HomeMy WebLinkAboutBuilding Permit #698 - 204 MILL ROAD 6/15/2009.BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NOL
Date Issued:
IMPORTANT:A
Date Received
must complete all items on this
Print /
PROPERTY OWNER , ,1,
Print
MAP NO: /07,2. -PARCEL: 62 ZONING DISTRICT: Historic District
Machine Shoa Villaae
et ,'• "' • , e OL
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One family
Addition .
Two or more family
Industrial
Alteration
No. of units:
Commercial
air,, eplacement
Assessory Bldg
Others:
Demolition
Other
Septic lllrrell
Floodplain Wetlands
Watershed District;
Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
Identification - Please Type or Print Clearly)
OWNER: Name:
Address:
0
CONTRACTOR Name: Phone:
Address:
Supervisor's Construction License: __Exp. Date:
Home Improvement License: Exp. Date -
ARCH ITECT/ENG I NEER
ate:
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: $ L; p 4 -6 FEE: $
Check No.: w S Receipt No.:.
NOTE: Persons contractingIvith _un
ered 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
-a 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
u 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
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 Reviewed on Siqnature
COMMENTS
HEALTH Reviewed on Signature
c bMMENTS
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
DPW Town Engineer: Signature:
Locatea 3tf4 us ooa Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signatureldate
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
Doc.Building Permit Revised 2008
LocatioAciy A(ff /zw
No. Date
NORTH TOWN OF NORTH ANDOVER
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+ ; , Certificate of Occupancy $
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cNBuilding/Frame Permit Fee $ '
s►us
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # a
221 1 8
Building Inspector
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The COMMM.-ZWealth of Massachusetts
I Department of industrial Accidents
Office of Investigations
600 ffrashington Street
�c ? Boston, MA 02111
www -h ms gov/dia .
Workers' Compensation Insitra.nce Affidavit: Builders%Contractors/Ei
Aectriciartsipiambers
• licant Information .
Please Print Leaibl
Name (Business/owization/lndividual):
Address: pb?
iiylState/
' / —
CPhone #.. 9�
... �F � ..
Are you an employer? Cheek.the appropriate box:
I. [� I am a employer with 4. ❑ 1 am a general contractor and IF7=n
roject (re qui*:
employees (full and/or part-time).* have Dred the sub-clantsaetors construction .
2. ❑ I am .a.sole proprietor or partner- listed on the attached sheet # odeling
ship and have no employees' These suis -contractors have
working for me in any capacity. workers' comp. insurance. olition
[No workerscom insurance .. 5. lding addition
P ❑ Weare a corporation and itsrequired ] officers have exercised their trical repairs oradditions
homeowner doing ail work right of exemption per MGL bing repairs or additions
myself: [No•workers' comp. c, 152, § I (4), and we have no
insurance required.] .t ter. Is, ees. I2.Q Roof repairs
• P Y [No wormers'
comp. insurance required..] 13.❑.Other
t Ho "Any applicant tient checks boZ # I must also till out the section below showing their workers' oornpeasetion policy information
meownets who submtt this afi'riiavit indicating they are doing an work and then his ornside contractors mrist Submit a new affidavit indi
4CotM=t01a that check this box nwaaftched an sdditi., shee.'show' . � such.
the name of the sub -contractors and their wortcera. torr. Ii„ • • ,
I am an employer first is providing workers' co ensadon t. paii—, rrfnrnmtian.
information. mP insurance for my employe: Below is the
PoBc!' andjob site .
Insurance Company Name:
Policy # or Self -ins. Lie. #:
Expiration Date:
Job Site Address:
City/ststmzlp:
Attach a copy of the workers' compensation policy deciaratioo page (showing the policy number and expiraiioa dafeeJ. .
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 ORDER 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.
I do hereby certify under the pars and penaid es of per*7 Mar the in .f nrmation ro '
p ntded above rs true and eorred
Sioature.,..
o iciat use only. Do not write is t"s area, m he completed by cky or town official
City or Town: Permit/License #
Issuing Authority (circle one):
I. Board of Health 2 Building Department 3. City/Town Cierk 4. Electrical Inspector 5. Plumping Inspector
6. Other
NContact Person• Phone #:
Information a end Instructions'
Massachusetts General Laws chapter 152 requires all emp Ioyers 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, assooiation, corporation or other legal entity, or any two or more
of the'fomping engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver ortrvstee 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 ori work m such dwelling house
or on the grounds of building appurtenant thereto shaU not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local Ficensing.agency shall withhold the issnance or
renewal of license or permit to operate a business or ito construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence.o'F compliance with the insurance 'coverage required."
Additionally, MOL 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
requircm=ts of this chapter have been presented to the corttrracting authority,"
Applicants
Please fill out the workers' ,compensation affidavit comple=tely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es): amnd phone number(s) along with their .cer ificate(s) of
ran
insuce. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not requiredito cavy workers' cc-mpensafion insurance. lfan LLC or UP 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, notthe Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please -can the Department at the nurmber listed below. Self-insured companies should enter thcir
self-insurance'lieense number on &e'appropfiate, line.
City or Town Ofiaciais
Please be sure that the affidavit is complete and printed legibly. The Department hes 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 W -M 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.officiaily stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for firtt m permits or licenses. A new affidavit must be Med out each
year. When 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
Tho 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 Massachuse=
Department of IndusttW Aacident
Office of Envestigatiutns
600 Washington Street
Bosfon, MA 02111
TeL # 617-727-4900 ext 406 or 1-8.77-MASSAFE
Fax 9 617-727-770
Revised S-Zb-t?5 wwwMass.gov/dia y
TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
1600 Osgood Stream Building 20, Suite 2-36
North Andover, Massachusetts 01845
Gerald A Brown ` Telephone (978) 688-9545
Inspectpr of Buildings +. Fax (978) 688-9542
HOMEOWNER LICENSE EXEMPTION
Please orifi
DATE: -IS— 4,9
JOB LOCATION: c9 -6i/ /'jj C�- Ale / 709 tlf ,e—_
Number Street Address
HOMEOWNER Zc�` l- J�� 1d / V -R �
Name Home Phone
IreO
PRESENT MAILING ADDRESS a M`"/% �a
City Town
work Phone
State
ZAP Code
The ctirnent exemptim fra Kms' was extended to include owner -occupied dwc hnp to two units or leas
and to allow such homeowners to engage an individual for but who does not possess a license, provided that the
owner acts as supervisor). State Building Code gectum 208.3.5.1)
DEFINITION OF HOMEOWNER
Person(s) who awns a parcel of land on which helshe resides or intends to reside, on which there is, or is intended
to be, a one or two family structures. A person who oonidzW" more that one home lit a two-year period shall not
be considered a homeowner.
The undersigned '"homeowner" assumes responsrbiI ty for --inpliances with the State Building Code and other
Applicable codes, by-laws, rules and regulations.
The undersigned "homeowner" certifies that helshe understands the Town of North Andover Building Departmerrt
minimum inspection procedures and requirements she will comply with said procedwes and
.• s
HOMEOWNERS SIGNA
/ n
APPROVAL OF BUILDING OFMCIAL
>zavind M=5
Form Honwowma Ego W ion
BOARD OF \PPE:US 699-9541 C0NCERV_1FI0\ Egg -953 IiTE.ILTH 698_9540 PL.L\'1NG r;gg_9535