HomeMy WebLinkAboutBuilding Permit #642 - 1857 GREAT POND ROAD 5/2/2008Permit NO:
Date Issued: 'l - Z-0
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received `S',,2- O b
2 7 C
TYPE OF IMPROVEMENT
PROPOSED USE
re rina,-Q
Residential
Non- Residential
New BuildingOne
famil
Addition
Two or more family
Industrial
A erf� at n
No. of units:
Commercial
Others:
Repair, replacement
Assessory Bldg
Demolition
Other
Septic Uyeli
Fioodpla n. Wetlands `
1lVate shed D s#riot
WaterP ewer
utacrar i JUN Ul- VVUKK I U 13t PREFORMED:
4 -
OWNER: Name:
0,(c 7—CD,
Type or Print Clearly)
one: &(l
ARCHITECT/ENGINEER
Phone:
t
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: $ "X0y FEE: $ 3 C,
Check No.: Receipt No.: I
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
re rina,-Q
OWNER: Name:
0,(c 7—CD,
Type or Print Clearly)
one: &(l
ARCHITECT/ENGINEER
Phone:
t
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: $ "X0y FEE: $ 3 C,
Check No.: Receipt No.: I
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
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
HEALTH
COMMENTS
DATE REJECTED DATE APPROVED
Reviewed on Signature
Reviewed on Signature
_ --Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted
f)IanninoY Board Decision: Comments
Conservation Decision:
Comments
Water & Sewer Connection/signature & Date - Driveway Permit
DPW Town Engineer: Signature:
yes
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 21 A —F and G min.$100-$10700 fine
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
F
❑ 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 Caldulations (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
TOWN OF NORTH ANDOVER
10
9;,-- a 0
-
Certificate of Occupancy $
CHU
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
I
Check # S
21 -, 25
Building Inspector
The Commonwealth of Massachusetts
Department of Industrial Accidents
tl
Office of Investigations
a 600 Washington Street
o
Boston, MA 02111
M 5V y www.mass.gov/dia '
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
pplicant Information Please Print Lej ibl'
Name (Business/Organization/Individual):
Address:
City/State/Zip: /U
/003-1 greq
4((`Zcv
�c
'6(Whone.#:
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with ' 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub-coaitractors have
working for me in any capacity. employees and have workers'
fNo workers' coma. insurance comp. insurance.$
3Xrequired.]
I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
❑ 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.]
Type of project (required)':.,
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12. ❑ Roof repairs
13.F Other
"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:
Job Site Address: City/State/Zip:
Attach.a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification
I do hereby certify under the pgins and penalties of perjury that the information provided above is true and correct
i
not write in this area, to be completed by city or town official
City or Town: Permit/License #
Issuing Authority (circle one):
L 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,opera'tera 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 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 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 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,
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
Revised 11�22-06
Fax # 617-727-7749
www.mass.gov/dia
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••..;+_ '°o� OFFICE OF
BUILDING DEPARTMENT
` 1600 Osgood Street. Building 20 Suite 2-36
North Andover, Massachusetts 01845
Gerald A. Brown Telephone (978) 688-9545
Inspector of Buildings Fax (978) 688-9542
HOMEOWNER LICENSE EXEMPTION
Please mint
DATE: /2 -
JOB
LOCATION: I ���1 i, ar
Number Street Address MRA&
HOMEOWNER 3S e
Name riome Phone �a,L work phone C Fl c
PRESENT MAILING ADDRESS I V Q
Cit}' Town State Zip Code
The current exemption for "homeowners" was extended to include owner -occupied dwellings to two units or less
and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the
owner acts as supervisor). State Building (Code Section 108.3.5.1)
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended
to be, a one or two family stnlctures. A person who constructs more that one home in a two-year period shall not
be considered a homeowner.
The undersigned "homeowner" assumes responsibility for compliances with the State Building Code and other
Applicable codes, by-laws, rules and regulations.
The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department
minimus► inspection Procedures and requirements and that he/she wjU comply with said procedures and
HOMEOWNERS SIGNATURE \ L
A
APPROVAL OF BUILDING OFFICIAL
I
Rid 10.2005
Foam Homeowmrs Exemption
BOARD OF \PPF:iLS 688-9541 CONSERVATION688-953n TiE.11 TH r xg_9; }p PL.L\vI,G 6x8_9535
Date..
1941
40RTH
TOWN OF NORTH ANDOVER;
TION
PERMIT FOR GASINSTALIA
CHU
This certifies thata.U,&YA� Ak.+A�6..
hag permission for gas installation A
in the buildings of",N().4 ... P�t�ZA
...........
2
J? ...... .
North An' clover, Mass.
F e e. L i c. N o. . ........... ......
A(T;J/12/95 11:50 25.0!PASPNIFECTOR,
WHITE: Applicant ANARY: Building Dept. PINK: Treasu
rer GOLD:. File
L\
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTiNG
wrint at Type)
ANDOVER - —,Mass.. Zate 9/27/95
-.Ig - Permit #
Building Location 18 5 7 GREAT POND RD, Owner's Name WANDA AVERKA
G
New ❑ Renovation ❑ Replacement In
Type of Occupancy ' RES
. Plans Submitted: Yes❑ ' No ❑
Installing Company Name CALLAHAN A/C&HEATING, .INC
Address 91 BELMONT ST.
NO.ANDOVER,MA. 01845
Business Telephone 508-6-89-9233
Name of Licensed Plumber or Gas Fitter JOSEPH K . CALLAHAN
Check one: Certificate
❑ Corporation
❑ Partnership
IX Firm/Co.
INSURANCE COVERAGE:
I have arc
current liability insu P No ran ce policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
if you have checked yes, please indicate the type coverage by checking the appropriate box
A liability insurance policy t Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner*s Agent Owner❑ Agent ❑
1 hereby certify that all of the details and information I have submitted (or entered) In above application are true and accurate to the best of my
knowledge and that all plumbing work and Installations performed under the permit issued for this application will be In compliance with all
pertinent Provisions of the Massachusetts State Gas Code and Chapter 142 at the neral Laws.
T e of Ucense:
Title Plumber atur ce s um er or Gas Ater
Gasfilter
Master License Number `yd
C�ly/Town Journeyman
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SUB—BSMT.
BASEMENT
1
ISTFLOOR
2ND FLOOR
3RD FLOOR
4TH FLOOR
STH FLOOR
6TH FLOOR
I
7TH FLOOR
8TH FLOOR
Installing Company Name CALLAHAN A/C&HEATING, .INC
Address 91 BELMONT ST.
NO.ANDOVER,MA. 01845
Business Telephone 508-6-89-9233
Name of Licensed Plumber or Gas Fitter JOSEPH K . CALLAHAN
Check one: Certificate
❑ Corporation
❑ Partnership
IX Firm/Co.
INSURANCE COVERAGE:
I have arc
current liability insu P No ran ce policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
if you have checked yes, please indicate the type coverage by checking the appropriate box
A liability insurance policy t Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner*s Agent Owner❑ Agent ❑
1 hereby certify that all of the details and information I have submitted (or entered) In above application are true and accurate to the best of my
knowledge and that all plumbing work and Installations performed under the permit issued for this application will be In compliance with all
pertinent Provisions of the Massachusetts State Gas Code and Chapter 142 at the neral Laws.
T e of Ucense:
Title Plumber atur ce s um er or Gas Ater
Gasfilter
Master License Number `yd
C�ly/Town Journeyman
MPIVNE O