HomeMy WebLinkAboutBuilding Permit #790-14 - 191 MASSACHUSETTS AVENUE 5/5/2014TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued:_ ✓ �
IMPORTANT:
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Applicant must complete all items on this page
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.TYPE OF IMPROVEMENT.
PROPOSED USE
Reside ial
Non- Residential
El New Building
R<_ne family
11 Addition
11 Two or more family
11 Industrial
El Alfmr,ation
No. of units:
El Commercial
PIR'epair, replacement
11 Assessory Bldg
11 Others:
0 Demolition
El Other
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RIPTION OF WORK TO BE PERFORMED:
Idd-Fq 7 nt�fication Please Type ?r Print Clearly) 6 7 - E -3S- - ka3S
71 1 ,�-
_S�L -�( �K �5i?cc�. Phone: 7
OWNER: Name:4::44/-,
Address:
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Horne tgbNEx
ARCH ITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT. $12.00 PER $1000.00 OFT -TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ FEE:$ (40
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Si nature=_ofA en
n
Plans Submitted LJ Plans Waived ❑ Certified Plot Plan El Stamped Plans 0
-14)
Plans Submitted ❑ -.Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
;TYPE OP SEW-ERAGE"DiSP.OSAL
Public Sewer ❑
Tanning/MassageBodyArt ❑ ..
.Swimming Pools ❑
Well ❑
Tobacco.Sales ❑
Food Packaging/Sales El
Private -(Septic'tank, etc._ . ❑
Permanent Dempster on -Site ❑
"
=THE- FOLLOWING SECTIONS FOR ,OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE.. REJECTED: DATE.APPROVED
PLANNING& DEVELOPMENT' ❑ ❑
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: Comments
Conservation Decision: Comments
Water & Sewer ConnectionZSignature Date Driveway Permit
�' PW Toiv 2 Engineer: Signature:
Located 384 Osgood Street
FIRE 1DEPARTI44IEIST Temp Dumpster on site . YeS no
Located at;124Mair Street
t
Fire Departure►rt"s"ignatu"re/elate
COMMENTS ,E
-Dim-enslon
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
_Total land area; sq. ft.
-ELECTRICAL: Movement of Meter Iodation-, roast or service drop requires approval of
Electrical Inspector Yes No
DANGER ONELITERATURE: =Yes No
7- MGL.Chapter166.Section 21A -F and G min.$100-$1000fine
ICU I t5 and DA I A — (i -or ge
® Notified for pickup - Date
Doc.Building Permit Revised 2010
enr use
Building Department
.-The folipwang is'a listof:the required, forms to be filled out-for:the appropriate. permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
o Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/O'r 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
o 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
o 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
o 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 cans if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the apw?al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be subm.tted with the building application
Doc: Doc.Bui?ding permit Revised 2012
Location
No. Date t
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $:;� x
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Building Inspector
Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
$ 41650.00
m
$ -
$
55.80
Plumbing Fee
$
6.98
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
6.98
Total fees collected
$
169.75
191 Masschusetts Avenue
790-14 on 5/5/2014
Bathroom Remodel
TQVq OF igORM AND OVEV,
OMCE OF _
IBUO DING DEPARTMENT
:1600 Osgood Street Building 20, •Ste 236
North Andover, Massachusetts 01845
Gerald A. Brown Telenlrone (978) 698-9545
InspeetorofBuiidings - Sax (978) 688-9542
. HONMRNER•LICENSE E-ENiPTIOI�t
BMING PFTMT ApPLICA'zT.ION
seunnt .
DATE: J ,
:OB LOCATION:
Number SfreetAddress
c)e, ti'I)JOk
g—W` 903-s Map/Lot
Name .Home Phone
WorkPhone
-PRESENT :MAILING ADDREss
C??�7 T �:n, Sfafti .
