HomeMy WebLinkAboutBuilding Permit #35 - 21 PEMBROOK ROAD 7/7/2010 BUILDING PERMIT NORTk
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TOWN OF NORTH ANDOVER
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APPLICATION FOR PLAN EXAMINATION '-
Permit NO: Date Received * °4 •
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Date Issued:
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IMPORTANT:Applicant must complete all items on this page Z
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RERTY � �' ERX
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
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Septic `W607 s Flood lain UI/etlands% �-; -�"
g r ,P Watershed District r
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DESCRIPTION OFWORK TO BE PREFORMED:
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Identification Please Type or Print Clearly)
OWNER: Name:_ t C1-7-or Phone:
Address:
FF- _ 75 �--
CT(DW477
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SupEr�rsorl(s Construction Licensea F. r
Q 3 � ��cp f Date. :
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ARCHITECT/ENGINEER
Phone:
Address: Reg. No. f
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FEE SCHEDULE:BOLDING PERMIT:$1200 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ %(frs 00 d FEE: $__
Check No.: a -;-3,4 Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
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
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THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
E
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature&Date Drivewav Permit
DPW Town Engineer: Signature:
Located 384 Os ood Street
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1Loca'ted�at124Ma . Str�eety � �
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��xFire D'epar:trnentsgnature/dates e
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Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
4
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.$10041000 fine
NOTES and DATA— (For department use)
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❑ Notified for pickup - Date
' s
Doc.Building Permit Revised 2010
i
Building Department ,
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
I
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
4
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition dation Or Decks
❑ Building Permit Application 1
I
❑_ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
o _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
i
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 2008
i
Location
No. 3C Date _ V
NORTH TOWN OF NORTH ANDOVER
; , Certificate of Occupancy $
��a ••°'E�� Building/Frame Permit Fee $ —�—
s•►cMus �
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
230 / 6
Building Inspector
ORTH
F
Tovm of 5 Andover
` -o dover, Mass.,
o 1.
COCMICKEWICK V
7d ADRATED p? C:)
7S BOARD OF HEALTH
RMI ,
PE
Food/Kitchen
Septic System
%T T D
BUILDING INSPECTOR
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THISCERTIFIES THAT................................ ......... /,vJ .....f�I....................................................................
...... Foundation
has permission to erect........................................ buildings on .ov.... 7.,,Cir. ' -........... ..................... Rough
to be occu ied as !/.....!/I.�. 4� �'�!. .: ....................:........................................................... Chimney
p' <�r- �........ ..�....... .
provided that the person accepting this permit shall in every"spec 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
PERMIT EXPIRES IN 6 MONTHS Final
UNLESS CONSTRU O TS ELECTRICAL INSPECTOR
�A Rough
Service
BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
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.
SEE REVERSE SIDE Smoke Det.
The Commonwealth of 1Vi¢ssachusetts
Department o f Industrial Accidents
Office of£nvestigations
600 Washington Street
Boston, Af,q 02111
w�+nv.mas�govidia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumb
Applicant Information ers
Please Print Lembiv
Name (Business/Organization/Individual): 4 V
Address: 4z h 0d X
City/State/Zip: h 4,D V` Phone -�S
Are you an employer? Check the appropriate boa:
1.❑ I am a employer with 4. ❑ I am a general contractor and I77. E7�
of project(required):
2.❑ employees(full and/or part-time).* have hired the sub-contractors Neu]construction
I am a sole proprietor or partner- listed on the attached sheet t Remodeling
ship and have no employees These subcontractors haveemolition
working for me in any capacity, workers com . D
[No workers' comp. insurance 5• P insurance. 9• Building
❑ We are a corporation and its ❑ b addition
required.) officers have exercised their 10•❑Electrical
3., I am a homeowner doing all work right of„ rept or additions
4),a do per MGL 11. Plumbing repairs or additions
myself [No re uued,workers'
t comp c. 152,§I(q.)�and we have no 1� ❑
insurance9 ] em to ees. ❑Roof repairs
P Y [No workers'
comp.mst'r=ce required,] 13.❑ Other
•°n ::,heat that �yjy�t must also fir,ou:'Lce sectio`bei ��o.�.,
I#offieown�s who submit cater s,. .
flus afiid8vrt rndreatmg the},are dc;-- aL' ✓o,e
+Contractors th-at check this box.,rust a—_ch-- s and thenhire outside contracts'4=;
an additional sheet showing the sbrr.it a new aGdavit indicating such.
name of the sub-contractors and their workers'comp•poircy information.
I am an employer that is rovui' o
uz w
P orker
e S CO
mrens�uon insurance for my employees. Below is the policy and job site
in,formation.
Insurance.Company Name:
Policy#or Self-ins.Lir,.#:
Expiration Date:
Job Site Address:
Attach a copy of the workers' compensation policy declaration page(showing the policy
F P Y umber.and expiration date).
Failure to secure coverage as required under Section 25A ofMGL c. 152 can lead to the imposition of
fine up to$1,500.00 and/or one-year imprisonment,as well as civil 0 criminal Pedes of a
Of up to $250.00 a day against the violator. Be advised that a co penalties m the form of a STOP WORK ORDER and a fine
Investigations of the DIA for insurance coverage verification , of this statement may be forwarded to the Office of
I do hereby certify under the pains and penalties of perlJ'thzt the in or
f madon.provided above is true and correct
Signature:
Phone#:
Official use only. Do not write in this area, to be completed by citi)or town o;ficial
City or Town:
Permitucense#
Issuing Authority(circle one):
I: Board of Health 2.Building Department 3. City/Towu Clerk 4.Electrical Inspector 5.Plumbiag
6. Other d Inspector
Contact Person:
Phone'#:
Information am d Instructions
Massachusetts General Laws chapter 152 requires all employs to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every peon in the service of another under any contract of hire,
express or implied,oral or written."
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 t3ae legal representatives of a deceased employer, or the
receiver or trustee of an individual,partnership, association ox-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 maintemance,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 onto construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of co3mpliance 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 um-til 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' comp a nsation 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 stare to sign and date the affidavit The affidavit should
be ivtiriuvd to the city or town that,the avulrCation.for the pet it Or Iicen3e LS being requested,not the.Depa�est.of
Industrial Accidents. Should you have.any o�uestiow regardir<g the kdw or u you are:�::ired to obtain a work=ers'
compensation policy,please call the Department at the numbe=r listed below. Self-insured companies should enter their
self-insurance license number on the appropriate Ime.
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/lic;nse 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 stampe=d or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future per-smts or licenses. A new affidavit must be filled out each
year.Wherea 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 Office of Investigations would Iilee to than 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 M ssachusetts
Department of FndustHal Accidents
Office of Inrestiations
6010 Washingtm Stre.;:t
Boston.,M-A 02111
Tel. -rur 617-72.7-4900 eaft 406 or 1-8—/7-MAsS. FE
Revised -26-05Fax #617-72.7 774 9
V'Vru7.mass._aov/dia
F µ0RTH - TOWN OF NORTH ANDOVER
"eo "`��° OFFICE OF
0 ba'- '.. .' :° oZ.
BUILDING DEPARTMENT
4L �, ,�* 1600 Osgood Street Building 20, Suite 2-36
q,,,,.P�{5 S North Andover,Massachusetts 01845
SACHU
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:
Number Street Address Map/Lot
HOMEOWNER
Name Ho e Phone Work Phone
PRESENT MAILING ADDRESS off ) &2_�
A/c-
City Town State Zip Code
I
The current exemption for"homeowners"was extended to include owner-occupied dwellings to two units or less and
to allow such homeowners 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"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. n ,
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Revised 7.2009
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535