HomeMy WebLinkAboutBuilding Permit #235-2016 - 200 BRENTWOOD CIRCLE 8/26/2015 44-� auiLumlu rtrcmi i 02
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
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Permit N0: Date Received
Date Issued: L
�4SSACHus s�
IMPORTANT:Applicant must complete all items on this page
LOCATION c2D0 '_6re n+coo ori/ Cir
Print
PROPERTY OWNER `'�"', o TH erserea
Print
MAP NO: PARCEL: ZONING DISTRICT: Historic District yeno
Machine Shop Village ye no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
XNew Building ❑One family
❑Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement NfAssessory Bldg she ❑ Others:
❑ Demolition ❑ Other
❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District
1�Water/Sewer
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Identification Please a or Print early)
OWNER: Name: irn If prer, Phone: ��- 935'3
a P �
Address:
CONTRACTOR Name: 7 1D� /�� Phone: q y33
Address: ICIP-S 66%-15�w t1 l 031 /
Supervisor's Constructi n License: Exp. Date: j
Home Improvement License: Exp. Date: ,
ARCHITECT/ENGINEER Phone:
Address: Reg. No. r
FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ 5, 000 FEE: $ 6n.DD
Check No.: 1IC32M Receipt N 'j 7_
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner mature of contractor
NORTH
BUILDING PERMIT o� Eo '6g4o
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received
'TS us
Date Issued:
IMPORTANT: Applicant must complete all items on this page
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4
iLOCATION':'
PIROPERTYtOWNER`
:o Y
={pun +1 t ear trac S u„wre yes. ono `
IMAP .__ T PARCEL . ._ Z®NING DfSTRICTr _ s�IstonclDist�icttl eyes ono 1,
IMachine+Shoq,Village Dyes �€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
�' - � � a.�. ®F d Iiia, f��Weands � -����Watershed Distnct �-
❑S tics ❑Well
DESCRIPTION OF WORK TO BE PERFORMED:
Identification- Please Type or Print Clearly
OWNER: Name: Phone:
Address
_ -- {
.r
,.. ._. T �Phone�
,�Contracor,}�Name
a."
ic4Addfess= -
Superbvisor s'C str�uctio License ' _.�_� E p. ®Atez A -
Horne ImprouementL cense_ xp> Date: __
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE,SULDING PERMIT.•$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ FEE: $
Check No:: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Slgnature_of Ager Owner _. r` r Signature Of
U
Location
No. Date
. • TOWN OF NORTH ANDOVER
� S�S'TL'�D'Tj646'
Certificate of Occupancy $
Building/Frame Permit Fee
Foundation Permit Fee $
Other Permit Fee
TOTAL $
Check# l rl
Building Inspector
2 .25<�
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer & Taming/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
PLANNING & DEVELOPMENT Reviewed On ' J(� ,-�) Signatu
COMMENTS 74 4I L��
CONSERVATION Reviewed on 7 `7 Si nature'-
COMMENTS
HEALTH Reviewed on l� 5� Signature
COMMENTS_ ]
Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
!:onservation Decision: Comments
Water& Sewer Connection/Signature&Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE D PARa M NT�-A'TernptDumpster omg
jsiteh yes .iz �u�no
�sLocated at 124 MainStreet `u Departmentsignature/da ���� �����a
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Ew .,r.r....,i..{ y♦. 41
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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 Permit 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
j Workers Comp Affidavit
❑ Photo Copy Of H.I.C, And/Or C.S.L. Licenses
j Copy of Contract
❑ Floor Plan Or Proposed Interior Work
Addition Or Decks
❑ Building Permit Application
❑ 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 Hydraulil
Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
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
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 1\SPEC'r10%AL SERVICES DF.1'.1RT"%1EN'r:uPFOR%1115
P,t^e d of-1
NORT#1
Town 1Andover
low
No. 0
� oh ver, Mass, o 5 015
,J- COC NIC Nl W.CN 0
7,4 AD'VAT. 0.P���4J
S U -
BOARD OF HEALTH
Food/Kitchen
PERM- IT T LD! Septic System
THIS CERTIFIES THAT , „"` .'.^wl maeurt�. ,,, BUILDING INSPECTOR
...........I.... ........... .... .................................... ......:..... .....
has permission to erect buildings ona.w. &Ao.A.W.�4 � ....... Foundation
.......................... .... .... ................
