HomeMy WebLinkAboutBuilding Permit #219-15 - 21 HAMILTON ROAD 8/29/2014 BUILDING PERMIT 01 "°oT" qti
TOWN OF NORTH ANDOVER F - -
APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received ED
��SSACHus����
Date Issued:
I O TANT: Applicant must complete all items on this page
LOCATION 4
PROPERTY OWNER !1 ►Q.lY 1 'l-- )Zh �r?✓I l
0 Print 100 Year Structure yeso
MAP 1/PARCEL ZONING DISTRICT: Historic District yes o
Machine Shop Village yes n
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building 1A One family
❑Addition ❑ 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:
I<! �C-hf,P, aetl 04t l
Identification- Please Type or Print Clearly
OWNER: Name: moor I e /2,e, /1)•e— Phone: T7 F- 91 S-yZra
Address: Z1 o�r^� � � �h �� V
Contractor Name: Phone:
Address:
Supervisor's Construction License: Exp. Date:
Home Improvement License: _ . Exp. Date:
_ v
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: $ FEE: $ \
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
SignaturCo Agent/Owne A•u.z Signature of contractor
Plans Submitted ❑ Plans Waived 0 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
PLANNING & DEVELOPMENT Reviewed On Signature_
i
i
COMMENTS
i
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
i
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
W
`Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Con neCtlOn/Signature& Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood 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
NOTES and DATA— (For department use)
i
❑ 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
o Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
o Copy of Contract
o 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
o Workers Comp Affidavit
Li 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
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:Building Permit Revised 2014
Location 3
}
No. " Date
• TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ n` 1`
a
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check#
Building Inspector
i
i
Enter construction cost for fee cal - North Andover Fee Calculation
Construction Cost
$ 2206.00 m
$ - $ 271.99
Plumbing Fee $ 34.00
Gas Fee 100 comm. $ 100.00
Electrical Fee $ 34.00
Total fees collected $ 439.99
21 Hamilton Road
219-15 on 9/10/2014
Kitchen Remodel
yhe Comr
donweaftfz o, ' 'amch. ett
l�epfftentoffAdtfsft!g1Acczc&fs
. . O,lee of fnvestigWons '
600 Washington Skeet
Poston,HA 02-111
mm-man.go-PId a
WQrkex>q'caxnpewatio�LInnsmaxtce Affidavit:�rt�c�erc�ICa��acto�c�/�X���re�cza�a�l�'�iiz�bex,�
'eax�$ orc�ma-do please.Pxint e 'bX
A�ppR..
Nama pusinessl0rgau aation/J'vdz`uid'a rn Q-Y 1 �-Q Yl Vl
City/SL t,/Zip: /�/ ne��✓�� /1� o�l'q'S�
Are youan exmplayer?check me,appropxiatebox: Type of project(xeguilreco):
o acta ands
f
4, lain a
enexal c ntx x
I am a om to ex with
� g 6. ��Tevt c6nsixuc�Zo�
em to ees Mandiox axe time)T havenedthe sub-confxactoxs
p Remodelin
p � ( z �. g
+2.[1 1 am a solepropxietor oxpall ex listed on the attached sheet t
-can ctorshave, S. l7emolztion
shY and'hagezza.em loyees These sols txa �(_,
woxkg fome in any capacity. workers,comp.insurance. �. � Euzidv
zg addztxon
[No workers'camp.insurance 5, ❑We are a corporation and its 10.r[Electricalrepairs ox additions
xecluixed.� officers have exercised.their
3. I am a homeowner doing all work light of exemption perMOL 11..�(Plumbingxepab or additions
myselr.Ego w9lka&camp. c.152,§I(4),andwahaven.o 12.ElRIO o£xepairs
irlsuxaxzc�re�zixed. i employees.[No Workers, 13.[]Otlier
comp.insuranceroTifred]
eAw applicantthat checks bmof must also:mdattheseetion beluvrshowiogtheir workers'eompensationpolicy Wonnafion.
i(Homeowners who submits;affidavitfadicatiuit icy Sze doing allwor]Vand then hire outside contractors must submit anew affidagitindica�ig such,
xConiacfosthat chcektisbox-must affahedMadtonalsheetshownghnameafthesut-confracforsandthe£worker'comp,poffoyffoiruafion.
am ax2 em
ptoyep fAt t is vrovi�ivg workers"cornpe�sation ir�sr��ar�c0 r -ay ernpToyees Burow istiie volley avd joh si�'e
Nfomadon
Lnsuxance cornpanyN'ame;.
