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HomeMy WebLinkAboutBuilding Permit #508 - 20 COMMONWEALTH AVENUE 3/6/2008Permit NO: log Date Issued: � 'A, 'd BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received IMPORs..TANT: Applicant must complete all items on this page LOCATION o� b a •%- CcS vv� ry� a-. '� 4-� - y/ PROPERTY OWNER gue/o Ip (11 , D MAP NO: PARCEL:_ ZONING DISTRICT: Historic District yes Machine Shop Village ves O'<��eO �6• tia TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Z2 Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: 1`e6, U4() sec®� `�i�, .� l- /Do 2 .S L-1 OWNER: Name: CONTRACTOR Name: PLease Type or Print Clearly) Phone: oi8-9 Address: V) 1) -T A--- C 's Supervisor's Construction License: 6 a Exp. Date: `© Home Improvement License: r 3 ! 1 �5_6 ARCHITECT/ENGINEER Date: 1//// d 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: $ 6� 4�1 FEE: $ Check No.: 5 s Receipt No.: ca)� 7 �� NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owmer _Signature of contractor Locatio.'Tnl w� No. D Date d NORTN TOWN OF NORTH ANDOVER O 0 w 9 Certificate of Occupancy $ C"Us t� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ gTOTAL $ Check # 2 0 I 77 Building Inspector 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. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS DATE REJECTED DATE APPROVED CONSERVATION COMMENTS DATE REJECTED DATE APPROVED HEALTH COMMENTS 1 Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit Located at 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 MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine NOTES and DATA — For department use ❑ Notified for pickup - Date Doc.Building Permit Revised 2007 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 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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 x ..� . . > rn \\ 7 \ \ ^ . ƒ/\ j 00 / ybzcr (Do . © r «' «� 2 j * _ « « : : 7, 0 : J y z0 \{ ° °.2 k - n X 0 » §k k $ %_ > . 2{ e 00 x x w O O x u o w° v a V)) 0 U 0.0 A w W o i w° w°' U w Q W a g2 m w a O W W ° � c� w C7 C4 m w W w A a W oco cn v Q cn E d co L r+ zipN 0 N C O ii m ID m c m O m c c O N O 45L Is O Z O CD F. z 0 W Z Z 0 U C/) f O Of IpCA� O LA O O �E m m co CD _~ co C3 O m o a C C Q eCv Cc v J.0 CA C Z � O p. C..7 C R C •= C _cc d 0 O ;= O • O � C � O N O C3 Gi R cm �= O O G3 Ea L 1 co o a N :Ec • c� 0 O cm CD C m co V N m m q4- CO� ADO, ;9=_a N O L—.N CD :c.v� N O CD ,: / C O Q N COL cc 0 y O W•CZ C O` O IS n yz 3 H ~ H m a WC O._.-0=CD C c N O.t 0 cm V L- 609 D m CO3 O. O:2O Z to tp = 0 h �7 Dai F- t m E d co L r+ zipN 0 N C O ii m ID m c m O m c c O N O 45L Is O Z O CD F. z 0 W Z Z 0 U C/) f O Of IpCA� O LA O O �E m m co CD _~ co C3 O m o a C C Q eCv Cc v J.0 CA C Z � O p. C..7 C R C •= C _cc d 0 The Commonwealth of Massachusetts Department of Industrial Accidents 92. Office of Investigations 600 Washington Street .Boston, AL4 02111 www.mass.gov/dia Workers' wCompensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): �, tA C. -D I Address: "\CT City/Slate/Zip: f G 4/5 AW_ y% Y74� Phone.#: T) 96 1` �S9 Are.you an employer? Check the appropriate box: LYII am a employer with ' 4• ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp• insurance.: required.] 5. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised, their . myself. [No workers' comp. right of exemption per MGL insurance required_] t C. 152, § 1(4), and we have no employees. [No workers' comp. insurance reouired.l Type of project (required). 6. ❑ New construction 7. []Remodeling . 8. ❑ Demolition 9. ❑ Building. addition 10.0 ,Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. ' t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp, policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: t 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 in the form of a STOP WORK ORDEk 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 rd der the pains and penalties of perjury that the information provided above is true and correct Sianatur`e: Date: Phone 1k f5 l 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 "ever state or local licensing agency shall withhold the issuance or renewal of a Iicense or permit to,bpera'te�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, §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 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-contiractor(s) name(s), address(es) and phone number(s) 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 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. Whe;e 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 Qftx of Investigations 600 Washington Street Bostan, MA 02.111 Tel. # 617-727-4900 ext.406 or 1-877-MASSAFE ` Fax # 617-727-7749 Revised 1122-06 vwww.mas&gov/dia N r M 2 H J W Z SO ZQ oU N w J UNU pN J U) J H U00 10 = M J LJJ w Cc Q s r+ 2 H LO J W Z OT z 0U � O n N UN N w J U 00 (n J D J Q i - U 2 H J 0 LL0 �p rT lei r 22 C v- OS -