141....� ...... Rough
tobe occupied as .. ........................:....................................................... 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
Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 NT S ELECTRICAL INSPECTOR
�� • UNLESS CONSTRUCT TA SRough
Service
.............. ... ..................................................... Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Buildine 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 N°RTN 7 TOWN OF NORTH ANDOVER
eo �
OFFICE OF
BUILDING DEPARTMENT
* 1600 Osgood Street,Building 20, Suite 2035
North Andover,Massachusetts 01845 SSAcHU E�h
Gerald A.Brown Telephone(978)688-9545
Inspector of Buildings Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
BUIDING PERMIT APPLICATION
Please print
DATE:
JOB LOCATION: 000 ��pr��wccdl C r
Number Street Address Map/Lot
HOMEOWNER —_ imy&j /getserer,ti '17K435-3001"_ cc-e11>
Name Home Phone Work Phone
PRESENT MAILING ADDRESS 000 1�rer.�wocxo C; r
/1)0 it, Ar,SoV,— 1tt- G13Lis
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 of162assachusetts
z .
Department of IndiustrialAceldents
1 Congress Street,Suite 100
Boston,MA 02114-2017
V 4�< wavw.rt�assgov/dia
Sy Workers'Compensation Insurance Affidavit:Builders/ContractorsfFIectricians/Plumbers.
TO BE FILED WITR THE PERMITTING AUTHORITY.
AI)plicant Tn£ormation Please Print Legibly
Name(Business/Organization/Cndividual): n rn p 44
Address: .200 _?:>-rer4wco, Cir
City/State/Zip: AA AKJvv,,- /04 phone#: `y-7 YSS ' 3 8,�S
A reyou an employer?Cheekthe appropriate box: Type of project(required)'
1.0 1 am aemployerwith employees(fulland/orpart time).* 7. t/New construction 5k
2.❑1 am a sole proprietor or partnership and have no ernployees working for me in g. 0 Remodeling
any capacity-(No workers'comp.insurance required.]
9. El Demolition
3.,❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t
4>(I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 E]Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees. 12.,Q Plumbing repairs or additions
5.❑1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 ROOF repairs
These sub-contractors have employees and have workers'comp.insruance.t
6.❑We are a corporation and its of kers have exercised their right of exemption per MGL c, 14.Q Other
152,§1(4),and we have no,employees.[No workers'comp.insurance required.]
*Any applicant that checks box 41 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 andtheu hire outside contractors must submit a new affidavit indicating such.
rContractors 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-conlraciors fiave employees,%ey must provide their workers'comp.policy number
I am an employer that is prdviding worker's'compensation insurancefor my employees.'Below is the policy and job site
information.
Insurance Company Name:
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 MGL o.152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
X do hereby Bert under tiro sins andpenalties ofperjury that the information provided above is true and correct.
Si nature:
Date:
Phone#:
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£or their empzoyees.
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,partnersbip,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint entexprise,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 comiaonwealtb,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 ofpublic 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 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 may be submitted to the Department of industrial
Accidents fox confirmation of insurance coverage. Also be sure to sign and date the affidavit. Tide affidavit should
be returned to the city or town that the application fox 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 w6rkers'
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 jffl 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 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 www.mass.gov/dia
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❑MVPC So Wetlands Zoning
[3 Municipal Boundary d Exempt Lands '; Busine 1 District
0 Busine 2 District Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83,
-Rail Line M Buslneu a 3 District Meters Data Sources:The data for this map was produced by Merrimack
Interstates O Busine s 4 District MORiN Valley Planning Commission(MVPC)using data provlded by the Town of
- A Genera Business District Of tto q North Andover.Additional data provided by the Executive Office of
-SR D Plann Commercial Dav ���Q Environmental Affairs/M-GIS.The information depicted on(his map is
L'Corrido Development Dist 3�• OL for planning purposes only.It may not be adequate for legal boundary
Roads O Corrido Development Dist O A definition or regulatory interpretation,THE TOWN OF NORTH ANDOVER
r Easements O Corrido Development Dist f- A MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING
❑ParcelsIndustri I 1 District « THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY
tl Industri il2 Districti •y OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT
Zoning Overlay O Industri 13 District °o 'r♦ ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF
,Zoning
Entertainment 12 Industri I S District �,eo '" .'� THIS INFORMATION
0 Downtown Overlay District ct Reside cc 1 District � e t
13 Hi District 1:Residei cc 2 District SSACNUSE
0 Water Protection O i cc 3 District
::Hydrographic Features del a 4 District
Streams 1"=240 ft -�_de cc s District
de ce 6 District
esidenlial District