HomeMy WebLinkAboutBuilding Permit #794-2016 - 207 FARNUM STREET 2/2/2016AJ"
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: C� 61(o
Date Iss
Date Received
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IMPORTANT: Applicant must complete all items on this page I
LOCATION 0� D
PROPERTY OWNER 116CI /V 'l T . /V1X- t.ayv
Print 100 Year Structure
MAP 0 S �-PARCEL:-6–A— ZONING DISTRICT: Historic District
Machine Shop Village
yes
yes
yes
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TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
A One family
A Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
D Septic ❑ 1Nell
Floodplain; Wetlantls� v
❑° Watershedl�DastnctdT �`
Water/Sewer
DESCRIPTION OF WORK TO BE PERFO)RMED:
a A 6-0(- Gae-4sA uj({1i1 �
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OWNER: Name:
Address:
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Contractor Name: Phone:
Email:
Address:
Supervisor's Construction License:
Home Imr)rovement License:
Exp. Date:
p. Date:
ARCH ITECT/ENGINEER,JI' Q�t1�`fTG"( C�� Phone:_I,��
Address: _Reg. �d ��-'!a Reg. No. !76 T_/
FEE SCHEDULE: ATlLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $�ya�a FEE: $®O�
Check No.: a f a,-,7 Receipt No.:q�f�
NOTE: Persons contracting wiegistered contractors do not have access to the,guaranty fund
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Locations+, // /;
No. ` %T -z` - 2a1� Date �O 1-20 t-zs
Check #
y38
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $ r
Other Permit Fee $ 1
TOTAL $ +�
Building Inspector
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
well ❑
Private (septic tank, etc. ❑
Taming/Massage/Body Art ❑
Tobacco Sales ❑
Permanent Dumpster on Site ❑
Swimming Pools ❑
Food Packaging/Sales ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On _ Signature
COMMENTS
CONSERVATION Reviewed on ___ _.___ _ Signature
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
P Planning Board Decision:
Comments
Conservation Decision: Comments
F
'Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
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
®ANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA — (For department use)
Doc.Building Permit Revised 2014
I
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 .
TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
4, 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
2012 IECC Energy code
Engineering Affidavits for Engineered products
TOTE: 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
Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
$ 84,000.00
m
$ -
$
1,008.00
Plumbing Fee
$
126.00
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
126.00
Total fees collected
$
1,360.00
207 Farnum Street
794-2016 on 1/7/2016
Construct 2 car garage with great room over
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The Commonwealth of Massachusetts
Department oflndustrzalAccidents
M X Congress Street, Suite 100
Boston, MA 02114-2017
www mass.gov/dza
WolI<kers' Compensation Insurance Affidavit: Buidders/Contractors/Electricians/Plumbers.
TO BE FMED WITH TEE PERMITTING AUTHORITY. —
Name (Business/Orgatvzation/In�tal): 1 %lOelM#1�"7
Address:
City/State/Zip:
Are you an employer? Check the appropriate box:
10 I am a employer with . employees (full andlor part time).4'
KI'am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3. ❑ I am a homeowner doing all work myself [No workers' comp. nisurance required.] t
4.Q
I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
5.❑ I am a general contractor and I have hired the sub-coiztractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance.1
6. ❑ We are a corporation and its oftigers have exercised their right of exemption per MGL c.
152, §1(4),8.4
1(4),and we have nc� employees. [No workers' comp. insurance required.]
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/00)
0)
410
Type of project (required):
7. [l New construction
8. [] Remodeling
9. ❑ Demolition
10 ❑ Building addition
11. FJ Electrical repairs or additions
13.0 Roofiepairs
14. ❑ Other
checks box#1 must also hll outthe section below showingtheirworkers'compensation policy information
i Aomeowners who cherstb�it This affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
*Amy applicant that
?Contrabtors that check this box must athached an additional sheet showing the name o£theeub-contractors and state whether or not those entities have
employees. Ifthe sub-con�raciors fiave employees, they mast provide their workers' comp. policy number.
I am an employer tTiat is pfovidirzg workers' compensation insurance for my employees ' Below is the policy and joie site
information.
Insurance Company
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 c. 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 Ofhce of Investigations of the DIA for insurance
coverage verification.
Ido hereby ceT,# y finder the
of pejyury that the information provided above rs true Std correct.
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
PermitlLicense ff.
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. Cityffown 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 6'ire,
express or implied, oral or written."
An employer is defined as "an indlvidual, partnership, association, corporation or other legal entity,' 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 ofthe
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 ba 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 commonwealth 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 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' ontractoi(s) name(s), address(es) and•phonenumbers) along with their certificates) of
insurance.—Limited. Liability-C-ompanies-(DLG)-ox Limited-L-rabil=ity-Rat tiarshr�(LL�.'�iith n eemp oyees other hand 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 aiddavit. The'affidavit should
be rettuned 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 yo'u'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 (ifnecessary) 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 burn 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 # 61.7-727-7749
Revised 02-23-15 www.mass.gov/dia
pORTW TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
a ; 1600 Osgood Street, Building 20, Suite 2035
North Andover, Massachusetts 01845
Gerald A. Brown
Inspector of Buildings
Please print
DATE:
JOB LOCATION: � O
HOMEOWNER
HOMEOWNER LICENSE EXEMPTION
BUIDING PERMIT APPLICATION
Number Street Address
Name Home Phone
PRESENT MAILING ADDRESS
Telephone (978) 688-9545
Fax (978) 688-9542
i►�Iq A /4 r7A-
Map/Lot.
Work Phone
r� eAJ
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 I IO.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/sherstands the Town of NorthAndover Building Department
minimum inspection procedures and requirements d that he/she will comply wit said procedures and
requirements. ��
r
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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