HomeMy WebLinkAboutBuilding Permit #161-15 - 250 BARKER STREET 8/12/2014 t&ORTfl
BUILDING ITTOWN OF NORTH ANDOVER 0
. .'
APPLICATION FOR PLAN EXAMINATION
Permit No#: fi e", /115 Pate Received .Arso
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Date Issued:
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TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building f8'6ne family
❑Addition ❑ Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District
❑Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
� .qtr dF P--,(td
Identification- Please Ty a or Print Clearly
OWNER: Name:��;A d G- ,gut•-c" Phone:,'-7f( ZTA41
Address: ?Sy &t--Ree- S1 Al- a
Contractor Name: Phone:
Address:
Supervisor's Construction License: Exp. Date:
Home Improvement License: _ Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $q0�1) FEE: $ d�T'0_0
Check No.: -,2 4g; Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Own �,.�f Signature of contractor f
Location
No. - Date
TOWN OF NORTH ANDOVER
.
p Certificate of Occupancy $
Building/Frame Permit Fee $ 4,1i:�od
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check# 1
f R
! U f /Building Inspector
1
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer Taming/Massage/Body Art ❑ Swimming Pools ❑
i
M
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
1
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
i l
COMMENTS
l
i
Zoning Board of Appeals: variance, Petition No: Zoning Decision/receipt submitted yes 4
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 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)
� I
❑ Notified for pickup Call Email
I
Date Time Contact Name
Doc.Building Permit Revised 2014
r
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
Li Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ 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
❑ 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)
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)
o Building Permit Application
o Certified Proposed Plot Plan
o Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
o 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 Clerks office must stamp the decision from the Board of Appeals
roof of recording
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and p g
must be submitted with the building application
Doc:Building Permit Revised 2014
NORTH
own of
' C - y,. 0
No.
��oh ver, Mass,
A- QAl
coc«K«ewrcw 1'
7a A0RA Te O
1S V
BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
THIS CERTIFIES THAT ....� � :.'F........................ ...... ............................................ BUILDING INSPECTOR
II � ��.. �� fi Foundation
has permission to erect .......................... bui dings on ........ C- ....................
Rough
to be occupied as ......... ... . �'..... .. . �.�G4 .. ..................... ..�`�+C`:` Chimney
provided that the person accepting this ermit shall in every respect confort to the terms of the application
Final
on file in this office, and to the provisions of the Codes and By-Laws relating to the I pection, 1 ration and
j Construction of Buildings in the Town of North Andover. / �77 PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION STARTS 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 Fina'
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until. Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
04 en is� TO"OF NORTH ANDOVER.
OFFICE OF
T -
• Q
-.1600'DEPOd Street Buff ft2D -Suite 2-36
North.Andovex,Massachusetts 01845
�S�scuus��•t
Gerald A.Brown � 'I`elephone(978)688-9$45
Inspectorof3uildings Fax (978)688--9542 '
RMMEOWNER-LICENSE BXENMPTION
B•[TED wa-m T"PLICATION
please•ormt .
DATE:
JOB LOCATION: -
Number
StreetAddress Map)Zot
' 15aMEO-iXNER
Name.
Horne Phone Workl?hone
-'RESENT MAMING.ADDRESS
Al
,efatP. _ zip Codi
The current exemption for"ho
to allow sucmeowners"Was extended to in0h0a owner-ocodp'sed diveIlings to t�vo units ox Tess and
h homey„Tees to e ing(an,'!ividual.forhire Who does notpossess a license,provided that the owner
acts as supezvisOr). Stateding (Code Section 3�8.3.S.I)
DEFINITION OPHOMEOWNER
PerSOn(s)Who awns a parcel of land on which he/she resides or intends to reside,an which there ior is intended to
s, '
be,a one or two Family structures. A person who constructs more that.one home in a two yearperiod shall not be
considered ahomeowner,
The undersigned"homedwner”assumesresponsibilityforcbmpliances with the StateBuildin .
Applicable codes,by laws,rules andzegulations, g Code and other
The undersigned"homeowner"certf es that he/she understands the Town of North AndoverBuzlding Department
xequhements,
minimum inspection procedures and requirements and that he/she wiff comply With�said procedures and
,
HOMEOWNERS SIGNATURE
APPROVAL OF BUMUNG OFFICIAL
Revised 7.2009
Form Homeowners Hxemp6on -
APPBATS 688 9541r
01\SERVATTON 688-9530
Fit L
A ZH 688-9540 PLANNING 689-9535 I
. the Commonwealth ofMaffsachtseM
DePartmentofh4strigl Accidiks
• -
Office of faves igadons
6#0 Washington Street '
Roston,MA 02111
www massgov/dza
Wgrckexcs'Compensation bsuranceAffidavit:Sui derig/Cont°actors&lectrciei[ansI,pi pexiopplxeanorr�aaZon Please PrintL bzv
` p L
'Name(Rusiness/0rganization/Tndz`vidud): �(�t fJ; � .
Address:
City'/S safe/Zip: /�/ d� c,1 dJ-t r-M� d(yc( f' Phone#: S' �6C.
Are yon an employer?Check the appropriate box: Type of project(re ed):
4. Q i am a general.contractor and I f
a employer with 6, New cOnstxmtion.
1.Q �am _--. Q
employees(lu11 andlox pax time),* have hiredthesub-contractors� 7, n Remodeling R
2.Q I am a sole proprietor or partner listed on the attached sheet:
to ees These sub-contractors have 8. [(Demolition
ship and`lav eno•em p Y , ,
working forme in any capacity. workers comp.71'{517Yance. 9. ❑Building addition
[No workers'comp.insurance 5. Q We are a corporation audits 10�ec calxepairs or additions
'
re ed.�
officers have exerczsed.thezt•
3. am a homeowner doing all work right of exemption per MGL 11..Q PXimbingxepairs or additions
,�,
myself[No workers'comp. c.152,§1(4),audwehaveno 12.P12. Roofxepazrs E
insuxancexecluixed.]? employees.�,I�I'oworkers' 13.[]Other •
comp.insurance reciuired,]
=.Anyapplicantthat checks box#I must also flloutthe,seefionbelowshowingtheirworkers'eompensagon.policyWon afion.
Homeowners wlio sabmitibis affldavltindlcatnjtfiek go doing allworlg andthen hire outside contractors must submit a new affidavit indicating such.
xCoutracfors that cheokthis bob must attached as additional sheet showingthe name of the sub-contractors andfhekworkers'comp.policy information,
JManemyroyerthat is,providingw AWS'coMPMationksuranceJoPrr�yez�rployees Bet owisthepalicyar2rijo�siPe
in foxrmadon.
Insurance CompanyName;.
Policy#ox Selma ins..L%c.#: Expiration Date:
Sob Site Address: City/Statelzip:
Attach,a copy of tete workers'coxapensatiort-policy declaration wage(showing.the policy number and expiration crate).
Failure to secure coverage as xequixed.under Section 25A of MOL o.152 can lead to the imposition of erimiitalPonalties of a
fine np to$1,500.00 andlox one-year imprisonment,as well.as civil penalties in the foam.of a STOP WORTS ORDER and a fm.e
of Up to$250.00 a day againstthe violator. Be advised that a copy of this statem.entmaybe forwa-rdedto the Office;of-
investigations
finvestigations ofthe DTA.for iiasurance,coverage verification.
do Hereby certify uriclergepalm and venaliles ofpeijary got tile ire,formation,provid'ed above fs ttae and correct, -
--�
Date: 811-2- /c•(
Si�natare
Phone 0
official use Oily. . O not wine in 61S area,to be eorazyreteci by c%ty or town official
City or Town: Permitl tLicense#
Issuing Authority(circle one): I
C
1.Board of Health 2.BuildingDepartmend 3. ity/Toww Clerk .Electxzcalxnspectox 5.]�Zu�mbingXnspecEor
6.Other
information an tions
.. .. d Instrue
Massachusetts General Laws chapter X52 requires all employers to provideworkers'compensation for their employees.
Parsuaat to flus statute,m employee is defined as"...every person k the service of another index an contract o '
express orzmphed,oral orwrittem" Y ��e'
An employes is defined as"an individual,partnership,association,corporation or other lagal entity,or any two oxmore
of the Foregoing engaged in a joint enterprise,and includingthe legal xepxesentatives ofa deceased emplQyez,.or the
xedeiver outrustee of an.individual,pa-tcter,%hip,asseelation or otherlegal entity,employing employees, 3Towevex the
owner of a dwelling house haviagnotmore thm three apartments and who resides therein,oxthe occupant ofthe
dwelling house of another who employs persons to do maintenance,construction orrepair work on such dwelling house
or onthe grounds orbuildiag appurtenant thereto shallnot because of such employment be doomed to bean employes."
MGL chapter 152,§25C(6)also states that"every state or local lic-ening agency shalt withhold the issuance or
renewal of a license orermit too operate a business or to cons
p p tinct buildings in the commonwealth for any
applicant who has not pxodueed.acceptable evidence of compliance with the insurance coverage requked"
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,fhe insurance
requirements oftbischapterhavebeenpresentedtathecontractin auth
g ori fY
Applicants .
Pleas,1711 out the workers'Compensailon affidavit completely,by checking the boxes that apply to your situation anal,if
iieces••
saty,supply sub-contractors)name(s),address(es)andphonenumber(s)alongwM their certidoafe(s)of
insurance. Limited Liability Companies(LLC)ox Limited Liability Partnerships(I LI')with no employees otfier than the
members oxpattners,are notrequireclto carry workers,cam pensationi�ance- If an.LL C orW doeshave
em ployees,apolicyisrequirA Be advisedthatlhx aftxdavitmaybesubmittedtotheDepartm.entof lndustrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. ilia affidavit should
be retained to the city or town thatthe application forthepermit or license is being requested,riot the Department of
Industrial Accidents. Shouldyou have any questions regarding fhe law or if you axe required to obtain a apartment
Compensation policy,please call the Department at fhe number listed below. Self insured companies should enter their
self insurance license number on the appropriate line. '
City or Towu Mcials
PleasebesurethattheafCdavitiscomplete andpxintedlegibly. The Department has provided a space at the bottom.
of the affidavit foryeu to f LU out ht the event the Office of htvestigations has to contact you regarding the applicant.
Please be-sure to tilt i athe pannit/license number whichwill be used as a reference number, I'n,addition,m applicant
t/Iz
thatmustsubmitmulti le ermi 'cense
p p applications in any given year,need only submit one affidavit indicating current
policy informai"on(If
Job Site Addess>l
the applicantshouldwxife"all locationsui (city or
tov )".A copy of•the affidavit that has been of Rdally stumped or marked by the city ox town may be provided to the
applicant asp" of that a validafidavit•rsonalefoxRiturepermitsorlicenses. .Anowadidavitmustbafilledo
• ut each
Year.Where a home owner or citi2en is obtainin a license o
g xpermitnot related toany businmsorcommercial 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 fox your cooperation and shquld ou have as est'to
Y. Y ns,
lease � - .
p do uo�hesitate to give us a call.
The Department's address,telephone ahA fax number.
The Cm—monweaM o ?S arhU P ,
Pap-ax env ofZudu x l ac cla t
• (.�fb�co o�'�Tnv��C�a�xo..xt� •
6Q0 Was gtc aStj:eGt
SQAoD, 02111
TOL 617.7.2.7:4900 QA 406¢x 1-877�MMMM
Revised 5 26-OS Fd 6 