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HomeMy WebLinkAboutBuilding Permit #532 - 20 MOUNT VERNON STREET 4/9/2009BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 59 Z Date Received Date Issued: Cl, -i'— a v'st`ae �6• ~C IMPORTANT: Applicant must complete all items on this page LOCATION c.2b /T?°t9�vPi'Zw c li.�Gti" Print PROPERTY OWNER . I�c��(' 'J Print .MAP NO: PARCEL: S 3 ZONING DISTRICT: Historic District yes no Machine ShopVillage yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building I q ne'family Addition Two or more family Industrial Iteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Set' 1Ne11 Floodplain: Wetlands Watershed District Z DESCRIPTION OF WORK TO BE PREFORMED: y?� OWNER: Name: /. or Print Clearly) Address: /l-lCvI- /fvfo-o�, CONTRACTOR Name: Phone: Address: Supervisor's Construction License: Exp. Date: `Home Improvement License: Exo. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. �O Total Project Cost: $ CZ` 00 FEE: $ �b Check No.: � D 1—� Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 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 DEPARTMENTMFORM07 Revised 2.2008 b 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 CONSERVATION COMMENTS HEALTH COMMENTS Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Com Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street •FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 MainStreet' Film'Departmentsignature/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 2008 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 2.2008 Permit NO: 53 Z BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received Date Issued: Vzd-- 01 IMPORTANT: Applicant must complete all items on this nage LOCATION c'!' b /ha -P, PROPERTY OWNER_ L.( Print MAP NO: 4!'4 PARCEL: S 3 ZONING DISTRICT: Historic District Machine Shop L yes no ves no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Buildingne famil Addition —at Two or more family Industrial Iterion• No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Set' Well Floodplain Wetlands Watershed District Cater/Sewer DESCRIPTION OF WORK TO BE PREFORMED: .dentification )'lease T�yyppe or Print Clearly) OWNER: Name: S �S-eV*9 Phone: Mtf-.Z5:P- 36 Y Address: A'&)w- CONTRACTOR Name: Phone: Address: Supervisor's Construction License: Exp. Date: Home Improvement 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. c.p �� dv Total Project Cost: $ C>a400 FEE: $ / Check No.: � � Z�1 Receipt No.: 65L NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor Location o M71 vz -N v,' SJ— No. J— No. Date NORTN TOWN OF NORTH ANDOVER 01 O a Certificate of Occupancy $ s�C"� Building/Frame Permit Fee $� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # -3o . 21 937 �---�_ Building Inspector tz W 0 W x W4 A c 0 � z z 0 a z a OH W A a O W a W pG d A u oC,, ww°' w° cn w d w W a� cn cn ui a z 0 U 0 4Q Qr co O co ■ L O Z CL. O y � C 03 cm I C C O■— Q h O O Co co 0 CD 3.0 CD O G O L mO CL CMa ca c CO CO2 C Z tsO 0 CL C.3 N2 O c ■C c _cc CL COD 0 LLI N LLI Y♦ 19 W LLI 19 w U) l - , The Commonwealth of Afi?ssachusetts �� ' ` Department Of Industrial Accidents . Office , , of .Fizvestigations "� ' 600 Washin ton Street Boston, MA 02111 r �- " W K'►�'-masa.; oz�/dia Workers' Compensation Insurance .Affidavit: guilders/Contractors/Electricians/piumbers Acant Information Name (Business/Organization/Individual): Address: �2c) 417' d City/Stat../Zip: Phone #:�� Are you anemployer., Check the appropriate box: 1. ❑ I an, a employer with 4. ❑ I am a oeneral co tra al or (hill and/or part-time).* 2. ❑ I an a sole proprietor or partner. ship and have no employees working for me in any capacity. workers' comp. insurance e'quired j 3. 1 am a homeowner doing all work myself. [No. workers' comp. insurance required.] t n ^tor and I have hired the sub -contractors listed on the attached sheet $ These sub -contractors have workers' camp. insurance. ❑ We are a corporation and its of r -e -M have exercised.their right of exemption per MGL c. 152, 1(4); and we have no employees, [No workers' comp, insurance r Type of project (required): 6. ❑ New construction 7. ❑ Rem.odeIing . S. ❑ Demolition 9. ❑ Building additi.on 10:❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12:❑ Roof repairs equtred] I 13.