HomeMy WebLinkAboutBuilding Permit #357-15 - 23 HOLBROOK ROAD 10/15/2014 XAORTy
BUILDING PERMIT 02 oy�tfVED q/�rO
TOWN OF NORTH ANDOVERZ.
APPLICATION FOR PLAN EXAMINATION
Permit No#: �'?s�S Date Received A� `"
7q A�RtTEO I.PP��S •.
� SSACHUS�
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION - _ _
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A_ac�P
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PROPERTY 01NNER _ _ ' s L-e `�'
Pnnt 100 Yeas Struc#ure '= yes x n
MAP _PAROL _ _F ONING DfS ,RIOT _ Historic District .yes- o,
- _
r
'Machine Shop Village yes €no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building Ione family
❑Addition ® ElTwo or more family F1Industrial f
N4teration No. of units: 0 Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition 0 Other '
❑ Septi ❑Wall: m y❑ Floodplain, z❑=1Netlands, ❑ VV'rshed'®istnct- i
Water/Sewer'- - 4$
-- - - -
DESCRIPTION OF WORK TO BE PERFORMED: 'k
CIT
Identification- Please Type or Print Clearly o
OWNER: Name: Phone: q7� �oZ SZd y
Address: a_? /4046/Wkw- 2� .
C0ntradto0Name
s�.
-- -
' struciomnL-ic _ _ y _
_ Exp. Date::SueisorsContensev
zHome Improvement License
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: $ (0) OUDd 0-p FEE: $ G/d
Check No.: 16 Receipt No.:
NOTE: Persons contr cting with unregistered contractors do not have access to the guaranty fund
Signature of:Agent/Ow -r. ,__: _ : __ � _ gr atore of contractor
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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 Signature_.
COMMENTS
CONSERVATION Reviewed on o '- /S- Signature
I
COMMENTS
r
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
1
I
Planning Board Decision: Comments
i
a
j.Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
'FURE'VEPARTMENT. - Temp;Dumpster on site yes
Locatedaat 124;MaimStreet
Fire Department signature/date _
-
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
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
o 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
o Workers Comp Affidavit
o 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)
o 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)
o Building Permit Application
a Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
Li Copy of Contract
o 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
Doe:Building Permit Revised 2014
Location
�0/n,
No....?s� Date
. - TOWN_ OF NORTH ANDOVER
m Certificate of Occupancy $
Building/Frame Permit Fee
*�alFoundation Permit Fee $
k • ' Other Permit Fee $
' - TOTAL $
Check#Al e C/o
ry
2813 cT
Bdilding Inspector +
Enter construction cost for fee cal - North Andover Fee Calculation
Construction Cost
�2�. .��:n O)OD I m
$ - $ 240.00
Plumbing Fee $ 30.00
Gas Fee 100 comm.
Electrical Fee $ 30.00
Total fees collected $ 400.00
23 Holbrook Road
357-15 on 10/15/14
Great Room over Garage
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NORTH
Town of
.`l. �.� n..dover
No.
1 _
Z ANh ver, Mass,
O COCN'CL"AtWICM
004T E D
_ V
BOARD OF HEALTH
PERMIT T Food/Kitchen
LD Septic System
THIS CERTIFIES THAT ....... �:.fG�,i'�;;;e,� ,,,,,,..,..,,, ,, .,,.., ~
................................................................. BUILDING INSPECTOR
has permission to erect .......................... buildings on Foundation
11(. .................................
to be occupied as ............. ..:(�:5.. ... �: '?' .. * . ;'`,�..... �.. . . ....�r.�.. Rough
provided that the person accepting this permit shall in every respect conform to the terms of the application Chimney
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Final
Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTIONS ARTS Rough
Service
................ .....i� .:T 9s,..�............................ Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Buildinz
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.
r
TO"f J-'i OF NVJ.4l.H AND O OVEP, -
`' ONCE OE
- BUMDINGli
• ' Q •" 1600 fJsgoodSIreet$nilding2 � 36
North Anclovex,Massaehusetts 01$45
s Accu
Gerald A.Brown Telephone(978)6889$45
InspeetorofBuiIdings Fax .(978)689-9542
RQMEOWNER-LICENSE PXEMPTION ,
BM1NG pR T.t'-'LICATZON
DATE:
rOB LOCATION; ,�
Number SfreetAddress
MaplLot
- .
aM�O�R Name. t:
�Z / 7d'
Hom Phone
WorkFhone
PRESENT SING ADDRESS
1--;y To_m. 8ta+w
lip Code
The current exempfion for"homeowners"was extended to
to allow subh homoo:,- -oaIude owner ocodpied dwellings to two units•or;ess and
uem to engage an?adividual•forhire.who does n.otpossess a J!oonse,provided that the owner
acts as supervisor). State Building (Cede Section x08.3.5.7)
DEFINITION OFHOMEOVINER
POISM(S)who gw,ns aparcel of land on whioli helsheres2es or intends to reside,an whiche is,or is intended to
there '
bb,a ane or two Family strmtares. A p erson.who constructs more that.one home in a two then erio d shall not b e
considered ahomeowner,
The undersigned"hontedwner"assumes res ponsibility forcompliances with the State Building Code
.Applicable codes,by-laws,zules andregnlafions. and other
- The undersigned"homeownez"certLfiesthat he/shoundersfandsthe TowuofgorthAndoverBuildiugbe�arEment
minimum inspection procedures and zequireznents and that he(she will comply with;said procedures and
requirements,
110AMOWN.BRS SIGN.A.
APPROVAL OF BUILDMC,OFFICIAL
Revised 7.2009
Form HomeownersFsxemption •
'13OARl]OFAPPEAM 688-954ICOI�SER�r r
• A•I;tON 688-9530 HEALTH 688-9540 - •
PLA-NN-WG689-95s5
TOWN OF NORTH ANDOVER
MASSACHUSETTS
Y Brian :Lea.the
Local Building Inspector
Building Department
1600 Osgood St.,Bldg,20,Ste 2035 (978)688.9545
North Andover,MA 01845 Fax; (978)688.9542
E-mail: bleathe®townofnorthandover.com
Office hours; 8.10 am M-F,and 1-2 pm M-Th
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Sualf '� Svfi wot�l
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Name(s) ., Company
Address Email
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PROPOSED ADDITI❑N ;y
NEW D.H. S
EXTG SECOND FLOOR PLAN
TO MATCH EXTG -
PEI OZB
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._ SSP - - --EQUAL EQUAL _�. _-
SHWR
CL
BATHROOM EXHAUSTI WC EXISTING
` L - - - _ - - -� JJUCJ T13 EPLUMBING CHASE
DN 3. �- - BAT.H!___
IL
1. lu- BEDROOM
1 �, EXISTING
i
~ R-13 - } EXISITNG GARAGE WALL I ; FIN.:',
INSULATION IBEL13W vv
t cL,
ST AGE � }
R=30CATI❑N BEDROOM ! 3 J i CL.
AT CROS HATCHED I I -EXISTING HALL
FLOOR 1
Y.I,F NEW Da
MR
TO EXISTING STWY
R ❑ L E D❑❑R
W WINDt]WS ` �_
I V,I,F SIZE j ALIGN WALLS u
.F. WINDOWA
BEDROOM I
w y EXISTING
tLN
UAL EQUAL
MUAL EQUAL
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MATCH EXISTING
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The Commonwealth of Massachusetts
Department ofIndustrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
'JIF www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectriciansfPlumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): i its e
Address: 12� / p
City/State/Zip: Ait51 /4y1 hone &f ;2
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors ee
2.El am a sole proprietor or partner- listed on the attached sheet.t I 9-Kemodeling
ship and'have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. F1 Building addition
[No workers' comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3. I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roofrepairs
insurance required.]t employees.[No workers' 13.❑Other
comp.insurance required.]
*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 tie doing all work and then hire outside contractors must submit anew affidavit indicating such.
(Contractors that checkthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:.
Policy#or Self-ins.Lic.#: 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 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$250.00 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.
Ido hereby certify under thepains and penalties o erjury that the in//formation provided above is true and correct.
Si afore: c-fs�'y7ate: d a
01
Phone#: "
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):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other - - -
Contact Person: Phone M.
Inform.ati®n 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 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 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 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 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. 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 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.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 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 Industrial.Accidents
Office ofInvestigations
600 Washington Street
Boston,MA.0.2111
Tel#617-727_4900 ext 406 or 1-877-MASS.AJFB
Revised 5-26-05 Fax#617-727-7749
wWW.Mass,govfclia