HomeMy WebLinkAboutBuilding Permit #586 - 21 LEANNE DRIVE 4/11/2008 BUILDING PERMIT * NORTH
0�t�eo ,6'91
TOWN OF NORTH ANDOVER c� a °'` *° o°,
APPLICATION FOR PLAN EXAMINATION
c/
Permit NO: 6R Date Received `` Dd "
��SSACHU`����
Date Issued: /or
IMPORTANT: Applicant must complete all items on this page
LOCATION Z Leyic Or 1y -
rint
PROPERTY OWNER -+ Gx- "��'} F /
Print
MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes 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 O* SX&4p Others:
Demolition Other
S tic Well Floodplain Wetlands Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
pool s � � _
Id ' Please Type or Print Clearly)
OWNER: Name: (34r,
/�r 4e ficat0S9"4U nti Phone: q 7 6g1-</!Y/
Address: { L-es�-n�� �r 1�1L A) /�- iI�Q �V er�' �`'t'7� 01,?
CONTRACTOR Name: Phone:
Address:
Supervisor's Construction License: Exp. Date:
4
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER (3l teS Phone: 6917521
Address: 50 Dell' /4e4,10o,,J /u.�1�0U 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: $ 7, 000 FEE: $
Check No.: y ;� Receipt No.: / O 6 C
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
gnature of Agent/Owner - Signature of contractor
Plans Submitted Plans Waived �ertified 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 �"� j'7l0 Signature
5 W r Y k(-LA
COMMENTS
HEALTH `. Reviewed on ` Signature
COMMENTS
O,
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
i
Conservation Decision: Comments
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 Main Street
Fire Department signature/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 j
❑ 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
VAORTH
Town af Andover
No.
C' LARo� over, Mass.,
0
"'
COCHICHEWICK
ORATED P? C,
S BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
BUILDING INSPECTOR
THISCERTIFIES THAT............ ........................... . ................................................................................
Foundation
has permission to erect........................................ buildings ............................................ Rough
to be occupied as............................
....42 Chimney
..... ......I......I......................................................
/ ... S xcl
provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final
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 MONTHS
ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION TARTS Rough
................... Service
BUILD INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Display in a Conspicuous Place on the Premises — Do Not Remove Rough
Final
-No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
SEE REVERSE SIDE_j Smoke Det.
CERTIFIED PLOT PLAN
LOCATED IN NORTH ANDOVER, MASS.
c� SCALE:1"=40' DATE:111612007
3/29/2008
Scott L. Giles R.P.L.S.
Frank. S. Giles R.P.L.S.
50 Deer Meadow Road
North Andover, Mass.
PROP
W/Ty S4H/GyF
y qN0 ELFC ENCS
6, r LATCH/ SOGq S/NG
icr) o gNOMOCgqLL S ATTE
� `� L CODES E
1A
27' Q�09.
5
6611
PROP
POOL.
,1373E+� .ySFFNO
�= 10803,
10.84'
L=97.77'
�R�VF
I CERTIFY THAT OFFSETS SHOWN ARE FOR THE USE or
THE OFFSETS o
OF THE BUILDING INSPECTOR ONLY �� ;; y�
SHOWN COMPLY
4 M.
�i
AND SUCH USE IS FOR THE
WITH THE ZONING DETERMINATION OF ZONING ' '9;'2
BYLAWS OF CONFORMITY OR NON-CONFORMITY
'
NORTH ANDOVER ':. `'�
WHEN CONSTRUCTED. ` '` .tl��•'-
WHEN BUILT 3 31 Zt»8
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o+ µoero# TOWN OF NORTH ANDOVER
•'"'° "� OFFICE OF
BUILDING DEPARTMENT
41
1600 Osgood Street Building 20, Suite 2-36
North Andover, Massachusetts 01845
s�c„us•
Gerald A Brown Telephone(978)688-9545
Inspector of Buildings Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
Please p i
DATE: 3' D
JOB LOCATION:
Number Street Address Map/Lot
HOMEOWNER /.AV n��,I ;;/n
Name Home Phone !1 Work Phone
PRESENT MAILING ADDRESS
A-A
oleo
City Town State Zip Code
The current exemption for"homeowners"was exft&d to include owner-occupied dwellings to two units or less
and to allow such homeo%=n 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 constructs 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"homeowmer"certifies that he! the Town of North Andover Building Department
minimum inspection procedures and that he/ ly with said procedures and
r�aquiremems.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Revised 10.2005
Fom►Homwwom Exemptkm
BOARD OF \PPE:V.S 698-9511 CU\S.ERV.1FION ASS-9530 F[EAL'rii 688-9540 PL.V\-N[\'G 6S8-9535
The Commonwealth of Massachusetts
Department of Industriat Accidents
R. Office ofTnvesdgations
600 Washington Street
.Boston, llf4 02111
r
www.mass.gorldia
Workers'. Compensation Insurance Affidavit: Builders/Contractors/Electricans/Plumbers
A Iicant Information PIease Print Legibly
Name (Business/Orpnization/Individual): rJ1A�'�//
Address:
City/State/Zip: ho
P ne#: ( K/.