ZapCodes
The Current exempfion for "homeowners" Was extended to inchrde owner-occripied dtye7�r -vS t0 two units -Ox loss and
acts
su;h homeo;.ruers to engage 'd
mmdual.forhire who does notpossess a license, provided that the owner
acts as supervisor). State3tilding (Code Section I08.3.5
.I)
DEF.IN.ITION OFHOMEOWNBR
Persons) who Awns aparcel of land on which he/she resides or intends to r is infendo
, d to
e ere
reside, on which there is, be, a one or two fau�ily structures. A person Who constructs more that eer shall not e
considered a homeowner, one home in a two yeiso
The undersigned "homeowner" assumesresponsibilityforcompliances with the StateBuildin
Applicable codes, by-laws, xules andzegulations. g Code and other
The undersigned "homeowner" ceztrfies that helshe understands the Town of North AndoverBuildin pariment
De '
minimum inspection procedures and requir
requirements, nts and that he/she will comply with,said procedures and
HOMEOW.N)ERS SIGNAT
APPROVAL OF BUMUN'G
Revised 7.2009
Form Homeowners Bxdmption
'BOARD OF APPEALS 688-9541 I CONSEi2VATiON 688-1530r
PIEALTH 688-9540 PLANNING 689-9535
O/S-V
The Commonwealth of Massachusetts -
DepartmentoflndiistriglAccidie is
Office of Investigations
600 Washington. Street
Boston, MA 02111
-www.mass gov1d1a
Workers, Compensation bsurance .Affidavit: Buffders/Cont°actors/Electricians/PliiWbers
Applicant Information Please Print Legibly
Name (Business/OrganizationlCnd%viduat): �t c � S 4 �
.Address: U�k4 SS ciLR
City/State/Zip: 6, Xv k Y1')GICJC>I-P-► , l Jc( Phone #:
Are you an employer? Check the appropriate box:
Type of project (required):
1. ❑ I am a employer with.
4. ❑ I am a general contractor and I
6. [] New construction f
employees (full and/or pari time).*
2. [l I am a sole proprietor or partner
have like dthe, sub -contractors
listed on the attached sheet.
7• ❑Remodeling
ship aud'haveno. employees
These sub -contractors have
8. ❑ Demolition
working forme in any capacity,
workers' comp. insurance,
g, Building addition
[No workers' comp. insurance
5. ❑ We are a corpora�on and its
10.[] Electrical repairs or additions
required.]
3. am a homeowner doing all work
officers have exercised.their
right of exemption. per MGL
I I.[] Plumbing repairs or additions
myself. [Nb workers' comp.
c.152, §1(4), andwehaveno
12.❑ Roofrepairs
insurance re ed. ]
employees. [No workers'
1311 other
comp. insurance required.]
xAny applicantthat checks box#1 must also fill outthe section below showingtheir workers' compensationpolicy information.
T'Homeowners who submit this affidavit indicatingthey Aie doing all work and then hire outside contractors must submit anew affidavit indicating such.
tContractors that cheAthis boar must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
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.
Job Site Address:
Expiration Date:
City/State/Zip:
Attach a copy of the workers' compensation-poliey declaration page (showing the policy number and expiration date).
Failure to secure coverage as xequiredunder section 25A ofMGL o.152 can lead to the imposition of criminal penalties of a
fine up to $1,50 0.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORD 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 DIAf6r insurance coverage verification.
Ido hereby cert li�a;ns an
dpenalties ofperfury that the informationprovided above is true and correct.
`<r/
Oficial use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit0cense
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 Inst°nctions '
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 ofhivre,•
express orimpiied, oral or•wxitten.,,
Au employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two ormore
of the foregoing engaged in a joint enterprise, and including the legal representatives of a• deceased employer, or the
receiver of trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having notmore 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 bean 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 cousiruct buildings in the commonwealth four 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 ofpublic work until acceptable evidence of compliance with the insurance
requirements of this chapter have beenpresented 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-contractor(s)name(s), address(es) and phone number(s) alongwiththeir certificates) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, axe notrequired to carry workers' compensation insurance. If an LLC or LLP does have
employees, apolicyisrequited. Baadvised thattbisafi"tdavitmaybe. submitted tothe Department of Industrial
Accidents for confumaiion 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 andpriuted legibly. The Department has provided a space at the bottom
of the afiYdavit 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/Iicense number whichwili 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 oftho affidavit that has been of icially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit -is on file'or future permits or licenses. Anew affidavit most be filled out each
year. Where a homeowner or citizen is obtaining a license ox p ermit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves eta) 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 Mid fax number:
Tho GQMIAOUwealtlt of Mmol .,'woos
Department ofludu*hl Accident%
Office olthmstiga-a0m
6b0 Waddugf a Sfte�t
Boston, MA 421.11
TO. # 617-727-49 ext 406 ox x-877 MAMME
Revised 5-26-05 Fax # 617"727'7749
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