HomeMy WebLinkAboutBuilding Permit #530-15 - 19 ELM STREET 12/8/2014BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: �""� I Date Received �- a
LOCATION 'Y1 T �i �N[yA
4_'
�R'7ED
Date Issued: 14
�ZA�
SSACHi
IMPORTANT: Applicant must complete all items on this paize
Non- Residential
OV ,/1%1 � C l i��
Print
PROPERTY OWNER, gekyc C L �°
Print 100 Year Structure yes o
MAP PARCEL: ZONING DISTRICT: Historic District yes no
I Machine Shop Village no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
Ili1 One family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
A Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septic ❑ Well
❑ Floodplain ❑ Wetlands
❑ Watershed District
❑ Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
�1"u h 11 a ► +4 Re h mace w,-eM�
Identification - Please Type or Print Clearly
OWNER: Name: Sae&�vv (---ee Phone: R7b1 3141-
rer:rrmM
Contractor Name:
Address: e, -
Supervisor's Construction License:
Home Improvement License:
-1.I-
Exp. Date:
Date:
ARCHITECT/ENGINEERPhone:
Address: -7/ Nfe e e)q f �-k 41,q o l717S" Reg. No.
FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ 3, COO FEE: $ ��
`2
Check No.: Receipt No.: �
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner �Signature of contractor.
Location
No. ` J Date
ftftTOWN OF NORTH ANDOVER
®Ira Certificate of Occupancy $
Building/Frame Permit Fee $ �~
>� Foundation Permit Fee $
Other Permit Fee $
f'k41 EW t TOTAL $
0
Check # '
._t
Building Inspector
C
r
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. ❑
Pennanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On
Signature
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
Comments
Water & Sewer Connection/Signature & Date Driveway Permit
4
DPW Town Engineer: Signature:
FIRE DEPARTMENT - Temp Dumpster on site yes
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Located 384 Osgood Street
no
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
Doc.Building 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
❑ 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/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
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: Building Permit Revised 2014
O-Fi gORTR
ANDovEp,
o e.:: OFFICE GB
. RUMDJNG )DEPARTMENT
• ' Q a z°y :' 600 DsgoodSireetBuiiding20, uiie 36
`j
North Andover
sr�cuus�_ , Massachusetts 01845
Crerald A. Brown Telephone (978) 688 9543
InspectorofBuildings Fax (978) 688-9542
- �SOMEO•WNER•i,I�ENSE EXEMPTIOI�I '
PPLICA.TZON
plea�rin-i .
-
DATE: ( c: -2-0 -
OB LOCATION: 19
Number StraetAddress
Map/Lot
' 15oVD-3OWNER
Name Horne I? one
workPhoue
MRSENT MAILING ADDRESS
C^ iv To=m: �fafpj
• 9,p Code
The current exemption for "•homeota_n_ers" Was extenaed to
to allo"V su:b ,o,nPO;, --nchide owner occupied di�e�gs to two units -ox 7,03s:an_d
ueis ro englge an diyidual•forbire Otho does aotpossess a T_iMMED, provided that the owner
acts as supervisor). 9fateDuizding (Code section log.3.5.1) .
DBFM'-TION OFROMONNER.
J'erson(s) whoyt a parcel Oland on which he/she resides or intends to reside, on -which there is, oris intended to
be, a one or two n'audly sfineiures. Aperson who constructs more diatAne home inatwo
• yearperiod shall not be
considered ahomeowner,
The'Mdersigued"homadwner"assumesresponszi�ilityforcbmplianceswithth
ApplicableeState J3uildin Code an
codes, nu es andzegalations, g d other
• The undersigned "homeowner" cexf des that he/she tuiderstauds the Town of NorE3i Aadover73uildiug De aztu�ent
im m inspection procedures and requirements and that he(she Wi11 comply tvzth;said procedures and
requirements,
-UOAMDWNERS SIGNATURE `
A PPROVAL OF BUJLD)NG
Revised 7.2009
�FormHomeowners $xemption
')30ARI) OFAPPEA.75 688-9541
►FFICIAL
CONSERVATION 688-9530
r Y;
HEALTH 688-9540 PLANN1�11 G 689-955i
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WA
The Commonwea%th of Massachusetts ,
Department of Inciustrigl Accid nts
Office of Invesfigations
600 Washington. Street
Boston, MA 02111
www.mass govIdla
Workers' Compensation Insurance Affidavit: Builders/Contrcaeio:rslEl Pease 1'sf Pl deb r
bers
Applicant Information
• ��� ���
Name (Business/Organizaiionitndividuai)
Address:__
City/State/Zip: N , %�i� l �1Ll-� Phone #:
T)
Are you an employer? Check the appropriate box:
1. ❑ I am a employex with �
4. E]I am a general contractor and I
I employees (fulland/or part-time).*
have, I&edthe, sub -contractors
2111 am a sola proprietor or partner-
listed on the attached sheet.
These sub -contractors have
ship an.d'have no employees
working for me, in any capacity.
workers' comp. insurance.
[No workers' comp. ansuxance
5. ❑ We are a corporation and its
Officers have exercised their
required.]
3. KAI am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, §1(4), andwehaveno
employees. [No workers'
insurance required.] t
comp. insurance required.]
Type of project (required):
6. ❑ New construction F
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
11.❑ Blumbing.repairs or additions
12.Q Roofxepairs
13.0 Other
AAny applicant that checks box#1 must also fill outthe section below showing their workers' compensation policy information.
?'Homeowners who submit this affidavit indicatingthey i're doing allworlt and then hire outside contractors must submit a new affidavit indicating such.
?Contractors that cheAthis box must attached an additional sheet showing the name of the sub -contractors and thele workers' comp, policy information.
.1 am an employer that is providing workers' compensation insurance for my employees, Felow is the policy and job site
information.
insurance Company Name:.
Policy #k or Self -ins. Lic. 9: 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 requiredunder Section 25A of MGL o. 152 can lead to the imposition of criminal penalties of a
dine up to $1,500.00 and/or one7-year imprisonment, as well as civil: penalties in the form of a STOP WORD ORDER. and a fine
ofup to $250.00 a day against the violator. Be advised that a copy of this statement: maybe forwarded to the Office- o£
Investigations of the DIA for insurance coverage verification.
X do Ilereby certo under the pains and penalties of perjury that the information provided alcove is trite and correct.
=11
Official rise only..Do not write in this area, to he completed by city or town official.
City or Town: PermitUcense 0.
Issuing Authority (circle one):
1. Board of Health -).Building Department 3. City/Towo Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other -
Contact Berson: Phone M
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 demoted as "...every person in the service of another under any contract ofbire,-
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 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, 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 compliance with the insurance
requirements of this chapter have been presented to the cgntracting 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), addresses) and phone number(s) along with their certificates) 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 au LL C or LLP does have
employees, apolicy is. required. Be advised that this affzdavitmay 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 retumed to the city or town that the application for thepermit 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 Dificials
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 (ifnecessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been of.0cially 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 ox 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 Office of Investigations would like to thank you in advance for your cooperation and shQ ald you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
Tho Cox o-moalth of V-
Departmmit off dusWax.Accidmts,
Otte ofTnt esugations•
E00 waftgtou fleet
Bmton.-XA 02111
Tel # 617-7.2'x_4900 eyt 406 ox 1-877-:NiA SAFF,
Revised 5-26-05 Fax # 617-727"7749