HomeMy WebLinkAboutBuilding Permit #736 - 18 UNION STREET 6/25/2009BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued: _ O
IM ORTANT: Applicant must complete all items on this pate
LOCATION IF Z6V-,
,r Print
PROPERTY OWNER ,I,¢1 /l tC lc r-' G,.� ,,6C
Print
MAP NO: PARCEL: ZONING DISTRICT: Historic District yes
Machine Shop Villaqe yes
6 n,
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
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
9e 5-1j 6:; -La a S L
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
Identification
OWNER: Name:1ck-
Type or Print Clearly)
—s 9— vv/, -,F
Address: S- 4.. S?:;
"est 4c AC 644- E
CONTRACTOR Name: Phone: j dgF-Safi -
Address:r6_ .5-7— 1l%
Supervisor's Construction License: 006.P 5-V Exp. Date: 643,6ao
Home Improvement License: Exp. Date: 1 oho 0
ARCHITECT/ENGINEER A/ Phone:
Address: Reg. No
FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BA$, VON $125.00 PER S.F.
Total Project Cost: $ �. S-0 0 FEE: $
Check No.: 31 Z Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
5ignature of Agent/Owner Signature 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
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
DATE REJECTED DATE APPROVED
Reviewed on Signature
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 Con nection/Siqnature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes }c no
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Dimension
Number of Stories:
Total land area, sq. ft.:
Total square feet of floor area, based on Exterior dimensions.
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
No
NOTES 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.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 submitted with the building application
Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2008
Location 1�s-
No. _ Date
NORTH TOWN OF NORTH ANDOVER
9
Certificate of Occupancy $
��b'•^°''<� Building/Frame Permit Fee $ 1!
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # -312,
22,bB
U Building Inspector
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The Common wealth ofMassachusetts
Department of industrial Accidents
Office of Investigations
600 IYashington Street
Boston, MA 02111
? lVWw-massgov/dia
Alicant nformation .
Workers' Compensation Insurance Affidavit~ Builders/Contractors/Eieatriciansipiambers
I
% > Please Print Le-'
Name (BusineKrJrmmn;"+;.. A-.1:....1- .. 'T ✓ ani• / / e-
Address:
City,
/P7 rin
Phone
Areyou as employer? Check the appropriate box:
I. ❑ I am a employer with
4. ❑ 1 am a general contractor and I
employees (full and/or part-time).*
2. ❑ I am.a.sole proprietor or
have Dred the sub -contractors
listed
partner-
ship and have no employees
on the attached sheet =
These sub -contractors have
working for me in any opacity.
[No workers' comp, insurance
workers' comp. insurance.
5. ❑ We are a corporation and its
required.]
officers have exercised their
3 I am a homeowner doing all work
right of exemption per MGL
myself [No•warkin' comp.
Q 152, § 1(4),'and we have no
insurance -required.].t
..employees. [No workers'
COMP. insurance required.]
Type of Project (required):
6. Dlew construction
7. Remodeling
g• ❑ Demolition
9. 0 Building addition
10.0 Electrical repairs or additions
11 -11 Plumbing repairs or additions
12.❑ Roof repairs
13.❑.Other
'�+ay ap wheint that checks bo>s a l moat also filco out the section below showing their workers' bompensatitm pollcy mformatim
t Homeowners who sriberit this afildavit indicating they am doing all work and tF:mi hire outside corturretors mast
�Cont+acters that cheat( this box must an adriitiowl sheet shoving. the name of fire suis- submit a nciv affidavit indicattiag suet(
cotmactors and their workers' rs corp i:—•
I ata an empu►yer t&at ro s r F^ , m£ornsaion
{� , vrdatg worlrers Clampeffsadan insurance for m1' employees: Below is the
inforniatinn, policy mid job site .
Insurance Company Name: '
Policy # or Self -ins. Lie. #:
Expiration Date:
Job Site Address:
CityistaL- Zip:
Attach a copy of the workers' compeosatioa poiticy cleciarattion page (showing the policy number and expiration dale), .
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal
fine up to $1,500,00 and/or one-year imprisonment; as well as civil penalties in the form imposition
Of a STOP WORK ORD
a mfl a foe
t
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
lnvestigations of the DIA for insurance coverage verification.
I dohereby certify ander the andpenaides ofperjWy rhar` the information provided above is true and correct
St tue:.
�- � 9- � _ Date: � � � S -- �
— 40/,
Offlcial ase only. Do not write in this area, M be completed by, or town officio[
City or Town:
Permit/License #
Issuing Authority (circle one):
L6.
oard of Health 2. Building Department 3. City/Tawn Clerk 4. Electrical Inspector S. Pinmbiog Inspector
thertact Person•
Phone #:
Fol
Information and 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, assodiation, corporation or other legal entity, or any two or more
of the'famping engaged in a joint enterprise, and includir-ig the legal representatives of a d6cxased employer, or the
receiver ortrnstm-of an individual, partnership, association or other legal amity, employing employees. 'However the
owner of a dwelling house having not more than th= apa.rtmerrts 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 gmunds or building appurtenant thereto shall not because of sucb employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local iiceusing agency shall withhold the issuance or
renewal of license or permit to operate a business or ito construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence.otr compliance with the insurance coverage required."
Additionally, MOL chapter 152, §25C(7) stones `Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until- acceptable evid== of compliI with the insurance
requirements of this chapter have bean presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit eomple✓tely, by checking the boxes that apply to your situation and, if
necessary, supply sub -contractors) name(s), address(es): and phone number(s) along with their certificates) of
insusamce. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required, to cavy workers' m rnpmsation insurance. Ifan 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 b- sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit .ar 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`
ooMpemtion policy, please call the Department at the number. listed below, Self-insured companies should enter their
salt-insurance'license number on the'appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department his 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 appli-cut.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, anappiicant
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 iocaiions in (city or
town)." A copy of -the affidavit that has been .officiR ly 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. When 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 advance for your cooperation and should you have any questions,
piease do not hesitate to give us a call.
The Depmtment's address, telephone and fax number.
The Commonwealth of Massachusetts
Department of Lindustrial Accidents
Office of InvestiiatEiiotns
600 Washington Street
Boston, Iv1A 02111
TeL # 617-7274900 ext 406 or I-877-MASSAFE
Fax # 617-727-7744
Revised 5 -26 -QS wwwmass.gov/dia v,
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