HomeMy WebLinkAboutBuilding Permit #324-16 - 227 MAIN STREET 9/16/2015 NORTH
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION 70
m
Permit No#: Date Received �y ADRATED
/ SSACHU`��
Date Issued: //
I PORTANT: Applicant must complete all items on this page
LOCATION
1
PROPERTY OWNER / . C t
Print 100 Year Structure
MAP PARCEL: ZONING DISTRICT: Historic District %yestMachine Shop Villag
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
XRepair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑ Septic ❑Well ❑Floodplain ❑Wetlands ❑ Watershed District
❑Water/Sewer
r � DSC I TION O O �) O� PER , RMED, E
Ventificatio - Please Type or Print Clearly
OWNER: Name: ¢ in M& Phone:
Address: /} �/�
Contractor Name: Phone:
Email:
Address: !PA,-,
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: $ � FEE: $
Check No.: l Receipt No.: C25 3rw
NOTE: Persons contracting with u ireg stere ctors do not have access to the guaranty fund
;Signature of Agent/Owner f Signature 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 0
Private(septic tank,etc. ❑
p Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
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 Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no,
Located at 124 MainStreet
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: 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 department use)
❑ Notified for pickup Call Email
Date Time Contact Name 3
Doe.Building Pennit 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
La Building Permit Application
o Workers Comp Affidavit
o Photo Copy Of H.I.C. And/Or C.S.L. Licenses
a Copy of Contract
o Floor Plan Or Proposed Interior Work
o Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
o Building Permit Application
o Certified Surveyed Plot Plan
o Workers Comp Affidavit
o Photo Copy of H.I.C. And C.S.L. Licenses
u Copy Of Contract
o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Mass check Energy Compliance Report (If Applicable)
o 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)
u Building Permit Application
u Certified Proposed Plot Plan
a Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
a Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Copy of Contract
o Mass check Energy Compliance Report
L3 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
Location
No. Date / !
f
TOWN OF NORTH ANDOVER
a4 Certificate of Occupancy $
Building/Frame Permit Fee $ •_
` Foundation Permit Fee
�
Other Permit Fee $
TOTAL $
` Check# v
f �` Building Inspector
NORTH
own ofndover
,
O 0
W h ver, Mass, -
O LAN! 1,
COCNIC Nl WICN V
AOR�TE0
li S U
BOARD OF HEALTH
Food/Kitchen
PERMIT L D Septic System
•
THIS CERTIFIES THAT ........... .1 ............................. I^...............................................
BUILDING INSPECTOR
� , f Foundation
has permission to erect . .................... buildin ........ .....�.... . .. �........... .....
• Rough
to be occupied as ....... ............ !�. ...... ................ ......... � r/.. .�..a. ew• Chimney
provided that the person accepting this permit shall in every respect conform to the terms of the application Final
on file in this office, and to the provisions of the Codes and By-Laws relating the Inspection,Alteration and
Construction of Buildings in the Town of North Andover. U
4 0PLUMBING INSPECTOR
om
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 M0 ELECTRICAL INSPECTOR
� �.
. UNLESS CONSTRUCTIO R Rough
Service
..................... ......... ... ...... ........................ Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building 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.
Smoke Det.
1
I
NORTH TOWN OF NORTH ANDOVER
OE ,,I. , 1(.
°oma OFFICE OF
A BUILDING DEPARTMENT
1600 Osgood Street,Building 20, Suite 2035
North Andover Massachusetts 01845
SS�CH�S�S
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: q
/Number Street Address Map/Lot
HOMEOWNER (,/l� `7 T--)- )- ",- - - 5`''
Name Home Phone Work Phone
PRESENT MAILING ADDRESS
City Town State Zip Code
The current exemption for"homeowners"was extended to include owner occupied dwellings of one or two family
dwellings and to allow such homeowners to engage an individual for hire who does not possess a license, rop vided
that the owner acts as su ervisor.
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 dwelling,attached or detached structures accessory to such use and/or farm structures.A
person who constructs more than one home in a two-year period shall not be considered a homeowner. (780 CMR
Section I IO.R5.1.2)
The undersigned"homeowner"assumes responsibility for compl' ce with State Building Code and other applicable
codes,by-laws,rules and regulations.
The undersigned"homeowner"certifies that /she unde stands the Town of North Andover Building Department
minimum inspection procedures and requu ments and/hat I.1-.Gmply-with-said-prDL es,,ind
requirements.
r
HOMEOWNERS S NA.r
APPROVAL OF BUILDING OFF C
Revised 8.2015
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
The Commonwealth ofMass�chusetts
_ . Department of Indus�lalAccade�ats
X Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dza
SV• Workers'Compensation Insurance Affidavit:Builders/ContractorslElectricians/Plumbers.
TO BE F" WITH THE PERAOMTiNG AUTHORITY.
Applicant Iicant Information 'b
Please Print Le l
• j ,
Name(Business/Organizadon/Individual): St
Address: �!
City/State/Zip d Phone##:
Areyou an employer?ChecktEe appropriate box: Type of project()Vequired):
1.❑I am a employer with employees(full and/or part tine).' 7. ❑New construction
2.E]I am a sole proprietor or partnership and have no employees working for me in &. [1 Remo delhig
any capacity.[No workers'comp.insurance required.]
9. El Demolition
3W I am a homeowner doing all work myself[No workers'comp.insurance required.]t
10❑Building addition
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 11.❑Electrical repairs or additions
proprietors with no employees. 12..Q Plumbing repairs or additions
5.Q I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof rep
�
These sub-contractors have employees and have workers'comp.insurance.T
' � 14.V
6.E]We are a corporation and its officers have exercised their right of exemption per MGL c. Other ' C
152,§1(4),and we have nQ employees.[No workers'comp.insurance required.]
'.Any applicant that checks box 41 must also fill out the section bclow showing their workers'compensation p olicy information.
7 Homeowners who submit tins a ffidavit indicating they are doing all work and then hire outside contractors must s4bmit a new affidavit indicating such.
rContractors that check this box must-atfached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors fiave employees,`they rimst provide their workers'comp.policy number.'
I am an employer that is pioviding workers'compensation insurance for my employees.'.Below is thepolicy and job site
information.
Insurance Company Name:
Policy##or Self-ins.Lie.#: ExpirationDate:
Job Site Address: City/State/Zip:
Attach a copy of the workers'coznpensation•policy declaration page(showing the policy number and expiration elate).
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 violato A:•opy o cement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.//
I do hereby c rd uradder the pains andpenaldes ofperjury that the information provided
�Jove i`shrue and correct.
Si a e:• Date: (/ /
Phone#:
Official use only. Do not write in this area,to he completed by city or town official.
City or Town: PermitUcense#
Issuing Authority(circle one):
1.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 empoyees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of lure,
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 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 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•phonenumber(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 Industrial
Accidents fox 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'
compensatiori 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. 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)and under"Job Site Address"the applicant should write"all to cations 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.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 burn 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