HomeMy WebLinkAboutBuilding Permit #491-15 - 230 ANDOVER STREET 10/20/2014Permit No#:
Date Issue44? _0
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
v 4�ti.�.. i6� •`•0\
°:
Residential
Non- Residential
❑ New Building
,p 1.
1/'/ 6IMPORTANT: Applicant must complete all items on this page
LOCATION? U
\ _ Print
;�
PROPERTY OWNER � d
Print 100 Year Structure yes o
MAP PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
ne family
❑ Addition
❑ Two or more family
❑ Industrial
I'Alteration
No. of units:
❑ Commercial
epair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septic ❑ Well
❑ Floodplain ❑ Wetlands
❑ Watersh--e--d----D-i-st—ric-t----
ElWater/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
OWNER: Name: aQ �
Address: a-3(3 \�, (\c
Contractor Name: _
Address:
Supervisor's Construction License:
Home Improvement License:
ei1
- Please Type or Print Clearly
�-(3-1 P -r Phone: c7 ?- SRi-519_3
S-�
Phone:
Exp. Date:
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: $ f 2�
Check No.: Receipt No.: QR_�a
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
nature of Agent/Owner /\)-) a—, >tO 1 q lc,�ianature of contractor
Locatior&3o #rIl d oyel ,
No Date 1
Check #035
2Ci2 0
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
� 1
`1✓ t
Building Inspector
Plans Submitted ❑
Plans Waived ❑
i
Certified Plot Plan ❑
Stamped Plans ❑
TYPE'OF SEWERAGE DISPOSAL
Public Sewer ❑
Tanning/MassageBody 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
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
A
Reviewed On
Signature_
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Commen
Conservation Decision: Comments
Wat,;;-& Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Os ood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
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
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
In all cases if a variance or special permit was required the Town Clerics 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
VIN
O
W
ci
0
OC
Q
m
ail
j�
\
LL
cu
>.O
N
u
(n
U
d
tA
Z
0
Z
a+
ns
6
LOL
t
W
T
ai
c
U
LL
W
d
Z
Z
m
J
t
�'
LL
W
N
Z
Q
V
U
W
UJI
t
cr
0
u
Ln
LL
Ix
0
a
Z
H
Q
0
t
w
LL
Z
CWC
C
°C
W
0
L
U.
v
m
.
Z
—
()
a)
w
N
O p
ca p
2
r a�
. cc
D
• O
O
H v
L �
•O �
O lC
O
C) In
O: W Cc
j
: > �
:°'yap
U)
— 'a
CD cc 0
0
N z
= o
- o =
L
Q Q d
d )
cc 0
.N
• _ a:
H O = _
Q L i cc
cn O O 2 m
W = ao O
LL ''2 M C
•� t O
W vi
v Q. 0-0
co CDc
141- N -0 p
F— t .. m o 0
F.
Z
L
co
z
W
w
CLX
LLIH
W
CL
z
0
U)
J
-0
• �
W
O
aW
E
ri
p[
O
O
G�
N
I
Q
_N
•�
v
W
W
O
L
O
CL
^^W
i
Q.
ti
aL
O
CL
U)
�a
Q
(a
cc
CL
O
4)
w
z
/+
vV
N
O
AC^
v
V
V/
O
c
The Commonwealth of Massachusetts
- Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www mass gov1dia
Workers' Compensation Insurance Affidavit: Builders/Cont°actors/Electri.cians/Plumbers
AppReant Information Please Print Legibly
Name Mushm s/L3rga za dz`vidu 1�a i c� . i-1'Q%�
Address: (� 3 C-
City/State/Zip: bio c, _M Q\r,d e.3,z- C V5 Phone #: q79- V 7- 5' t k_f
Are you an employer? Check the appropriate bog:
Type of project (required):
1. [] I am a employer with
4. El am a general contractor and I
6. J] New construction
employees (fall and/or part-time).*
2. El am a sole proprietor orpartner-
have Hired the sub -contractors
listed on the attached sheet T
/• E] Remodeling
ship and'have no employees
These sub -contractors have
8. ❑ Demolition
working for me in any capacity.
workers'_ comp. insurance,
g, ❑ Building addition
[No workers' comp. bsur'ance
5. ❑ We are a corporation and its
10.❑ Electrical repairs or additions
equired.]
