HomeMy WebLinkAboutBuilding Permit #838-15 - 223 CHICKERING ROAD 4/22/2015BUILDING PERMIT NORTI�
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TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received A-
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Date Issued: vI /ZZ 111
IMPORTANT: Applicant must complete all items on this page
J,LOCATION '7Z iJ2
}Print
PROPERTY OWNER
ii6rint 100•Year Structure yes,
MAP PARCEL _ ZONING, DISTRICT: Historic District yes no
Machine Shop Villagp yes . o
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
Kone family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑Smeptir✓ ❑dell
❑Fool dplanUVetlands-�❑
xUl/atershed� District
s ❑=Wester/vie
-
-
DESCRIPTION OF WORK TO BE PERFORMED:
A# P� ad YJ wevL/ rp-�.�
Identification - Please Type or Print Clearly
OWNER: Name: Phone:
Address:
'ContractoEmail:r. Name: Phone:
_ _ _ .; _.., _ .
Address:'
Supervisor's Construction License: Exp. Date:
Home Improvement License: _: Exp. Date:
ARCHITECT/ENGINEER
Phon
Address: Reg. No.
FEE SCHEDULE; BULDING PERMIT: $12.00 PER $1000.00 OF TT �}Ic�STIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: v ' OTT`
FEE: 0 ---
Check No.: IQS Receipt No.: r-'���
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Location -
2 1 Z
No. Date
Check # ;�49
TOWN OF NORTH ANDOVER
Certificate of Occupancy $-
Building/Frame Permit Fee svj-o�
Foundation Permit Fee
Other Permit Fee
TOTAL
Building Inspector
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ IJ,
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
Taming/Massage/Body Art ❑
Swunming Pools ❑
Well ❑
Tobacco Sales ❑
Food Packaging/Sales ❑
Private (septic tank, etc. ❑
permanent Dempster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF m U FORM
PLANNING & DEVELOPMENT
COMMENTS
Reviewed On
Signature,
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
ti
Conservation Decision:
Comments
Wafter & Sewer Connection/Signature &Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osqood Street
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
DAGGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
NOTES and DATA -- (For department use
❑ Notified for pickup Call Email
Date Time Contact Name
Doc.Buildinng Pen -nit Revised 2014
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
Building Permit Application
Workers Comp Affidavit
Photo Copy Of H.I.C. And/Or C.S.L. Licenses
Copy of Contract
Floor Plan Or Proposed Interior Work
Engineering Affidavits for Engineered products
TOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
Building Permit Application
Certified Surveyed Plot Plan
Workers Comp Affidavit
Photo Copy of H.I.C. And C.S.L. Licenses
6 Copy Of Contract
6 Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
4 Mass check Energy Compliance Report (If Applicable)
� Engineering Affidavits for Engineered products
TOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
Building Permit- Application
4, Certified Proposed Plot Plan
Photo of H.I.C. And C.S.L. Licenses
Workers Comp Affidavit
Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
Copy of Contract
2012 IECC Energy code
Engineering Affidavits for Engineered products
TOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc: Building Permit Revised 2014
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TOW OF NORM AND OVEP,
OFFICE OF
.x600 D401) d Stxaet$uif ft2Q� -Suite 2-3 6
R eewn K �
7 paRatxn F4�yd5 Naith A ado -ver, Massachusetts 0184S
�$SR�iitSS��
Gerald A. Brown Telephone (97$) 68$ 9545
Inspector of Buildings -Fax (978) 689-9542
zo oms LICENSE t7fflMPTION
BM)WG PPIPM- T APPLICATION
p]eas._ euriui .
DATE: by 1 2L 7rt1(`�
SOB LOCATION:
w.•,...,�,. uuac�.AC7dre5S Maplx,ot '
Name. _. HOMO Pho ' WorkMo.=
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-PRESENT MAff NCI ,AD}JMS
M/ - fu l cq ? �Ef
tet~ dip Cods
The current exemption for "homeowners"' Was exteaded to :iUoItlde owner occupied ftallings to tvo units •or lam, and
to allow such hompo„tiers to engage an iaaividuam• rhise vho does uotp0ssess a IicG%is%provided that the owz�r
acts as supervisor). Btafe.3305 ding (Code Section 108.3.5. i_)
bMMITION- OPROMEOWNBR.
Persons) who awns a parcel of land on tubicle h elslze resines or intends to reside, on w�iclz there is, or is intended to
7ie,aoneortwo azrulystrociures. A.personwhoconstmatsMOM tiiat.onesomeiu•atwoyearpeziodshaTla�ofbe
considered a hOMODwiler.
The undersigned ` orrteowner"' assumes responsibilzty£orcbmpliazices wj the Stafe$uildang Code and oilier
Applicable codes, by laws, rules and -regulations.
The undersigned "homeowner" cexirfes ilzat lzelslze uuderstauds the Towji ot:gorih AadoverBuzlding De�artnzent
;,,,n„z um inspection procedures and requirements and that he/size y- M comply with said procedures and
recluiremenfs,
110MEOWNi33RS SIGNATURE • t
A-PPROVAL OF BDMDMG 0F`ICIAI:,
Revised 7.200g
Fbrm Homeowners Bxempfion
EOARb OF'APPBAIS 688-9541 CONSERVAIxON 688-4534
- - - - HEALTH 6889540
PLANNING 689-9535
The Commonwealth of Massachusetts
Department of IndustrialAccidents
• 1 , �p = f I Congress Street, Suite 100
Boston, MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Nanle (Business/Orgmization/Individual): 1_2 /A p�� �f 03A
r�
Address:
City/State/Zip: 4 4- 040 ,P/j' 4 Phone #:
Are you an employer? Clreck tiie appropriate box:
1.❑ 1 am a employer with ! employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3.fI am a homeowner doing all work myself [No workers' comp. insurance required.] 1
4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance.$
6. Q We are a corporation and its ofF, tcers have exercised their right of exemption per MGL c.
152, §1(4), and we have no employees. [No workers' comp. insurance required.]
Type of project (required):
7. 0 New constriction
8. [] Remodeling
9. ❑ Demolition
10 E] Building addition
11.❑ Electrical repairs or additions
12. Q Plumbing repairs or additions
13. (1 Roof repairs
14.0 Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
#Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub-cor16ct6rs have employees, they must provide their workers' comp. policy number.
I air an employer than is providing workers' compensation insurance for my employees.' Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lie. #: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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 $250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under thepains and{pennaalties of perjury that the information provided above is true and correct.
Sign atu_ r4ae �% t'1.� , Date: 0 �4 2 7,0,/J-
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License
Issuing Authority (circle one): ;
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
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 6.1'.,
express or implied, oral or written." f hire
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 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 or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonvgealth 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 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 may be submitted to the Department of flidustrial
Accidents fok confirmation of insurance coverage. Also he 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 -i'n'sured 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/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary)- 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. Anew 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 bum leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia