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HomeMy WebLinkAboutBuilding Permit #533-15 - 217 BEAR HILL ROAD 12/9/2014BUILDING PERMIT TOWN OF NORTH ANDOVER s° 2 APPLICATION FOR PLAN EXAMINATION J "^� Date Received 1z eb Permit NO: °9 °�•�•'` �9SS�cHus 's�5 Date Issued: ?,/C, IM ORTANT: Applicant must complete all items on this page LOCATION I - a- N � l -I. ' AN tJ Printf PROPERTY OWNER Print MAP cict NO:(6_PARCEL: ZONING DISTRICT: Historic District yesno 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 [IAssessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑Septic ❑Well . ❑ Floodplain 0 Wetlands ❑ Watershed District, n Water/,Sewer -bACP6mm1- r& -rt- onj-- J M � ar2 wawS iv2 O rN i - t7 -V lipV ni) AW -0 �GLnSC-0 STo+A(5e 5fl Z. Ili A)6 .... ►- I" Identification Please Type or Print Clearly) OWNER: Name: �Pryl D lit/► K� �c-a2 Phone: q 7g - 173-9335 Address: 21 l L4_, Pa - `�- }-N w liL>- — CONTRACTOR Name: Phone: rA, Address: Supervisor's Construction License: Exp: Date:. Home Improvement License; Exp. Date: J ARCHITECT/ENGINEER Phone:_ Address: Reg. No. FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ S `ZjeR-® FEE: $ - Check No.: Receipt No.: NOTE: Persons c retracting igith unregisted tractors do not have cess to the guaranty fund nature of contractor. 3 i BUILDING PERMIT "° o' TOWN OF NORTH ANDOVER 02 APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received �R ,9 °gwre° SSACH Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER Print 100 Year Structure yes no MAP 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 ❑ Others: ❑ Demolition ❑ Other ❑ Septic 0 Well ❑ Floodplain ❑ Wetlands ❑ Watershed District 0 Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification - Please Type or Print Clearly OWNER: Name: Arlrlracc- Contractor Name: Phone: Address: Supervisor's Construction License: Exp. Date:_ Home Improvement License:_ ARCHITECT/ENGINEER Date: 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 Signature of Agent/Owner Signature of contra -66V- ---2-d'-'- Locations-�(L/� No. r Date( 2i1 TOWN OF NORTH ANDOVER Certificate of Occupancy $T Building/Frame Permit Fee z./J �7— Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 2 5�J Building Inspector Plans Submit' &d ❑ Plans Waived 0 Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swinuning Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On COMMENTS Signature_ CONSERVATION Reviewed on Sianature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Commen Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: uocatea Jb4 usgooa 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: .: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine No NOTES and DATA — (For department use) ❑ Notified for pickup Call Email 1 Date Time Contact Name 3 ...... _.._........... -- _..__ _..._..............._....._.._..._._..__...._._._.. — ---- --- ----- 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 ❑ Building Permit Application L3 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 a Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) a 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 o Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract ❑ Mass check Energy Compliance Report o 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 0 Cc v .Q 0) 0� (,a � � o O O •+ o 44 O Q h c a I xC.O P V i **4W, Q r M J N (t I �, m 00 41W : U : c L O i 'a O tm an0 C _V Q N 6 0 0 0 Z QC ••- 0 0 L aQ�4, mom m . to F c o c c Q L L cc 0 lipN O - m coN W_ r-4) O LL .N cL O N 0 y OSZ. :6. V V W E V O V m:aN M o = m cc 0"= 0m -w CL 0 0 IM 0 m Z f— AJ G E Z O y — U v W ce- Oj C x Z U d cn W c W J a z_ 0 _ 0 N d O Z O Q J 0 i' w .ti E GC •rr Z 0 N^` ,W L t O V CL V .y _ U cc cc CL .N rm1 0 O O a a Q 0. Z Z ZCL W oC LL O H Q Z u Z p , Z W Q co LA Q W 0 (7 w co D V W �y aJ a1 m d W +_u+ ? O O y al Y N cYa N Z � u rc t u s L v o Q @ t _ _ oa = ai O E LL N LL LL d' LL (n LL d' LL m (n N N 0 Cc v .Q 0) 0� (,a � � o O O •+ o 44 O Q h c a I xC.O P V i **4W, Q r M J N (t I �, m 00 41W : U : c L O i 'a O tm an0 C _V Q N 6 0 0 0 Z QC ••- 0 0 L aQ�4, mom m . to F c o c c Q L L cc 0 lipN O - m coN W_ r-4) O LL .N cL O N 0 y OSZ. :6. V V W E V O V m:aN M o = m cc 0"= 0m -w CL 0 0 IM 0 m Z f— AJ G E Z O y — U v W ce- Oj C x Z U d cn W c W J a z_ 0 _ 0 N d O Z O Q J 0 i' w .ti E GC •rr Z 0 N^` ,W L t O V CL V .y _ U cc cc CL .N rm1 o£tAtori ayo TOWN OT{`NORTH AND pVip OEEICE OF `-` DsbOd W00t Buffding20, Svite 74-36 7�S�Aca05 �5 - - North Andover, Massaahuseits 01845 , Gerald A. Brown Telephone (978) 6889545 Inspector ofBildings -fax (97$) 689-9542 ". HON.iEOW.N"EK•i.TCEN�E E�ENIPTION B [7 G pE It CT A�'YLZC ON Pleaseprmt , DATE: r , /,,,7 © ' OD LOCATION. Number StcatAddress 2VIap/Lot , kv Name.. Home AMC) S'�� � Wo&Phone -PRESENT MA6NCT ADDPMss Sff)�M .. . L a lip Code TI e current exemption for `$omeotvnexs" was extended to chrde owner occupied to allow subh 3�ompo: vers to e - di�ellings to i4vo units or Les:,a nd n 1�e a i. i' �' � �-xvx nal forl�zre •wno does no acts as tposscss a 7icGalse provided that snperyzsor). Statel3�ilding (Code Section rt)8.3.S.i) � P the owner DEFMI.TION OYHOMEOVMR 1.'ers0n(s) whO Awns aparcel ofland on t�tbich $e/sizeresic%s or " OR - be, cone or two amiTystniciures. Aperson.�who constracEsraore aione7zome�in aiwo yarpeziere od shall n �or is be to ecnsidered a homeowner• The IMcIcTsigaed "homedwner" assumes responsibility fOT c-tI npliances with the State Building Code and other .Applicable codes, by-laws, xules andxogulations. The undersigned`'homeownez"ceztifesV athe/sheilnderstandsV10Townofgorlh.AadoverBuildingDe�axtnjent nunimum inspection procedures and requirements and that lae/she will requiremeco pIy with,said procedures and nts 130.'NMOWN'ER5 SIGNATURE AI'P•ROVAL OF BMD)NG OFFICIAL Revised 7.2009 Form Homeowners Bx&nption . '13dARD OFAPPEArS 688-954IC01�SERirAr ITON 688-9530 I3EALTEI 688-9540 PLAMING 689-9535 The Commonwealth of.M•assachusetts , - Department of indif.strigl AceMiks 01 Office of Investigations 600 Washington. Street Boston, .MA 02111 www mass govldia Workers' Compensation LmuranceAffidavit: BuUderslContractoxs/El ctr Plea� PsimLeb r Applicant Xnformaiion Name (Business/Organizationgndividual)- Address: e2 i 7 6 DA ✓L City/State/Zip: QYLTtl' -Amao Vat 04 Phone #• X 79 - q 73 -- 9 33 Are you an employer? Check the appropriate box: illI am a employer with 4• ❑ I am a general contractor and I _______. employees (full and/or parE time).* have nod the sub -contractors listed on the attached sheet.' 2.E1 I am a sole proprietor orpartn.er These sub -contractors have ship and'liave, no employees working for me, in any capacity. workers' comp. insurance. jNo workers' comp. zusi1zCe 5. ❑ we are a corporation and its officers have exercised their /kequired.] 3. [ X am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no employees. �,No workers' insurance required.] ? COMA insurance required.] Type of project (required): 6. Q New construction 7. 1 Klemodehing S. Q Demolition 9. Q Building addition 10.Q Electrical repairs or additions 11.Q Plumbing repairs or additions 12.Q Roofrepairs 1311 Other -Any applicant that checks box#1 mustalso fill outthe section bel6w showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they s're doing all work and then hire outside contractors must submit a new affidavit indicating such. Tconiractors that checkthis box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policy informatlon. I am cin employer that is providing workers' compensation insurance for• my employees: Below is the policy anti jolt site information. Insurance Company Policy # or Self -ins. Lic. Expiration Date: Job Site .Address: City/State/Zip: Attach a copy of the workers' comp eusation -p olley declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a tine up to $1,500.00 and/ox one�year imprisonment, as well as civil penalties in the form of a STOP WORD ORDER and a tine of up to $250.00 a day against the violator. Be advised that a copy of thus statement may be forwarded to the Office- of investigations of the DfA for insurance coverage verification. Phone#: ai6-_q13- 835 official use only. Do not write in tlais area, to be completer) by city or town official. City or Town: Permit/License # Dsuing Authority (circle one): 1. Board of Health 7. BuildingDepartme nt 3. CitylTown Clerk 4. Electrical Inspector 5. Plumbing )inspector 6. Other y 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 of hire,- express hire,-express or implied, oral orvaitten." An employer is defined as "an individual, partnership, association, corporation or other Iegal 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 xecelver or trustee of an hndiv3dual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartnents and who resides therein, or the occupant 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 be an employer." MGL chapter 152, §25C(6) also states that "every state or local tic -ening 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 -contractors) name(s), address(es) and phone numb er(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 notrequired to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. De advised that this affidavit may be submitted to the Department of Industrial Accidents fog 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, not the Department 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 self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. TheDepartnenthasprovidedaspaceatthebottom 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 (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has b eon 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 oz 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 like to thank you in advance for your cooperation and shquld you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: Tho Commonwealth ofMassarhv4PtN - Depar(m tofkftfdal,A,ccxdent,- Ofte ofl vesizgatto)as- 600 Wagtan ftoet Boston, J.-021XZ Tei, # 617-7-27-4900 ext 406 ox 1-87 -:MM- 9 -AFF, Revised 5-26-05 Fax # 617-727-7749 WWW.Masa,gov/dia