HomeMy WebLinkAboutBuilding Permit #572 - 189 HIGH STREET 4/7/2008 NORTH
BUILDING PERMIT 0.4t,,Eo
TOWN OF NORTH ANDOVER c? �°�,
APPLICATION FOR PLAN EXAMINATION '' 70
Permit NO: Date Received �q p�R4TED
SSA
use I
Date Issued: `�� ' /�'
0/0' cH
IMPORTANT:Applicant must complete all items on this page
LOCATION 1 C ��h T 3 l / yl c 0 V-e,�"
Print
PROPERTY OWNER `� L2S o -Ps ftr
Print
MAP NO: 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
R�pair, rep ace nt -Assessory Bldg Others:
on Other
Septic Well Floodplain Wetlands Watershed District
Water/Sewer _
DESCRIPTION OF WORK TO BE PREFORMED:
I
ePt& `e yrl� or
Identification Please Type or Print Clearly)
OWNER: Name:_ D K✓► Les d S h�z Phone:
Address:
CONTRACTOR Name: t Phone:
Address;
Supervisor's Construction License. Exp. Date:
I
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER 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: $ FEE: $
l
Check No.: 3907 0 Receipt No.:
NOTE: ersons contracting with un egister ontractors do not have access to the guaranty fund
i
ignatureof Agent/Owner Signature of contractor
II
i
i
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 Application
Permit A lication
❑ 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
i
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
I
TYPE OF SEWERAGE DISPOSAL I
Public Sewer Tanning/Massage/Body Art Swimming Pools
Well Tobacco Sales i 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
I
COMMENTS
i I
CONSERVATION Reviewed on Signature
I
COMMENTS
i
H=ALTH Reviewed on Signature
F 1
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
I!
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 signature/date
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 j
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA— (For department use
i
I
i
I
❑ Notified for pickup - Date
i
_........................................._.............................................----.._...._......................_....._........................__._._........................................................................._............_.................................._.__.............._..._...._...----................._........__............................_...._._.._...._..._...........
.
I
Doc.Building Permit Revised 2008
i
Location�O �• < n�
No. ,�fs� Date '
NOR7M TOWN OF NORTH ANDOVER
�1
' Certificate of Occupancy $
�ssncNusEt Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # !1
2 i 054 Building Inspector
NORTH
TO" of' .:W -,� 6 Andover
No. Al
0 dover, Mass.,
0 .0- =,* A.
COCHICHEWICK
0R4r E 0
BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT....7 ......ks.� ....... ......................................................... �***** �I... Foundation
... buildings on IM 10
has permission to erect . . ........ .. .... .....!................................ Rough
A Chimney
to be occupied as..... .......... . 1.1
el��i� ........... ..............
P that the person adze tin this permit shall in ect coifform to the terms of the ap`p`Ii*ca't'1'ono...Wilie"'In Final
this office, and to theprovislons 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
Ila PES EXPIRES IN 6 MONTHS Final
ELECTRICAL INSPECTOR
UNLESS CONS N TARTS
Rough
...... Service
BUILDING INSPECTOR Final
Occupancy Permit Required to Owipy Building GAS INSPECTOR
Display in a Conspicuous Place on the Premises — Do Not Remove Rough
Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
SEE REVERSE SIDEJ Smoke Det.
-- - ;. ..........
o
4
�---
r"
I
I
alp ,
1p vy
V - __jilt yr jD
>� 7r,
d F
P
ke d (I
l
4 �
�` 9l"' '£� �.: � I^r �' ../ fad '.fr = � ' I�•.��`�' Ax
ray o �
04.
mt.tx
��7 ~x '
�:. ' icy � �., _. .,,,,._. ., ''�,w,.;... °y'�"• .. '� Y :v.; v�,lz `� a�d'�£�+"{�,T.s� a: ,3� k �;.-. r i�r� „;41^ ,�s r.• �_.