❑ Other Any applicant that checks box # 1 .must also fill out the section below showing their workers` compensation policy mtamiation. t. rlomcowners who submit.fhis a%idavit indicarin� ti;ey era uuir:r E!'. s ,,ta xConuactors that check this bos.must at -ad =n hi au�iae eoniraeiure must su'omii a new amdiiVir atffiched an additional sheet showing indiWtir.F such. the name the sub contractors and their work=, trim, c: .:_ r ..,.rm rmpwyer rr:az cs prove ina workers' compensation iftsurance for n9' employees. Below is the ori-......� Lnformaiiort P cy and job site Insurance Company Name: Policy # or Self -.ins. Lic. #: Expiration Date: ------------- .lob Site Address: City/State/Zip: Attach s COPY of the workers' compensation policy declaration page (showing the policy number and ex iia" .Failure to secure coverage as required under Section 25A of p ti date), fine up to 11,500.00 and/or one-year imprisonment as well as civil penalties inythe to of a STOP WORimposition Of K ORDER p�altres of a of up to .S250.00 a day against the violator. Be advised that a co RDER and a fine Investigations of.the DIA for insurance coverage verification. copy of this statement may be forwarded to the Office of I do hereby, certify under the pains and pnnlfies of perjury; that the information provided above is true and correct Ufecial use nnlp. Do not write in. this area, to be completed by city or town ofp=iaL City or Town: Permit/Lic—e 41 Issuing Authority (circle one): L Board of Health 2. Buiiding Department 3. City/Town Clerk 4. Electrical Inspector 5- Plumbing Inspector 6. Other - L)e Contact Person: Phone Information and Instructions Massachusetts General Laws chapter 1 S2 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 inclucii ri.Q the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, associati on 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 maint-nance'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 o r local licensing agency shall withboid the issuance or renewal of a license or permit,to operate a business or to construct buildings in the commonwealth fnr'any applicant who has not produced acceptable evidence o►f 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 contraztmg authority." Applicants Please fill out the workers' compensation affidavit compki-etely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) amid phone number(s) along with their cefficate(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,affiidavit should be returned to the city or town that the application for the permit or iicemr, is being requested, not the Department of Industrial Ac:cidemts. Should you have, any questions re°Frdirg the law or if you are required to obtain a workers' compensation policy, please call the Department at the ntxnber: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 foryou to fill out in the event the Office of' Investtgations has to contact you regarding the applicant: Please be sure to fill in the permit/iicense 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 siarnped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for futwe permits or licenses. A new affidavit must be filled out each year. Whore. a home owner or citizen is obtaining a licenser or permit not related to any business or commercial venture (i.e. a dog license or permit to burnleaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would iike 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, teiephone and fax number: The Commonwealth of Massachusetts Department ofLndustrial Accidents. Office of Investigations 600 'Washt ington Street Boston; SIA 02111 Tel. 4 617-727-4900 C= 406 or 1-877-MASSAFE Revised 5-26=05 Fax 4 617-72.7-7749 v^vwmass.gov/dia Gerald A Brown Inspector of Buildings Please plW TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT 1600 Osgood Street Building 20, Suite 2-36 North Andover, Massachusetts 01845 HOMEOWNER LICENSE EXEMPTION DATE:,�2� %9 JOB LOCATION: 1&2Ape) X-11 Number Street Address Telephone (978) 688-9545 Fax (978)688-9542 HOMEOWNER txyoc�f :� a.�.