HomeMy WebLinkAboutBuilding Permit #968-15 - 184 CARLTON LANE 5/27/2015 BUILDING PERMIT of 14ORT11
TOWN OF NORTH ANDOVER N4,
TOWN
APPLICATION FOR PLAN EXAMINATIO
Permit No#• Date Received
°R1reo
�SSACHUsti�
Date Issued:
-Eti It I
ORTANT:Applicant must complete all items on this page
LOCATION A
rint
PROPERTY OWNER A ,
Print 100 Year Structure yes no .
MAP PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes. no
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
g =ept c e V\le I _ _ `-13 Flo®tlp e e`i'st c- => �.
�c ate,/.Sewer ��k
DESCRIPTION OF WORK TO BE PERFORMED:
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I enti icati Please Type or Print Clearly
OWNER: Name: t Phone: �4000P
Address:
Contractor Name: Phone: j
Email: _—
Address:
Supervisor's Construction License: Exp.. Date:
Nome Improvement License: Exp. Date:
ARCHITECT/ENGINEER Phone:
i
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
Total Project Cost: $_ qt 060 FEE: $
Check No.: Receipt No.: dZ5
NOTE: Persons contracting with unregiste ed contractors do not have access to the guaranty fund
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Location 189�4(-1 �� ;
No. '�
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. - TOWN OF NORTH.ANDOVER
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Certificate of Occupancy $
{ Building/Frame Permit Fee $At �, . . . .I .1
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Foundation Permit Fee $
11 Other Permit Fee $
TOTAL $ i
- Check#{2 .
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Building Inspector
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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 m U FORM
P
PLANNING DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on < /1 �� Signature _ .✓
COMMENTS
HEALTH Reviewed on �Si naturl
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OMMENTSav
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Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes
PIa�ining Board Decision: Comments --
Conservation Decision: Comments
Water& Sewer Connedlon/S�nature� IDate Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
F LL*7.:2rY t'.' -S}
gilt
FIRE ,DEPAON"ln"!Z
NT - Ternp DumpYsfe��on;site yes
+Located at 1'2treet
Fire Department sign ur%a et :74.
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,� e �.�.�3�..'��is"c►£Yx.,.3�`�.et'i=..t'�y;3�- r •:�fi.�;ka:��.:.`t,.�c' •Rf:
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 lies No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$10041000 fine
NOTES and DATA-- (For department use)
1
Notified for pickup Call Email
3 e
Date Time Contact Name 3
Doc.Buildiug 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
Building Permit Application
Workers Comp Affidavit
Photo Copy Of H.I.C. And/Or C.S.L. Licenses
� Copy of Contract
t. Floor Plan Or Proposed Interior Work
a.. Engineering Affidavits for Engineered products
OTE: 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/Cross Section/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
OTE: 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
46 2012 IECC Energy code
Engineering Affidavits for Engineered products
OTE: 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:Building Permit Revised 2014
F NORTH
Town of T E ., Andover
O - �., to
No.
,� oh ver, Mass, P,
COCNIC Nl W�CN ���
S U
BOARD OF HEALTH
PERMIT T LD Food/Kitchen
Septic System
THIS CERTIFIES THAT .........., BUILDING INSPECTOR
. . .. . . . . .. .. .... . .
has permission to erect buildings on ......... . �CA4— . ,,,,,,, fir, Foundation
Rough
to be occupied as ..1U....xlie........... .. .......... ........ .. ..................... chimney
provided that the person accepting this permit shall in every respect conf rm 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
Q�D�• UNLESS CONSTRUCT T S Rough
Service
............ . .. ...... ..... ................................ Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Buildinz 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.