Are you an employer?Check the appropriate box:
1.❑ I am a employer with ' 4• I am a en Type of project(required).
'. 0 general contractor and I ,
employees(full and/or part-time).* have hired the sub-contractors 6• ❑New construction
2.❑ I am a:sole proprietor or partner- listed on the attached sheet 7. []Remodeling
ship and have no employees These sub-contractors have
working forme in any capacity. employees and have workers' E. ❑Demolition
[No workers' comp.msuranCe comp. insurance.# 9• ❑Building-addition ,
required.] 5. We are a corporation and its ME]_Electrical repairs or additions
3. 1 am a homeowner doing all work officers have exercised their `
//\\ 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
insurance required.]t c. 152, §1(4), and we have no 12.0 Roof repairs
employees. [No workers' 13.[1 Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their work=,
Hocornpensatian policy information.
t niconrers who submit this affidavit in carng$ey are doing all work and th=hire outside conttazetors must submit a new affidavit indicating such.
+Contra.-tors that check this box must attached an additional sheet showing the name of the sub-contractors mid state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their wor
kers'comp:Policy number.
I am an employer that is providing workerscompensation insurance for
information. my employees. Below is the policy.and job site
Insurance Company Name:
Policy y#or Self-ins.Lic.#i
Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declarafion page(showing the policy number and expiration date).
Failure.to secure coverage as
required under Section 25A of MGL L c.
152 can lead to-the.imposition of enmmal
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in Penalties of a
p the form of a STOP W
of u to$250 WORK ORD
p .00 a day against the violator..Be advised that a c R and a fine
Investieations of th DIA for ce coverage verification,copy.of may be forwarded to the Office of
Ifey ce under a ai Viand penaltie f rjury that the information provided above ire co ect
Si p /•p �` Date: � Q
Phone*. 7 0 t�O 1J l
Offiq=...use only. Do not write ur this area, to be completed by city or town.official
City or Town:' Permit/License#
Issuing Authori circle one): .
t3'( )
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector
6.Other
Contact Person:
Phone#:
Information an d 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 of hire,
express or implied,oral or written." r
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 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 dwell ing house having not:more than three,apartaieats and who resides therein, or the.occupart 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 bean employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agendy`shall withhold the issuance or
renewal of a license or permit to,opera°tea business or to construct buildings in the commonwealth for any%,
applicant who has not produced acceptable evidence of co mpliance with the insurance coverage required."
Additionally,MGL chapter 1-62,§25CM 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-contractors)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 maybe 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 perrriit or license is being requested,not the Departinent of
Industrial Accidents. Should you have any questions regarding the-law,or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
n
self-insurace 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 sureto fill in the permitllicense 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 stanped 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 1-40T required to complete this affidavit
The 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 Massachusetts
D!epaTtme✓nt Of Industrial Accidents
Office of Investtati ons
600 Washington Street
Boston,MA 02111
Tel.# 617-727-4900 ext.4.0.6 or 1-877 RdASSAFE
Fax # 617-727-7749
Revised 1122-06 www.mass-go.v/dia
c
Location /,,aa III n/f l/
No. .�i c��a DateOf
NORTh TOWN OF NORTH ANDOVER
I.
Certificate of Occupancy $
Building/Frame Permit Fee $ �y ,
sACHUSE
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
2 U66 .
�guirding Inspector