Eollcy#ox Sem 7ns.�c.#: Expiratzon.Da4e: .. .
lob Site.A.ddrom', City/StatelZip:
.A-ffaeh,a copy a t ewnxkexs'compant atlon-polley declaration page(showing-the policy nua herr and expkatioa date).
Failure to securer coverage as xecluireclunder Section 25.A.of.N OL c.152 Cali lead to the impositlan of eximinalpenalties of a
faze up to$1,500A0 andlox ones-year npxzsopmextt,as well as chRpen:altzes;in the fom of a SWOP WORTS ORbM and a fn e
Dfup to$250AD a day against the violator. 13e advised that a copy ofthis statementmay be fazwardedto the Office-of
7nvestigatzons of;the DIA.fox ihsnxaace,coverage vexiBcation.
do Xiereby ee tEfy zrric�e'irieprzir��c t �er2aZtie of veT qy txiat trio information provided above%s true anc correet,
Sian.atzrre• Date:
one#:
Oficial use oxfy. vo not vrite in this area,to he eomWXetecl by city or torn official.
City or Town: Permit/License 0
Issuing.Anth.arffy(circle one):
1.Boar+l of fealtle 2.BuildinPepartmeeE I Cityl7Coym Clerk 4.Electrical.Inspector 5.0umbinglaspector
6.Other - "
NORT1y
Town of 2 s ndover
No. o * -
Wth ," ver, Mass,
1 COC NIC Mf WICK y1.
S U
BOARD OF HEALTH
PER IT T LD Food/Kitchen
Septic System
THIS CERTIFIES THAT ......... . .....o%.n.%,&.... ........... .'.Cr.!h...� "'♦ kt.^4A' 0......... BUILDING INSPECTOR
(10.40............
Foundation
has permission to erect .......................... buildings on .................. ftfr.
i Rough
to be occupied as ..Kvla&w......
...........^.......................................................... 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 MONT S ELECTRICAL INSPECTOR
UNLESS CONSTRU N RTS Rough
Service
............. .............................................................. Final
BUILDING 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.
1
TO"Off`NORTH AND OVER -
' OFFICE OF
B-MONG-'DErIMTWNT
• ' �� ,' Y600DSPod5freetB�RH&g20 •Suite2
7 s� Hu5��5 •NorthAndovox,Massachusetts Q1845y36
Gerald A.Brown - . Telephone(978)688-9545
Inspeetorof$uildings _ Fax (978)689-9542 '
�OMEOWt`TER•LICENSE EXEMPTION '
B�T)<DXNG PES MUT A°PLIC-ATION
pleaseyrinf •'
DATE: r 1 j q /,g -
()B LOCATION: . ^' - Na rn, g ,j goC7
Number SireetA,ddress
Mapl'Lot
- a o mR Mckr
Name, Home Phone
Work Phone
PRESENT 11 OINGADDRESS
/ J, /end„ v-),4 •
CT
si o==M. l� l
�faP•n. .
zip Ccdde
-
T'aa ttcurrent exemption for"homeow-n-ers”was extended to�ohide owner-occdpied divelLngs to tvo units.or less and
LQ alJOIN s$ C 1 7Q-meO.�ners to engage an L-'dzvidual•for hire-Who does not-0 a license,provided that the
ervisor) oy,�er
acts as sup . StateBui�ldiag (Code Secf?on 108.3.5.1)
DEFINITION OFHOMEOWNER
Persons)Who QWns aparcel ofland on which he/sho resides or intends to reside,on WhicSz there is,or zs intended to '
a one or two family sh uctares. A person Who constructs more that'Dne home in a twQ yearpeziod shall not be
cansidered a hozrzeoVjner.
The undersigned".homeowner°'assumesresponsibilityiorcbmpliances wifla the State$uildin Co
Applicable codes,bylaws,rules andzegulatiom. g ode and other
The undersigned"homecwnera'certifies that he/she tmdersfiauds 6e,Town of North,AndoverBuilding De��emt
i rinspection prooedures and reuirements and that he/size will comply Withtsaid procedures and
xequirangeznents, q -
HOMEOWNERS SICMATURE Gt A'U'
APPROVAL OF BUJLDMG O.F.FZCIAL
Revised 7.2009
Form Homeowners&xemptim -
'EOA1ib OF APPEALS 688-954Ir
CONSERV,t;.'HON 698-9530 AEALTH 6$8-954o
PLANNING 689-9535
Information and lust
actions
Massachusetts General Laws cha tex l52 xe
p quires all employers to provide workers compensation for Moir employees.