� -q © vd- - o Name Home Phone Work Phone PRESENT MAILING ADDRESS 0`X3 ��lctel� J City Town State Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings to two units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) 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 structures. A person who contracts more that one home in a two-year period shall not be considered a homeowner. The undersigned "homeowner" assumes responsibility for compliances with the 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 10.2005 Form Homeowners E=V ion Rcl_.\RDOF \PPF:\1.S 68K0541 CONSERV. VRON688-9530 14E.UJ1i 688-9540 PLA-NN1\G 6K8-9535 Location "` D ✓''� ( 004011 �- No. �' Date r 143x2 //0 L:: �: -�- Building inspector TOWN OF NORTH ANDOVER Certificate of Occupancy $ sqCMUSE<'� Building/Frame Permit Fee $ 3 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ `" Check # 143x2 //0 L:: �: -�- Building inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: BuildinCommissioffe'r/lETector of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address::/ 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: �- Acs c�>✓`L 1.4 Property Dimensions: O ` d 11 ZoningDistrict Pr osed Use Lot Area s Fronts e 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide ReqWred Provided R 'red Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public Q/ Private ❑ Zone Outside Flood Zone 3, 1 1.8 Sewerage Disposal System: Municipal V", On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record G. N me (Print) Address for Service: Signature Telephone 71 2.2 wnof Record: P,4 'Print NameAddress for Service: Si na r Telephone SEC ON 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: �-- OAJ f---� 00 License Number Ad&i➢ess 7�° / a / Ro /,:;z/ _ CP Expiration Date QsS. re Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Tele hone SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buileng permit. Signed affidavit Attached Yes ...... 4 No ....... ❑ SECTION 5 Description of Pro osed Work check all a 6cahle New Construction ❑ Existing Building 0 Repair(s) Alterations(s) ❑ Addition 0 Accessory Bldg. 0 Demolition 0 Other ❑ Specify Brief Description of Proposed Work: A SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Com leted by permit applicant K O�ICIAI. IiSE (9NI.Y k, 1. Building _p90 _ (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (@) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 7 I as Owner/Authorized Agent of subject property. Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name of Owner /A-ent Date Mature NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIIvMERS is 2` 3 RD SPAN DMIENSIONS OF SILLS DINIENSIONS OF POSTS DMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHD NEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE r.t� is/ D. Robert Nicetta Building Commissioner (978) 688-9545 688-9542 Fax Town of North Andover Building Department 27 Charles Street North Andover, MA. 01845 HOMEOWNER LICENSE EXEMPTION Please print DATE JOB LOCATION , Number "HOMEOWNER AL— Name— PRESENT MAILING ADDRESS City Town Address Home Phone Q/V State Map / lot - m ol Work Phone Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings of two units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. (State Building Code Section 108.3.5.1) DEFINITION OF HOMEWOWNER: 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 ac- cessory 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. The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned "homeowner" certifies that he/she understands the Town of No. Andover Building Department minimum inspection procedures and requirements and that herwi comply with said procedures and requirements. l/ HOMEOWNER'S SIGNA APPROVAL OF BUILDING OFFICIAL 4 "!r Cf) m M m C/) 0 W Mo .p C d .7 CO2 C-) CD p Z co) CL =� O � o o p CD CD O Q C �dCD CDo CD C CD CO) CD-� A. v co) CD O aN < m N = o d.a cH O Co o Cl) C) o CO) 14 m Z ?-0 C4Co NCO) CD O O N O O IE �m : m 2 >CD N 0 m O ; !7 C r* n ON O ec�S W 'O 7R: qWN oCL-� �: Cl)� rV�J o o N Cl1 n ynio o �cr in 0 d a� m N �• N �� O En n � C'S.d-► zoCD Cn H 3 z ,C CD CD cn CD CD CL C-3' . . ca ywo Cn R cp to M z r 0 x t" a- "ti Z CA Q a :jr G7 C/) 9 CL n to ° x 9 Qa M V 0=3 0 9 0 c