HomeMy WebLinkAboutBuilding Permit #466 - 22 HAMILTON ROAD 3/3/2009Permit NO:
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
/3?40..,x_
PROPOSED USE
eb
Date Issued: 5- 5 D
IMPORTANT: Applicant must complete all items on this pate
LOCATION Z -Z 1 -14n411,7 -OKI
Print
PROPERTY OWNER
Print
MAP NO: PARCEL: ZONING DISTRICT: Historic District yes
Machine Shop Village yes
I
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 Well
Floodplain Wetlands
Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
W
-r)'J 6 .,,4 o
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
Arlr mcc-
CONTRACTOR Name: Phone:
Address:
Supervisor's Construction License: Exp. Date:
Home Improvement License: Exp. Date:
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: $ r 6 FEE: $ 20
Check No.:
Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agen#/OwnerVAISignature of contractor
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
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
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 land area, sq. ft.:
Total square feet of floor area, based on Exterior dimensions.
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
NOTES and DATA — (For department use
❑ Notified for pickup - Date
Doc.Building Permit Revised 2008
No
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
❑ 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: Building Permit Application
Revised 2.2008
Location
No. Date
� r
TOWN OF NORTH ANDOVER
9
Certificate of Occupancy $
�� s'••° E��'
Mus Building/Frame Permit Fee $
nc
Foundation Permit Fee $
Check #
Other Permit Fee $
TOTAL $
Building Inspector
t 0ORTM TOWN OF NORTH ANDOVER
Q•' 0 - %,Rb a OFFICE OF
BUILDING DEPARTMENT
1600 Osgood Street Building 20, Suite 2-36
North Andover, Massachusetts 01845
Gerald A Brown Telephone (978) 688-9545
Inspector of Buildings Fax (978) 688-9542
HOMEOWNER LICENSE EXEMPTION
lease iLipt
DATE: 3 3
JOB LOCATION: e'ZS LM L1Ll,% 121,>
Number Street Address map/Lot
Y
HOMEOWNER_ T>,e 21 2161L f�f�h/`. �2 �q'�g) 6�S 7
Name Home Phone Work Phone
PRESENT MAII.ING ADDRESS
City Town
State
zip Code
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 "homeownez" assumes responsibility for compliances with the State Building Code and other
Applicable codes, by-laws, rules and regulations.
The undersigned "homeowner" certifies that helshe understands the Town of North Andover Building Department
minimum inspection procedures and raluirements and that helshe will comply with said procedures and
requirements. A
HOMEOWNERS
e
APPROVAL OF BUILDING OFFICIAL
Revised 10.2005
Form Honum ne:s Exemption
BOARD OF \PPE:\1.S 689-954.1 CONSERVVFIONfgg_9510 TTE.11.;1H 688-9510 PL.L\\I\G 698-9535 9535
-� The Commonwealth of Miusachusetts
Department o
k 146. f Industria114ccidents
ii ice
".,;• �i • O .fJ o f Investigations
600 W
ashinaton Street
Boston
o
, MA 02111
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Workers' Compensation Insurance.Affiday.it: $udders/Contractors/Eleeiricians/Piumbers
Applicant Information
Name (Business/Organiration/Indivi dual):
Address: '7,Z
City/State/Zip:
Are you an employer? Check the appropriate box:
1 ❑ I
Phone #:
an a employer with
(full and/or part-time).*
4. ❑ 1 am a general contractor and I
have hired the subcontractors
2. ❑employees
I am a sole proprietor or partner_
Iisted on the attached sheet x
ship and have no employees
These strb_contractors have
working for me in any capacity.
[No workers' comp. insurance
workers, comp. insurance.
5. ❑ We are a corporation
and its
officers have exercised.their
3#Yserequired_]
I am a homeowner doing all work
right of exemption per MGL
lf. [No workers' comp.
C. 152 § 1(4), and we have
insurance required.] t
no
employees. [No .workers'
COMP. insurance re u d
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ DemoIition
9. ❑ Building addition
I0:❑Electrical repairs or additions
11.❑ Plumbing repairs or additions
12i[]Roofrepairs
q ire ] 1.3.❑ Other
Any appii ant.that checks box # 1 .must also fill out the section below showing their workers' compensation policy miormation.
riomevwnw who submit.illis a;,.1de.vit indicating atey art uuieg aEt w;.r; ml
zConttactors that check this box must attached an additional sheet showier the- name. irv�cu" °E euntraciurs must submit a new arndavit indite ink sccii,
of . _ , ,,Metors and their worice
. Wft ur,. emp[Oper mat IS providing - -••-, .... ,.,,ai,vu.
e workers' compensation tiPnurance for ml' employees. Below is the oft
information. p cy and job site
Insurance Company Name:
Policy # or Self -.ins. Lic. #:
Expiration Date:
.lob Site Address:
City/State/Zip:
Attach a copy of the workers' compensation policy declaration Pa. (showin;g the policy Dumber and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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 S2S0.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereb certify,u�� er the p 'ns a d a es o
Si --nature/
1 fury that the information provided above is true and correct
Official use Delp. Do not write in this area, to be completed b3, city or town�c�
City or Town:
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3
6. Other
Contact Person:
Permit/License #
ChYlTown Clerk 4. Electrical Inspector
Phone #f:
S. Plumbing Inspector
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 ofhire,
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 includir:.g 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 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 o r 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 o.f' compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither *he 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 compi-etely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) grad 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 afncd`a.vit may be 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 fawn that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions re�P rdinw the liam, or if you are required to obtain a workers'
compensation policy; please call the Department at the nttanber:Iisfwd belovr. 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/beense 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 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. Nhrhere a home owner or citizen is obtaining a licenses or permit not related to any business or commercial venture
(i.e. a. dog license or permit to burnleaves 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 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
Department of l ndustrial Accidents
Office of Iavesfigatioas
600 WashLington Street
Boston, MA G2111
Tel. # 617-727-4900 e) -t 406 or 1-877-MASS:4FE
Revised 5-2645 Fax 4 617-r-7-7749
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