3. I am a homeowner doing all work
officers have exercised their
right of exemption per MGL
11 • El Plumbing repairs or additions
yself. [No workers' comp.
c. 152, § 1(4), and we have no
12. ❑ Roof repairs
required.]
insurance d. re uire
employees. [No workers'
I311 Other
comp. insurance required.]
'Any applicant that checks box#t must also fill outthe section below showing their workers' compensation policy information.
i -Homeowners who submit this affidavit indicating they hire 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.
lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company
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 requiredunder 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 civR penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
f do Hereby cert ,fide a n enaldes ofperjury that the information provided above is
true and correct.
Official use only. Do not write in this area, to he completed by city or town of iciaZ
City or Town:
Permit/License
DsuingAuthority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. EIectrical Inspector 5. Plumbing Inspector
6. Other - - -
Contact Person:
Phone
�4 rnrH .q� TO OF NORTR AN Dovm
OMCEOF
�" 'bK t • k;gA 13
Yr BLUD•+-1.\ G IMPARTAWNT r
_.1600 OSg0QdgtrOOtB11H&920,,Siit,, 2 36
7�S Raimo r4 �5 NorthAndovez' Massachusetts 01845
�RCf1115�. a
Gerald A. Brown Telephone (978) 688-954-5
7nspeeforof$uildmgs
Fax (978) 689-9542
xoyMowNEx LICENSE P -Mb TzON
BU[DrII�TG PEPMT APPLICATION
Pleam Pring ,
DATE:
M LCCATZ0N.- -Sc
Number SizedAddress lYIapJZot .
• zO�ER i ►� �a hese r7 4�-7- �3
Name. . Home Phone Worlt ?'hone
M qs
-a 8t�. -,p Cods
The current exemption for "homeowners" was extentted to ?ncInde owner -occupied diveliings to tvo units -ox ;$ss an_d
fo all su;% T,o Po: re to engage an iudiv; dual .for hire vho does notpossess a license, provided that the
acts as supervisor). Stato ilcling (Code Seation.108.3.5.1) owner
DBFINI.TION OP`HOMEOWM R
persons) who 9was aparcel of land on which he/sha resides or intends t0 reside, an which there is, or is intended t0
be, a one oz two family structures. A person who consimots mom ifiat one home xn. aiwa ysarperiod shall not be
considered a homeowner.
The undersigned ",homeowner" assumes responsibility for abmpliauces with the State Building Code and other
Applicable codes, by-laws, rules and -regulations.
The- undersigned "homeowner" cerir
;,,;ri;,,,um insffes .at he/she tmders"tauds the Town oflr%rth AucloverBuilding De&it meat
Portion,procodiires and tbrequirements and thathe(she WM comply with,said procedures aad
requirements,
HOMEOWNME SIGNA.TME .
APPROVAL OF BLULD)NO OFFICML
Revised 7.2009
'60xm$omeowners Exemption .
'130A D OFAPPBAM 688-9541 CONSBRVAMN 699-9530=
HEALTI3 688-9540 PLANNING 689-9535 .
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 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 ofpublic 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-contractor(s) 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 returnedto 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 (ifnecessary) 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. Anew affidavit must be filled out each
year. Where a homeowner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license orpermit 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 anal fax number:
Tho Cm4ionwealth of Mo ssa ehmets
De,pada.ent ofhtdustxxal , raddonts
Offtco offavostigation
6.Q()Washhigtoa ftea
B osion, MA 02111
TQL # 617-7-27-4900 at 406 ox 1-$77-MASS.AFE
Revised 5-26-05 Fax # 617-727-7749
vaWW Rias,%g0V1d1a