HomeMy WebLinkAboutBuilding Permit #86-15 - 22 INGLEWOOD STREET 7/24/2014f
TYPE OF IMPROVEMENT -
PROPOSED USE
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Identification - Please Type or Print Clearly
Residential
Non- Residential
❑ New Building
One family
Address: Z2_ �A.)G-C.E-Loon,
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
❑ Others:
Repair, replacement
❑ Assessory Bldg
Demolition
❑ Other
Septic 0 Well
❑ Floodplain ❑ Wetlands
' TWatershed'Dls
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Waer/Sewer y
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ARCHITECT/ENGINEER
Phone:
Address: Reg. No.
FEE SCHEDULE. BULDING PERMIT. • $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F.
Total Project Cost: $ _ $_, z 0 ea FEE:
Check No.:�S eceipt No.: r- -J
NOTE: Persons contracting at i gr ed co ty ors do not have access to the guaranty fund
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Identification - Please Type or Print Clearly
OWNER: Name: Xf/'i,,;,S .�IA;bA-
140e-7-
Phone 97S'-68'6 99
Address: Z2_ �A.)G-C.E-Loon,
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Contractor'Name
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ARCHITECT/ENGINEER
Phone:
Address: Reg. No.
FEE SCHEDULE. BULDING PERMIT. • $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F.
Total Project Cost: $ _ $_, z 0 ea FEE:
Check No.:�S eceipt No.: r- -J
NOTE: Persons contracting at i gr ed co ty ors do not have access to the guaranty fund
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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
PLANNING & DEVELOPMENT Reviewed On Signatu
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
Reviewed on
Sianature
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:
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 d
❑ Notified for pickup Cal
rtment use
mail
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
❑ 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/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
N -
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
17 V11711:V17_�rr^.n-:v __
Location:zz-- 0 QQ
No. Date
W24044
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee
Other Permit Fee $
"S TOTAL $-
Check #
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27813 Building Inspector
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The Commonwealth of Massackusetts -
-
Department oplidustriglAccie ks
Office of Investig0ons
660 Washington Street
.Boston, MA 02111
-www.massgovId a
Workers' Compewation 1Cni urance Affidavit: EuiZdex�/Cod °ac ox:�L lecix�icxanslZ'Z�aibex'.-
Applkant Information Please Print L�e�b�
.uo-
6G-r—
.Address: a-,`
City/State/7�ipe� K �iN DO tri /�4- c� C �s 3 Phone #:_ 97 -- Lo ?<>
Are yon[ an. employer? Check the appropriate box: Type of project; (required):
1 • ❑ I am a employer with 4. F]I am a general contractor and I 6. E] New cOnsfruction f
employees (full and/or pax time) * have Wredthe sub -contractors
2. C] I am a sole proprietor or partner
listed on the attached sheet. T 7• E] Remodeling
ship and'havena.employees These sub -contractors have 8. [] Demolition
working forme in any capacity. workers' comp, insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its 10 1] Electrical repairs or additions
required.] officers have exorelsed.their
3"& 1 am a homeowner doing all work right of exemption per MOL 11.[] Plumbingrepairs or additions
Myself [Eo workers' comp. c. 152, §1(4), and wehave no 12,[] Roofrepairs
insurancarequh4l ? employees. Wo workers' 13.64 Other.Ao S c a tti G -
comp. insurance required.]
Any applicaat that checks box#1 must also fill outthe section bel6w showingtheirworkere compensationpolicy information.
Homeowners who submitihis afddavitiadicatingthey kedging Awork andthen hire outside contractors must submit anew affidavit indicating such.
Tcontractors that chodahis box must attached an additional sheet showingthe name of the sub -contractors and their workers' comp. policy information.
.1• man emy.foyer Mai 19providingwosTAerls'comperasationinsuranceformyernpoyees Below isihepolieyancijobsite
info;�mation.
Insurance Company
Policy #k or Selz ins,Lic. #: ExpiratioaDate:
Tob Site Address: City/State/Zip:
Attach a copy of the workers' comp ensationTolley declaration page (showing -the policy number anal expirations crate).
Failure, to secure oovexage as requixedundex Section 25A ofMCL o.152 can lead to the imposition. of critakalpenalties of a
flue up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORM. ORDER. and. a fm e
of -up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DTA. for insurance coverage verification.
I do Hereby ce, t urider'tlie initis andpenalties ofper y that irie in, formation,provided above is true and correct.
eet.
v
Phone#
Off,.eial use o'ely. Do not wfite in this area, to be completed by city or town official.
City or Town: Permit/License #
fssuing Authority (circle one):
1. Board of Health 2. Building Department 3. Cziy/Towa Clerk 4. Flectxical Inspector 5. Numbing Inspector
6, Other - - -
'01-- 44, 44.
Informa%an and InstructioJIN
Massachusetts General Laws chapter 152 requires alt employers to provide workers' compensation for their employees.