t �
E `� '� ¢'�� t� � � r��` ' ��s>r,w;, _k P�ss�M� � �x x �"�m � �,� .:a y'�4•� ,.i, v'�,*'�y 4"� ���`_,�6!p� � �, � �
�. "t: fi .' ,`,.. ?.�cf°w'F,ti'w {f'°+�.. ,?'�4^1i'� s'�'M +, """*+o- ""*s r*7��, 'e�`.»'"tt �.,+ate 1 ''; � ,�,� 5R� i. �, •''
-,3 -y� .,.h¢� ,p `f g`.tF. ° R �� Y ...t!'' a � yt aa��'"'�,� -z�"�4„�,,,�+ss: •"�,,,.a�sY�¢ ,��, s« .. '�.-,;-.�•�.� ra,. ,� ""' E+ �'`�4'�� +�',�•
arx
IA
,
's 41
law
+ �oRTM TOWN OF NORTH ANDOVER
OFFICE OF
- p BUILDING DEPARTMENT
1600 Osgood Street Building 20, Suite 2-36
��► :. :�t�* North Andover, Massachusetts 01845
ss�c �
Gerald A Brown Telephone(978)688-9545
Inspector of BuildingsFax (978)688-9542
Y,
HOMEOWNER LICENSE EXEMPTION
Please mint
DATE:
JOB LOCATION:
Number StPE Address Map/Lot
HOMEOWNER To,4 a J'-
Nat tomefione i
PRESENT MAILING ADDRESS
i
City 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 lianas,provided that the
owner acts as supervisor). State Building (Code Section 108.3.5.1)
DEFINITION OF HOMEOWNER
Persou(s)who owns a parcel of land on which helshe resides or intends to re ide,on which there is,or is intended
to be,a one or two family structures. 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
minimum
inspection procedma and requirements and that he/she will comply with said procedures and
�• I
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Revind 10.2005
Form Honw mrs Eumption
BOARD OF \PPE:VLS 68&9541 CONSERV.VRON'638-9530 TTE.1L'11i 688-9540 PL.INNTNG 688-9535
i
The Commonwealth of Massachusetts
Department of Industrial,4ccidents
Office of Investigations
600 Washington Street
.Boston, AL-4 02111
WNW.mass.gov/dia
Workers'. Compensation Insurance Affidavit: Builders/Contracto
cant Infors/Electricans/Plumbers
A Iirmation
Please Print Le .bl
Name(BusinesslOrganizationllndividual . Q p
Address: S .
City/State/Zip: Phone.#:
Are ayou an employer? Check the appropriate box: .
1.❑ I am a employer wi ' 4. I am a Type of iro'ect re
th T_ ❑ general contractor and I P J ( quiredr.`
employees (full and/or part-time),* have hired the sub-contractors 6• ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. 0 Remodeling
ship and have no employees These sub-contractors have
working forme in any capacity, employees and have workers' 8. ❑Demolition
[No workers' comp.insurance comp. insurance.t ' 9. ❑Building-addition
required.].. 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
XMYself
I am a homeowner doing all work officers have exercised their .
mp. 11.0 Plumbing repairs or additions
[No workers' co right of exemption per MGL
insurance required.]t C. 152, §1(4), and we have no 12.0 Roof repairs
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing the it workers
eFlanrrov hers who submit this affidavit indicatinb¢ey are doing all work and th=hire outside cont�etorss,compensatan Amus subxruolicy �new affidavit indicating such.
niplo ces. that check this box must attached a additional sheet showing the name of the sub-contractors and state wh=the:or not those entities have
employees. If the sub¢ontrictars.have employees,they must pravide their .war
l=v'comp:poficynumber.
I am..an emPLoyer that is providing workers'compensation insurance for my employees. Below is the policy.arid job site
information.
Insurance Company Name:
i
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 m
of up to$250.00 a day against the violator..Be advised that a c .the form of a STOP WORK ORDER and a fine
Investi ations of the DIA for insurance cover a a verification.copy.of statement may be forwarded to the Office of
Ido hereby ce an t pains-on en 'es of perjurythat the information provided above is true and correct
Si atur'e:
Phone#: IVA —
Officiat use only. Do not write w this area, to be completed by cuy or town official
City or Town:* Permit(License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town
6.Other Clerk 4.Electrical Inspector7PIumbing
Contact Person:
Phone#:
i
Information as d Instru ti
c ons
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 p=rson in the service of another under any contract of hire,
express or implied,oral or written." r
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 thanthiee 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 emp�'loyment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"ever state or local licensing agency sliall withhold the issuance or
renewai'of a license or permit to,bpera'tem 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 1,52, §25CO)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 insun-ce
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(g)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 maybe 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 pern3it 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 callthe Department at the number listed below. Self-insured companies should.enter their
self-insurance license number
on the appropriate Ime.
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 sbreto fill in the permittlicense number which will be used as a reference number. In addition,an applicant
that must subnut 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 b the city or town may be provided to
Y h' Y Pr 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 1-10T 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 Deparbnemt;s�address,-telephone-and fax number. l
The Ca monwealth of MassachuseG V
Department Of In&zstrial Accidents
Office of Investtaf ens
640 Washington Street.
D3oston,MA,02111
Tel.#617-727-4300 ext.4.06 or 1-877 MASSAFF
Revised 11-X22-06
Fax # 617-727-7749
www.II uLgovidia