Pursuant to this statute,an employee is defined as",.,evexp exson iii the service of
anothex under any contract o,—bio,.
express onimplied,oral oxwxitten."
.Att er�playeX is defined as"an.zndzyzci�xaZ,pa�nexship,assoczafzoxt,coxpoxafzort a�otlzex.legal entity,ox any�ro ox�noxe, .
ofthe i•'oxegoing engaged iu a joint enterprise,and includingthe legalxepxesenfafives ofa'deceased emplQyex,.or Elie
receiver O.T.fnisfee o an individual,partxxexship,association or other legal enfity,employing 0.r p gees, I owevex the
owxxex of a dweliinghousehavingnotmoxe thanthree apartments a-adwhoresides theroid,ortlxe occupant owve
dwel&gh.ouse Ofanother AD employs poisons to do maintenance,construction Or Ee
xepair work on such nt Of nghouse
or Onthe
grouuds orbuR&'-appurtenantthereto shall not because of such employment be deemedto be an employer.
VIGL chapter 152,§25C(6)also states that"every state or Io cal Ye-enslug agency shall withhold the issuance ox
renewal of a license ox permit to operate a business ox to Constrict buildings in the commonwealth for any
applicant who Inas not produced.aeee�pfabfe evidence of compliance with fixe insurance cover age required:'
Additionally;l CxL chapter 152,§25C(7)states'Weitherthe 0 ommonwealth nor any of its political subdivisions shall
enteriRto any contractfor theperfonnance ofpublicwoxkumizacceptable evidence ofcoznpliancewith the insuxance
requirements of this chapter have b aon presented to the M tracting authority;'
h.ppReancs
Please fill out the workers'compensailon affidavit completely,by checking the boxes that apply to our sifua an and,if
iiecessaxy,supply b-contractor{s)name(s),addxess(es)andPhonenumbex(s)alongwiththeir cextifioate(s)of
insiaxanae, LimiteduabilityCompanies(LLC)orLimifedLiabilityPartnsxships(LLP)withno employees ofliexthatxthe
znembexs oxpaxtnexs,axenotxequixeclto carryworkexs'compensation iasuxance, SfanLLC ox ,Lp doeshave
employees,a policyisxeq*od. Deadvisedthat-tlii afddavitmaybesubmittedfotheDepartmentofIndustrial
Accidents fox coniirmafion of insurance cavexage. Also be sure to sign and date the affldavl: The afcidavit should
b e retuxnedto the city ox town that'she application fox thepexmit or license is being rogyosted,xtot the Dp,partm.ent of
industrial Accidents, Shouldyou have any questions regarding the law or ii you axe required to obtain avorkexs'
cornpensationpolicY,Please call the Department atthe numberlisted below.
Self-insuxedaompaniessltouldenfexthe
self insurance Incense number on the air
ppxopxiate line.
city or Town Officials
'Ieasebesuxefhatthear;zdavitiscomplefeandpxintecllegibll? ThaDepaxtmenthasProvidedaspaceatthebottonx
ozfhe a£t7rlavztforyoutafdl outixltbe eventthe Office
Pleas oxlnvestigatzonskasta cantactyouregaxdingtheapplicant,
ebe-suxetai�itt.thepe�mit/Incensenumberwhzchv�.illbeusedasarexexencenumber, addition,anapplicant
�idiatniust submitmultiple permit/license applications fix any givenyear ,need only submit one ha.azfxdavit indicating current
palncy anfomlation 0Cnecessary)and under"M Me Address"'the applicantshouldwdte"all locationsin. (city ox
fow:u):'.tA:copyo tha affidavitthat has beenoidciallysLampedormarkedby!hecityoxtown.maybepxovidedtothe
applxcantaspxoofthatavalidafddavif•YsoneoriutuYeperm%fsoxlicenses. AnevTafdavitmustbeftlledouteach
year.Where alxome owner ox cifi�en is obtaining a licewe or exmit notxelafed to auybusiness or commercial venture
(i.e.a dog license oxpexmit to burn leaves eta,)said person.is NOT xegalred to complete this aff[davzt.
The Ofdce of Xn-vasdgatfons would like to thaw you in advance for youx coopexafion.and should you have any questions,
Please do:aotheaitateto giveus a call. .
The.Depaxtment's address,telephone aixd fa�numbex. ,
CQ4xawta1,,t:h ofM={Ssa vawottq
() xc ofGn � to
600 asWingtQj
TQL 9 617,,7.2,&4qQQ W40,6 Qx x-8-7H _
Revised 5-26-OS