HomeMy WebLinkAboutBuilding Permit #222-2017 - 20 METHUEN AVENUE 8/31/2016 BUILDING PERMIT of NORTy q
E�t`ED /6T~�
TOWN OF NORTH ANDOVER ;
APPLICATION FOR PLAN EXAMINATION
T .• y T
Permit No#: 0a— �1 Date Received ��ssACHus�`��y
Date Issued: �-17 t
IMPORTANT: Applicant must complete all items on this page
LOCATION �� /4`eke 4,e
Print
PROPERTY OWNER KZ_
Print 100 Year Structure yes no
MAP PARCEL: ZONING DISTRICT: ?�C/ _Historic District ye no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
es' ential Non- Residential
❑ New Building One family
❑ ddition ❑Two or more family ❑ Industrial
Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District
❑Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Identification- Please Type or Print Clearly
OWNER: Name: Qy, SCtw�� Phone: 7�I- 7�G- S/$
Address: 2v /�l e �,� t-� /� •L
Contractor Name: Phone:
Email:
Address:
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: $ /,zoo() FEE: $
Check No.: I Receipt No.: ®goZ�
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tauuaxig/Massage/Sody 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
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
± HEALTH Reviewed on Signature
COMMENTS
i
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
i
Conservation Decision:
Comments
Water& Sewer Connection/Signature& Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARaTMENT - TempDumpster gnysite ;yes_.._ ;nod
. , _ _ i
11 dEa(0 1 at, 241Main:Sti'bet -7
Fi,re�Department.�ignature/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 Call Email
Date Time Contact Name
Doc.Building Pennit 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
OTE: 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
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
.6 Building Permit Application
4 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
2012 I ECC Energy code
Engineering Affidavits for Engineered products
OTE: 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
+ ! n
Location -' i{ � t t, 3
Date I `
• r
• - TOWN OF NORTH ANDOVER
,n •
y ` Certificate of Occupancy $
Building/Frame Permit Fee $ -�
Foundation Permit Fee $
Other Permit Fee $_
TOTAL $
Check# A
`� Building Inspector
Enter construction cost for fee cal - North Andover Fee Calculation
Construction Cost
$ 123000.00 m
$ - $ 144.00
Plumbing Fee $ 18.00
Gas Fee 100 comm. $ 100.00
Electrical Fee $ 18.00
Total fees collected $ 280.00
20 Methuen Avenue
222-2017 on 8/31/2016
finish basement
NORTH q
Town - of1., sAndover
O
No. a _ r7
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1 1 VIA
In h vero
Mass, Ax2
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Coc"ICNIWIC
��AERATED PPa��S
1 S
U BOARD OF HEALTH
Food/Kitchen
PERM T L D Septic System
THIS CERTIFIES THAT .,.... ..,.,,., BUILDING INSPECTOR
........................ . ........S�MZ ..................
',,, Foundation
has permission to erect ............. buildings on .. ...... r.
............. ......................... . •
. ..OW
x*.!. � Rough
to be occupied as ��jr?'' ►, � -�j Chimney
provided that the person accepting this permi shall in every r spect conform the terms of theaplifation Final
on file in this office, and to the provisions.of the Codes and By-Laws relating to the Ion teratiand
Construction of Buildings in the Town of North Andover. E PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit.
s � Rough
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONS TIONS A Rough
Service
Final
BUILDI 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.
MEN
NO ME
,. son v Asn
■ ■ p � i
No
M OEM 0 No
- mom
MEN 0 No so 0
���� ■ 0 No
■■vON No so mom
MEMO mom 0 MEMO MENEM -- I
im. - �� ■
SEEN MMEMEME 0 No 0 ME
t■ �SEEN�N ■t ■ MINE
MENOMONEE mom ME 0
MMMIMMMIMMM 0 M No mom w mom so
ME MONSOON ON 0 mom mom No E. M ON 0
NM
TOWN OF NORTH ANDOVER
,� ` _ *•�� OFFICE OF
_ BUILDM DEPARTMENT -
r�* 1600 Osgood Street,Building 20, Suite 2035
+1 North Andover,Massachusetts 01845
Gerald A. Brown Telephone(978)688-9545
Inspector of Buildings• Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
DIADING PERMIT APPLICATION
Please print
DATE:
JOB LOCATION:
1�Number Street Address Map/Lot
HOMEOWNER �ji �I T 2O8 6 7
Name Home Phone Work Phone
PRESENT MAILING ADDRESS Meye e
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 o Massgr husetts
.Department of T>v dustriaZAccidents
1 Congress Street,Suite 100
.Boston,MA 02114-2017
www rnas,-govldia
1W,a kers'Compi sationInsurance.A£�davit:Builders/Contractors gctxaeians/P1 hers.
