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HomeMy WebLinkAboutBuilding Permit #329-2017 - 2 UNION STREET 9/28/2016 r10RTFi BUILDING PERMIT TOWN OF NORTH ANDOVER - p APPLICATION FOR PLAN EXAMINATION Permit No#: 3�� — �I Date Received ��ssgcHus���y Date Issued: I PORTANT: Applicant must complete all items on this page LOCATION .� G� �u 0/1' J' Pnnt PROPERTY OWNER tdq"v '4•v�(Q k / POW 100 Year Structure yes no MAP PARCEL:- 3 -7 ZONING DISTRICT:`Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family 11 Addition El Two or more family ❑ Industrial ❑ Iteration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFO MED: e la.c,e wig G, — Identification- P ease Type or Print Clearly OWNER: Name: Bo Aez v �a�e `� Phone: 339 yyo �•��3/ Address: - . - Contractor Name: .Phone: Email: Address: gtl- Supervisor's Construction License: _Exp. Date: - 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: $ 9,0,0'0 , C--o FEE: $ 1 CJ� Check No.: 19-7 (o Receipt No.: 30q-'Y- U NOTE: Persons contracting with unregistere . ontractors do not have access to the guaranty fund Sgnature of Agent/Owner Signature of contractor i r 1 NORTH - . wn . ve' 'o a G �* o h ver, Mass, w COCNICMlWICM r IA�DRATE D lV V BOARD OF HEALTH PERMIT. - T LD Food/Kitchen • Septic System THIS CERTIFIES THAT .........B.I�. .., . .N ,! ,r>t BUILDING INSPECTOR has permission to erect buildings on �, Foundation .............S. III�t ... Rough to be occupied as T .................... ........��.'.0......................�.. ......................i�........... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and J Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR I VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR 4 UNLESS CONSTRUCTV TI Rough Service ....... ... ............................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. Of NORT.1ti TOWN OF NORTH ANDOVER 3a +•.'e oL OFFICE OF A BUILDING DEPARTMENT * 5o a + 1600 Osgood Street, Building 20, Suite 2035 North Andover,Massachusetts 01845 ,SSNCHUS�� Donald Belanger Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE: 09/R V JOB LOCATION: oL' I t le,"aw Number Street Address Map/Lot HOMEOWNER AegW t�y Avelw I�`y S39 e/•S/"® _72 3/ Marne Home hone Work Phone PRESENT MAILING ADDRESS OC L7 ti 10AI/ /112 t14 74,W©t✓e /_14- 0 If lis- City Town State Zip Code The current exemption for"homeowners"was extended to include owner occupied dwellings of one or two family dwellings and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. 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 dwelling,attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner. (780 CMR Section 110.R5.1.2) The undersigned"homeowner"assumes responsibility for compliance with 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 procedures and requirements and that he/she will comply with said procedures and requirements. � ..- HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 8.2015 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 The Commonwealth of Massachusetts _ F DepartmentoflndustrialAccidents 1 Congress Sheet,Suite 100 _ F Boston,MA 02114-2017 �r www mass.gov/dia Workers:Compensation Insurance Affidavit:Builders/Contxactors/Electricians/Plum exs. TO BE MED WITH THE PERMITTING AUTHORITY. Please Print Le 'bl A '•licant Information N 2 �`V Name(Easiness/Orgariizaizon/Indivi(tual): W&N Address: �r�i`O� 4 /(/� ,��/a0oy�2 Phone#: 3J l/ela Z City/State/Zip: Are you an employer?Check the appropriate box: Type 0project(required); em toy ees full and/or part-time).* 7. ❑NeV,t'constriiction 1.Q I am a employer with P 2.Q I am a sole proprietor or partnership and have no employees Working for me in $. Remo delliig any capacity.[No workers'comp.insurance required.] 9, ❑Demolition 3 /�!am a homeowner doing all work myself[No workers'comp.insurance required.]t 10❑Building addition <11 am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.0 Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole b1n repairs OT additions proprietors with no employees. l2.[]Plum g p 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13•_ Roof repairs These sub-contractors have einployees and have workers'comp.insurance.$ 14.0 Other 6.Q We are a corporation and its.officers have exercised their right of exemption per MGL c. 2 §1 4 and We,have no employees.[No workers'comp.insurance required.] *Any applicant that checks bbk#1_must also fill out the section below showing their workers'compensation policy information: Homeowners who submit.this affidavit indicating they are doing all work andthen hire outside contractors must submit a new affidavit indicating such tContractors that check"box must attached an additional sheet showing the name of the sub-contractors and state whether or,not fhose,entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. X am an employer that isProviding worker's'compensation insurancefor my employees. Below is the policy and job site information. Insurance Company Name: Expiration Date: Policy#or Self-ins.Lie.#: City/State/Zip: Job Site Address: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). al violation punishable by a fine up to$1,500.00 Failure to secure coverage as required under MGL c.152,§25A is a crimin 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 may be forwarded to the office of Investigations of the DTA for insurance day against the violator.A copy of flus statement coverage verification. Xdo Ziereby certify u e:Ihepains andp hies ofperjury that the informationpr•ovideda Bove i true adcorrectDate: Si afore:Phone#: i 2 3 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): 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 1.Board of Health 2.Building Department 6.Other Phone#- Contact Person' 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'd'efnied 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 receivez'or trustee 6fan 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 ofthe 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 h'as'not produced-acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152,§25C(1)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 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 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 IndustrialAccidents. 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-insura'nc'e 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"fob 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 burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 wwwmass.gov/dia Location 9 U N U No. 330 -r?+Ut7 Date Of • - TOWN OF NORTH ANDOVER Certificate of Occupancy $� Building/Frame Permit Fee $ l'0 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# Building Inspector