Pursuant to this statute, an eraployee is defined as "...ever, person in the service of another under any contract of hire;
express orimplied, oral orwrittem"
An employe is defined as "an individual, partnership, association, corporation or other legal entity, or any two oxmoxe
of the Foregoing engaged in a joint enterprise, and including the legal xepresentatives of a:deceased employer,.or, the
receiver onixristee of an individual, Partnership, association or other legal entity, employing employees. I10wever the
owner of a dwelling h.ousehavingnotmore thanthree, apartments andwho 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 bean employer.,,
MOL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or p ermit 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 ofpublie work until acceptable evidence of compliance with the insurance
requirements ofthis chapter have beenpresented 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-conlxaetor(s) name(s), address(es) andphononumber(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees oilier thm the
members or partners, are notrequired to carry workers' compensation insurance. If an LL C or LLP does have
BM ployees,apolicyismquired. Be advised thatthisaffidavit maybe. submitted tothe Department of Industrial,
Accidents fox confirmation of insurance coverage. Also be sure to sign and date the affidavit 'he 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 ox if you are xequired to obtain a workers'
compcnsationpoliqy-, please call the Department attho numbar listed below. Self-insured companies should enter their
sell insurance license number on the appropriate line.
Ciiy 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 fox you to fiill, out in the event the Office of Investigations has to contact you regarding the applicant.
Please be -sure to lilt iu the pemait/license number whichwili be used as a reference number, lir addition, an. applicant
thatroust submitmuttiple permit/liceme applications in any given year, need only submit one affidavit indicating cutrent
Policy information (ifnecessamy) and under "Job Site Address" the applicant shouldwxite "all locations in (city or
town): ' .A copy of the affidavit that has been officially stamped or marked by 4h.e city or -sown maybe provided to the
applicant as Proofthat a valid affidavit -ii on file fox future p ennits or licenses. Anew a fidavit must b e filled out each
Year. Where a home owner or citizen is obtaining a license ox permit not related to any business or commercial venture
(i.e. a dog license orli ermit to burn leaves eto) said person is NOT required to complete this affidavit.
The Office of Investigations would lige to thank you in advance fox your cooperation and should you have any ctuesfions,
please do nothesita%to give us a call.
The, Departm.ent's address, telephone and faxnumb er,
Tho CQxr_1w onw alto-
A'Ta 7.eut Q -f dU*!a1 Aceldent$ ++
6b Wa gi'on
TO, # 617-7,27-4900 ext406 Qr 1-877�AM,�AFF,
Revised 5-26-05 Fax
• w�•zxta�s,gQ.��c1Za
4 ��RrH fi TOWN OF igO
a..t.I. ANDOVER ..
e :t_✓ °M OFFICE OR
IRUMDING
:'Z6Q0�JsgoodStreei •�`�-ARTdY�n,1�lT
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B ding20,-Suite 2--3 6
7 a�"'n's , MassachnsetEs Q1845
4S NOlt71 AndOvex
Renu ,
Gerald A. Brown Telephone (978) 688-9545
InspectorofBuildings - F jx .(97-8) 688-9542
HQNlEOWNER•LTCENSE .tYBYiPTION
Bbi7�I1�TG PERMT A'RLIOAUON
Please�rint •
DATE: JULY 17 204
QB LOCATION: 7 -
Number SireeiAddress 1VIapIZot
' I�OIVI-OWNER
Name. Horne Phone Work Phone
'RESENT MAILING ADDRESS
Am I
(• fv Tn ' L 0 `�•�
c a Stat - - 'Tip Code
The cuzreni exemption for "-homeowners" teas extencfied to
to allow such ho_meo:� chide owner -occupied dwellings to itvo units-oY cess and
uers to engage an ncividual.for dire who does note ossess a h cense, provided that the owner
acts as supervisor). State3u?Iding (Code Section, l08.3.S.1)
DEFINITION OFHOMEOVMR.
I'erson(s) who awns a parcel of land on which helshe resides or iutends to reside, an which there is, or is intended to
c003 s idered ahomeownez. one or two Family stzuciures- A person who constructs more that one home in- a two yearpmiod shall not be
ons
The undersigned "homedwace assumes responsibilityforcompliances with the State Building Code
Applicable codes, by-laws, rales andregulations, and other _ '
The undersigned "homeowner" certmes that helshe understands the Town ofNorflt A,ndover$uildingDeliarfinent
rn� uire m inspection procedures and requirements and that he/she Will comply withtsaid procedures and
requirements •
�iOMEOW.I�7BRS SIGNATURE Ji'��e��J C 1 ,
v
APPROVAL OF BMI)ING OFFICIAL
Revised 7.2009
III Form Homeowners Bxempfion .
'EOARI) OFAPPEA7 S 688-9541 OONSEit,VAMN 688-9530
r r;
HEALTH 688-9540 PLANNING 689-9535