HomeMy WebLinkAboutBuilding Permit #843 - 1929 SALEM STREET 6/5/2013TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued: I
IMPORTANT: Applicant must complete all items on this page
LOCATION
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PR®PERTY° OWNER -
/ Print 10O, ,earod,structure, ye no.
MAP�NO/o 6 .aRCEL: ®NLNGxDISTRICT,: Historic ®,istnct ye no
Machine; S.hop1Village: 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
❑ Septic ❑1Well
❑+Floodplain ❑ Wetlands,
p Watershed4District?
`V1/ater/S;ewef
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I_Yl lSln
OWNER: Name:
Address:
WORK TO BE PERFORMED:
Please
or Print Clearly)
19
me: qrlC<
CONrsRACTQRf Name: Phone:. f -
Address:
Supervisor's, Construction License:. --Exp:. Date
Improvemenf.Lice
ARCHITECT/ENGINEER
Date::
Phone:
Address: Reg. No.
FEE SCHEDULE. BULDING PERMIT. $12.00 PER, $$1y000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ FEE: $ U
Check No.: b Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner Signature of contractor
Plans Submitted ❑ Pla s Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
Plans Submitted ❑
Plans Waived❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE.DISPOSAL
Public Sewer ❑
Tanning/MassageBodyArt ❑ ..
_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
DATE REJECTED
70
DATE APPROVED
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
DPW Todwz Engineer: Signature:
Located 384 Osgood Street
FIRE DEP,�RTM- fN -Temp Dumpster on site yes no
Located at '124 Main Strdet
Fire Department sigdature/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,
MGL Chapter 166 Section 21A -F and G min.$100-$1000 fine
NOTES and DATA — (For department use
B Notified for pickup - Date
Doc.Building Permit Revised 2010
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
o Photo Copy Of H.I.C. And/Or C.S.L: Licenses
❑ Copy of Contract
o 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
o 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)
o 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 app, al 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: Doc.Bui!ding permit Revised 2012
Location e,,
No. Date&
Check #a (aoor
26482
TOWN OF NORTH ANDOVER
Certificate of Occupancy
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee $
TOTAL $
wilding Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
1600 Osgood Street, Suite 2-36, North Andover Ma 01845
.,NOTICE OF VIOLATION
Date:
Arlriracoz- Oaq 501 -,fm -->-t-
0 Building
13 Zoning Bylaw 7
Sto p Work Order
0 Certificate of Inspections
Gas
0 Electrical 0 Plumbing
Violation observed -1
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Failure on your part to comply with this notice within 10 days may su6ject you to penalties prescribed by Massachusetts Law
780CMR or North Andover's Zoning)3� law. Please contact the Building Department for further information at 978-688-9645
A
inspeftr'
Home Owner
Contractor
TO" OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
• 1600 Osgood Street Building 20, -Suite 2-36
North .Andover, Massachusetts 01845
Gerald A. Brown Telephone (97$) 688-9545
l f Inspector ofBuildings .Fax (978) 688-9542
HONMOWNER-LICENSE EXENIPTIOI�T
DMING PERMIT .APPLICATION
Please print
DATE:L��
JOB LOCATION:
Numbejr� Street Address �3 Map/Lot
HOMEOWNER C/C
Name Home Phone WorkBhone
PRESENT MAILING .ADDRESS 01 S .
City Toon, efw+ti .
zip Co_;
The current exemption for "homeowners" was extended to include owner -occupied dwellings to two units of less and
to allow such horneoti;�neis to engage an hr1dividual.for hire who does not possess a license, provided that the owner
acts as supervisor). State Building (Code Section 108.3.5.1)
k—FINITION OFHOIIBOVMR
Pe rson(s) who Awns 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 structures. A person who constructs more that one home in a two-yearpeniod shall not e
considered a homeowner.
The undersigned "homeowner" assumes responsibility for compliances with the State Building Code and other
Applicable codes, by-laws, rules and -regulations.
idle undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department
mginimum inspection procedures and requirements and that he/she will comply with,said procedures and
1 . quirements.
HOMBOWNBRS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Revised 9.2009
Porn Homeowners Exemption
BOARI) OFAPPBALS 688-9541 CONSERVATION 688-9530
. HEALTH 688-9540
PUNNING 688-9535
The Commonwealth of Massachusetts
Department of IndustrialAccidints
Office of Investigations
600 Washington Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance .Affidavit: Builders/Contractors/Electricians/Plumbers
Name
Address:
k _ 1
d" k
City/State/Zip:
N
Aq,-d
MM-
0 1 Y
q --?t vc,4::, q!���
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. F1 New construction `
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet.
E] Remodeling
ship and'have no employees
These sub -contractors have
8. ❑ Demolition
working for me in any capacity.
workers' comp. insurance.
5. ❑ We are a corporation and its
9. ❑ Building addition
[No workers' comp. insurance
1011 Electrical repairs or additions
equired.]
officers have exercised their
3am a homeowner doing all work
right of exemption per MGL
ME]Plumbing repairs or additions
\\myself. [No workers' comp.
c. 152, § 1(4), and we have no
12. ❑ Roof repairs
insurance required.] t
employees. [No workers'
13.❑Other
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 anew affidavit indicating such.
#Contractors that check this box 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 thepolicy and job site
information.
Insurance Company
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 requiredunder 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.
Ido hereby cu der the pains and nalties ofperjury that the information provided above is true and correct.
—Sip _ Date:
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-contractor(s) name(s), address(es) and phone numbers) 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 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, # 617-72.7-4900 ext 406 or 1-877:MASSAFE
Revised 5-26-05 Fax # 617-727-7749
vvww.nlass,govldia
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