North Andover MIMAP May 26, 2015
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—SR Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83,
Roads Meters Data Sources:The data for this map was produced by Merrimack
Easements t NORTH 7 Valley Planning Commission(MVPC)using data provided by the Town of
North Andover.Additional data provided by the Executive Office of
MVPC Boundary = �e �s oO Environmental Affairs/MassGIS.The information depicted on this map is
Parcels3 L for planning purposes only.It may not be adequate for legal boundary
0 '` la definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER
MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING
L Y t► THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY
U^ `'�� ♦ ^ i OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT
• o��•111... E _ �3' i ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF
THIS INFORMATION
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The Commonwealth of Massachusetts
s Department of Industrial Accidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
www mass.gov/dia
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Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.Applicant Information Please Print Le 'bl
Name(Business/Organization/Individual):
Address:
City/State/Zip: ----- d
Are you an employer?Check the appropriate box: Type of project(required):
1.❑I am a employer withemployees(full and/or part-time).* 7. ❑New'construction
2.Q I am a sole proprietor or partnership and have no employees working for me in 8. E]Remodeling
3.B7capacity.[No workers'comp.insurance required.] 9, El Demolition
1am a homeowner doing all work myself,.[No workers'comp.insurance required.]t 10❑Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
1LE]Electrical repairs or additions
ensure that all contractors either have workers'compensation insurance or are sole
proprietors with no employees. 12Plumbing repairs or additions
S.F1 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.F1 Roof repairs
These sub-contractors have employees and have workers'comp.insurance3 14.❑Other
6.❑We are a corporation and its,officers have exercised their right of exemption per MGL c.
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
#Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date: ,�p
:Ak�
City/State/ZipA 2piration
ce
Job Site Address:� —T t'
Attach a copy of the workers' compensation policy declaration page(showing the policy number and d
ate).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine 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 of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA.for insurance
coverage verification.
Ido hereby cert'y u der the pai and penalties of perjury that the information provided above is true and correct.
Signature:
Date:
Phone#:
Official use only. Do not write in this area,to be completed by city 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#:
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 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 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-contractors)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 permittlicense 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 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 burn leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-NUSSAFE
Fax# 617-727-7749
Revised 02-23-15 www.mass.gov/dia
1A,
IIrr. TOW'OF NORM ANDOVEP, .
OFFICE OF
• ,�a b -:1670 0590()drStrOOtBuff&g2 -S-Ditp, 36
Noith Andovox'Massach.-asetts 41845
-
Gerald A.l3ro-wa � � Telephone(979)688-9545
1nspeetorofBi ldings _ Fax (978)689-9542
. HC�S�l ORNER LICENSE BXF-Y PTfON" • .
BUID►)'C-PEW-MT AWLIC.A.'�'ION
1?lease�rint
DATE:
�O$LOCATtN., • ' "
• •�Tuzn ex St<eet�.ddzess IYS'ap/Zot .
. � e• . piozne Phone Rozkl?I1one
-PRERENTUC NCT MMS
Usi'I'e�=1r
a - . RAP,-
TAT current exemptio11 for g%OMeDW-U-exs"was extended to�neIude ownex❑cetipied d��elti'r gs to two nests or:ass and
fo allow such hoanPo„vers to engage an.isaividual•forbire Who roes notpossess a license,provided that the owner
acts as snpazvisor). S,ateDOdiag (Co do Seotion 108,3.5.1)
DEMITION OFHOMEOW.NER
Persons)who awns aparcel ofland on which hafsheresides or intends to reside,on which there is,ox is iafended to '
b�;,a one or two family siamt vcs- .A.person,who constra efs mote that one home iv a two yearperzod shall not h e
considered ahomeowner. •
The undersigned"homedwner”assumes responsibilityforcompliances with the State
Building Code and other
.Applicable codes,by-laws;rales anal-xegoatlons.
The nndexsigned"homeownez"cexlfiesoafh.e/sheunderstands the Town ofNorlfiA_adovarBuRdzngDr,&ti mut
'�Y77Ti1T7tum.inspection,procedures and recluiremants and thathelshe+ZU comply with,said procedures and
zecluizements, ,
€IOMEOWM9RS SI rC�`l*I'A7'M
.APPROVAL OF 13 UMD)NO Op`FIcIAL '
Revised 7.2009 y
)'oxmlSomeownersExemption
30ARD OFAPEEAM 688-95'41 •• CONTSBRVf3.'RON 588-9534 -
BEALTH 688-954U PLANNING 688-953 -