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Home My WebLink AboutBuilding Permit #449-15 - 26 WEST BRADSTREET ROAD 11/6/2014 L NORTH BUILDING PERMIT OF�i�Eo •b�ti TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION yy 1• b _t Permit No#: 16,5 Argo Date Received �gSSACHU`��t�y i Date Issued: .x/60 `J IMPORTANT:Applicant must complete all items on this page LOCAT1,ONI --tin 1PROPERTY OWNER 100Yua Y` y _ noPrnt earStruc e t_ MAP .. , _PARCEL ZONING,>®ISTRICT.wr Historic District ' yes; no �Mashme. �hop Ui�llage- yes ono_r TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial C�Zair, replacement ❑Assessory Bldg 11 Others: olition ❑ Other Septic 0:1Nell ❑`Floodplain ❑*Wetland$. D, Watershed`District ❑Water/Sewer- - 3 DESCRIPTION OF WORK TO BE PERFORMED: �I i Identification- Please Type or Print Clearly OWNER: Name: �� `�� Phone: � Y Address: Contractor Name:T 'Ph - . _ - one:: Address - - -s0ervlsor's Constructiorn,Liceni Lse:__ __ _-_ Exp Date _ ` _ �� F loM-9,11 mprovernenticense:.�.�- _ — 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: $ C � Check No.: Receipt No.:�cS 01 q�� NOTE: Persons contracting W4 unreg' tepW contractors do not have access to the guaranty fund Signature.of»Agent! >w r. ; _r y= 0,L_of-ontractora.mrt_ e _ . 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 I INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS 1 CONSERVATION Reviewed on Siqnature i COMMENTS i HEALTH Reviewed on Siqnature -OMMENTS I Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments j Water & Sewer Connection/Siqnature& Date Driveway Permit i DPW Town Engineer: Signature: Located 384 Osgood Street - . --- IF-IRE DEPARTMENT TOM, Au.mpsterfon elite yes_ �. ILocoted?at 124 Main Street F: re'DPPA rtmentsignature/elate. DOMENTS; i i 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.$10041000 fine NOTES and DATA— (For department use) i ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 I 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 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 ❑ Engineering Affidavits for Engineered products NOTE Bldg All dumpster permits require sign off from Fire Department prior to Issuance of g Permit Addition Or Decks ❑ Building Permit Application Li. Certified Surveyed Plot Plan L3 Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract Li 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 NOiTE: 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 o 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) o Copy of Contract o Mass check Energy Compliance Report o 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 tlxat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording nx mst be submitted with the building application Doc:Building Permit Revised 2014 ��,� 1J� Locati007 VV• a te r No. r Date o - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee O$ E Foundation Permit Fee $ r Other Permit Fee $ TOTAL $ Checkr t 28242 Building Inspector a4 Jnr Sy �oWN OF igORTH AND OFFICE of _ JBUMDING DEPARTMENT • . 'S` Q R w}� .% • -1600 00.I s )d Street Bifflding 20 •Silite 2-36 .j1 [ eX •1' p ahrn rY �5 North Andover,Wassachusetts 41845 S RC}ggs GezaId A.Brown Telephone(978)688-9545 l'nspectoroi=Buildings Fax (978)688-9542 ,. H(TMEOWNER-LICENSE P-XENkLOrr BMING PFIPMT APPLIOAUON Please�rint , DATE: �� b JOB LOCATZDN: Number SixeetAddress map)Lot Mime. Homo 1?hone Work Rhone -'.RESENT MAMING ADDRESS S dam;y ToLm. �f�fw • ?ip Gode The current exemption far"homeowners"was extended toinclude,owner-occupied diYEgs to i4vo units ox;ess and f0 allOrN$11�rOR7P0.r l ` g^¢ • nets zo en 1^e an? dividual•for bice'Wbo does uotpossess a licause,provided that the owner acts as suparvisor). StateStilding (Code Section 708.3.5.1) -i DEFMITION OF.HOMEOWNEIR. Persons)who 9yyns aparcel ofland ozi whi.cli he/slle resides or intends to reside,on which there is,or is intended to , be,a one or two family stmctares. A person.who constructs more that one home in•a t hi h then Brio 0 shall not c considered a homeowner. The undersigned"homedwner'assumes responsibility for compliances with the State Building Code and other Applicable codes,by-laws,xules andzegalations. The undersigned"homeowner"cert les that helshe understands the Town of North AndoverBuilding Department minimum inspection procedures and req ' eme is andthat he/she " requirements, mplY with,said procedurEs and HOMEOWMER5 SIGNATURE Al?l?ROVAL OF BUJL,D)NG OFFICIAL Revised 7.2009 Form Romeowners Fixdmption , ')3OARDOFAPPFAM-688-954Ir T <;. COhSER4ATi0N688-9534 HEALIT3688-9540 PLXNNING6899535 The Commonwealth of Massachusetts - Department of Industritjl Accidents Office of Investigations 600 Washington Street Boston,MA.02111 www mass gov/clia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): �� 7 �!/ ✓ Address: City/State/Zip- �? ' �' Phone 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 I ` 6. F1 Now construction • employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. FJ Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their ME]Electrical repairs or additions 3111 am a homeowner doing all work right of exemption per MGL 11.F1 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. 7-Homeowners who submit this affidavit indicating they a're doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. X am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy 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 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 civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Bo advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby c t under t pan s a d enal nes ofperjury that the information provided above is true and correct. Si ature Date:/Z,., 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#: 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 ofhire,- express or implied,oral or written." An employeiis 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-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 maybe 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 permitilicense 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 Massachimetts Dqpartwnt of htdustrlal AccxdeAts Offitce o£In.�esti�atitons 6,00 Washiugtoa Stzeet Boston,MA 02111 TOL#617-772,7-4900 ext 406 or 1-877-MASSA FE Revised 5-26-05 Fax 4 617-727-7749 _WWWMEtaguldia NbRY Tow- n of . 10 No. 9..- &) * - h h ver, Mass, A- coc«�cMewrcw ��• A°RATED ►PP,�'�y s � BOARD OF HEALTH Food/Kitchen PERMIT. T L D Septic System THIS CERTIFIES THAT ..............3.. ... .................... ).. l... . ............................................................ BUILDING INSPECTOR .... . Foundation has permission to erect buildings on ..................... ................�?......1.6ra . . .......... .^ ,. Rough g led as <r.-!'kl��?....... p � ��.....�....... A�L��d............................... Chimney to be occupied 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 to the Inspection,Alteration and 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 CONSTRUCTIONAR Rough Service .......................... .. .............................................. Final BUILDING INSPECTOR GASINSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final 71ST'; No Lathing Or Dry Wall TO Be Done FIRE DEPARTMENT a X� Ukil Inspected and Approved by the Building Inspector. Burner Street No. zrI Smoke Det.011 vn Aq mi _