the guaranty fund
Signature of Agent/Own ignature 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
COMMENTS
HEALTH
MMENTS
Reviewed on Signature
Reviewed on Signature
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:
FIRE DEPARTMENT Temp Dumpster on site yes
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Located 384
no,
Street
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
NU I 17-5 and DATA — (For department use
❑ Notified for pickup - Date
Doc.Building Permit Revised 2008
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
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ 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.L.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 submitted with the building application
Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2008
Location
No. 41'+ Date
MORT�y TOWN OF NORTH ANDOVER
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Certificate of Occupancy $
s„CH <� Building/Frame Permit Fee $ a _.
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
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The Commorirvealth ofMassachusetts
j - i
Department of Industrial Accidents
Office of Investigations
�'IIi
600 Nrashington Street
tiff
Boston, MA 02111
Z�
Worker$' Compenssfion Inskrance
A Benet Inform
www_masssgov/dia .
Affidavit: Builders/ContractorsMectriciaas/Pinmbers
tion
Please Print LeAiibl
7
Name (Business o gmization/individual);
r
(�
Address: % 7
n
CitylSta%/Zig:_/�_��i
one
employer? Cheek.the appropriate bo z:
�Y�
employer with
70�1
4. ❑ Ix:a general contractor and I Type °f Pel (required):
ees (full and/or part-time).*
ole proprietor err
have hired the sub -con Tactors 6' ❑New construction .
listed
partner-
sip and have no employees'
ori the attached sheet ? 7• ❑Remodeling
These suii-corrft=rs have g ❑ Demolition
working for me in
. g arty opacity.
o workers comp. insurance
' P
workers' comp. insurance.
5. 9• ❑ Bw7ding addition
❑ We are a corporation and its
required.)
3.. I aiu a homeowner doing all work
officers have exercised their 1 Q-❑ Electrical repairs or additions
right of exemption per MOL 1 I.❑ Plumbing repairs
myseIt (No•workim' comp.
insurance required.] .t
or additions
q 152, § 1(4), andwe have no
em to ees. 12.❑ Roof repairs
P Y [No workors'
comp. insuranecrequired_] 13 Other
*limy applicant that dmcks boat # l mast also fill our the section below showing their workers' aompeiesetion policy information
t Fioeneownt th who submit this vit i they ars doing
mustffffid
hgd=ting an work and than has outside conuactots must submtt a new affidavit indite such
�Conttarrfnrs that check thin box mttsrritPchx ser additioasl sharshaw' .
tg the mffm of tie- sub-coammlom and their worksrs'
car_ pclicJ ir{omeatioU.C
I ars° OR employer fiat is proving workers' c wensation insurance or
information. / f �' eniP�J'ees: Below fS the poffcy amd job site .
Insurance Company Name
Policy # or Self -ins. Lic. #:
Expiration Bate:
Job Site Address:
Attach a copy of the workers' city/starzip:
compensation policy declaration page (showing the
policy number and expiration date} .
Failure to secire coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal pena}ties of a
to $25
fine up to $1.SOQ,DO and/or one-year imprisonment; as well
as
civil penalties in the form of a STOP WORK ORDER and a fine
In 0.00of a day against the violator.Be advised that a copy of this statement may be forwarded to the Office of
invea stigations tine DIA for insurance coverage venin"cation.
I do hereby certify under the pains and penaltfet of perjrcry thra the fnformatfon provided above
is tritereorrPet
Si r�ratrrre:
Of ,1oial «se onfy. Do not write in this area, m be conrleted b town
y '
or ial
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Fiesith
6.Othe'r 2 - Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
Contact Person
Phone #:
Information a. nd Instructions
Massachusetts General Laws chapter 152 requires all emp Ioyers 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, mc:)diation, corporation or other legal entity, 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 ortrrrstee of an individual, partnership, associatio-n 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 an 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 Geensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or *o construct building in the commonwealth for any
applicant who has not produced acceptable evidence.of compliance with the insurance coverage required."
Additionally, MOL 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 compliancx with the ineure
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' .compensation• affidavit compbmtely, by checking the boxes that apply to your situation and, if
necessary, supply sub -contractors) name(s), address(es): En d phone number(s) along with their certificate(s) of
insusance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members orpartners, are not required to carry workers' coornpensation 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
Acciderits 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, notthe 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 nu nber listed below, Self insured companies should enter their
self insurance'Iieense number on the'appropiiate tine.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. lire Department hes 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-currern
policyinformation (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 marred by the city or town may be provided to the
applicant as proof that a valid afidavit 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 persorz is NOT. required to complete this affidavit
The Office of InvestiWions 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 Massachusetts
Department of imidustriai Aacidents
Off ce of Investtiatiotns
600 Wa&ington Street
Boston, IIIA 02111
TeL # 617-7274900 ext 406 or 1-9-77-MASSAFE
Fax # 617-727-7744
Revised 5 -21i -QS www.mass_gov/dia