TO BB MM WHR TEE PMAMING.AUTHORYff
Applicant Information Please Print Legjhly'
Name (Business/Orgmization/Tndividual): 4 Pl
Address: 2y e-
City/State%Zip: /U. ,. �o��i !44 01 V(Phone#: —7 — 7G6 — '37 �
Areyou an employer?Checktlie appzopriate,bar: Type of project(regtrixed):
1.[]I am.a employer v&h s employees(full and/or part time).* 7.• Q NeW co is motion
2.�I am a sole propiietor or partnership and have no employees working forme in 8. U Remodeft
any capacity.[No workers'comp.insurance required-] S, Demolition
I Q I am a homeowner doing all work myselk[No workers'comp.dusursace,required.]
YO FIBuilding addition
4.$CT am a homeownerandwill be hiring contractors to conduct all work onmy property IwiIl
ensure that all contractors either have workers'compensation insurance or are sole 11:F]Electrical repairs or.addition.s
pro'p'rietors-wi.$ino employees. 12:�(Plumbing repairs or additions
5.❑I am a general contractor and I have hire dthe sub-contractors listed on the attached sheet. 13:Q Roofrep airs
These sub-contractorshade employees andhaveworkers'comp.insurance.;
. • ld•.[l Other
6.0 We are a corporatip pndifs officers have exercisedtheir right of exemption perMGL c.
152,§I(4},andwehaveno,e�iiployep.[No workers'comp.insmancerequired.]
*Any applicant that;oheeksbox#1 must also'M out the section below showingtherrworkers'eompensationpolicy i6ormation.
T Homeowners who sulimitt affidavit indicatmgthey are doing all work and then hire outside contractors must s41bm{t a neve affidavit indicating such
?Contractors that checkthis bog must attaghed an additional sheet showing the name of the sub-contractors and state whether ornotthose entities have
employees.-Ifthe sub-confrac6Irate employees,they must providetheir workers'comp.policy number.
I awn an erripZoyer tlz at as pYoridzng-lvor•kers'compensation insurance for my employees.' Belo3v is thepolicy and-job site
inforrnadon.
Tnsarance Company Name.
PORGY or Self-ins.lir'.#: ExpirationDate:
Tob Site Address: City/State/Zip:
Attach.a copy ofthewoykers' compepsationpolicy declaration page(showing thepolicynnmber and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A 7s a criminal violation punishable by a fine up to$1,500.00
and/or one-•year:immprisomnent,as well as civil penalties in the form of a STOP WORK ORDER and a ane of up to$2$0.00 a
day against the violator_A,copy of this statement may be forwarded to'i e,Office ofluvestigations of the DIA for insurance
coverage verification.
Ido hereby certify user the pains andTimaide•s ofperjury that the informationpr ovided alcove is true and correct
Signature. � _ _ Dare/ �/;,0/(-
Phone#--
7 k1- -204-- ;!�-tis 1
Official use only. Do not in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority-(circle one): ;
1.Board of Healtla 2.Buffd:i)agDepaxbnent 3.City/Town Clerk 4.Electrical Inspector 5.Plumbingluspectox
6.Other
Coxatact 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 oi'hire,
express or implied,oral or written."
Au employer is defined as"an iud viduA 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 b6 deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or to cal licensing agency shall withhold the issuance or
renewal of a license or permit to operate a busness or to construct buildings in the common-ffealtlx;for any
applicant who lias 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 cheekinglo'boxes that apply to your situation and,if
necessary, supplysub=contractors)name(s),address(es)and•phonemmber(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees'o-therthan the
members orpartners,are notrequiredto carryworkers' compensation insurance. If au LLC orLLP doeshave
employees,a policy is required. Be advised that this affidavit may be submitted to the Depaitm.ent of•Industrial
Accidents foi:confttnnation 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-i'n'sure_d companies shouid'enter their.
self-insurance license number on the appropriate line. -
City or Town Offiicials
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 site to fill in the permit/license number which will be used as areference number. In addition,an applicant
that must submit multiple pennit/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 buin 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•-MA.SSAFE
Fax#617-727•-7749
Revised 02-23-15 www.mass.gov/dia