HomeMy WebLinkAboutBuilding Permit #513-15 - 26 WEST BRADSTREET ROAD 12/1/2014BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#:Date Received
Date Issued: J2-11 A7
IMPORTANT: Applicant must complete all items on this page
IPR
op, ERTrY OWNER'
Pnnt z x100 Year Structure#yes
iMAPL� EPARCEL _ ZONING ®ISTRICT _ °HistonclDlstnct es
r _ � y
�_aMachinezS,h6p.Vilb e yes
/ V" tt �.EO �64yNC
e
q 1•
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
ne family
❑ A Otion
❑ Two or more family
❑ Industrial
91�lteration
No. of units:
❑ Commercial
14-Kpair, replacement
❑ Assessory Bldg
❑ Others:
demolition
❑ Other
DaSeptic ❑ UVell,
❑Floodplain <❑ Wetlands.
❑ WatershedFDistncf _
ater/Sewer
OWNER: Name:
UtS'GKIP(I ION OF WORK TO BE PERFORMED`:
Identification - Please ape or Print Clearly
Address:
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: $ � �o
U
Check No.: �l 9.� Receipt No.: 2-t 3 l Ll
NOTE: Persons contracting-?—
ontractingh unreg. er contractors do not have access to the guaranty fund
O / ,a _`
lgnature of-contractor'F .t
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. ❑
Pennanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
Signature
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comme
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
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
vg ppuildin Permit A lication
orkers Comp Affidavit
�:✓ hoto Copy Of H.I.C. And/Or C.S.L. L' s ,y,
opy of Contract ����' �d�l/
'
Floor Plan Or Proposed Interior Wor
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit j
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)
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)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
o Photo of H.I.C. And C.S.L. Licenses
Li 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 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
Locations—
Na ��� _ � S Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee
TOTAL
Check #
I
28314
- Building Inspector.
Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
$ 55,000.00
m
$ -
$
660.00
Plumbing Fee
$
82.50
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
82.50
Total fees collected
$
925.00
26 West Woodbridge
513-15 on 12/1/14
Kitchen and Baths Remodel
TOWN OF NORM A NDt)VEP,
OBFICE OF
' JB GI]�JQ
DEPARTMENT `
• ' o ;e 1600 DsgoaaStreetBuilding 20 -Suite 2-06
• NorihAnrlavex, Massachusetts 01845
�SSRcaus�� -
Gerald A. Brown Telephone (978) 68$-95h5
InspeetorofBuildings _Fax (978) 689-9542
. HQ1`EOWt�TER LICENSE E.EMPTION '
B�TEDB G PERMT A PLZOATIO N
i
pleas�iinf -'
� -
DATE:
iz• ��
JOB LOCATION.,
Number Street Address Map/Zot e,
ISOMEOWNER �I-V' ���
-
Name. I%me Phone Work Phone
PRESENT :CATLING ADDRESS
C `ny TnT�r ,faf� • . ?,n CSA
The current exemption for "homeowmers" teas extended fo
fo allow such ho -ma t,-nohide owner-occtipzed di�elings to t�vo units 'Or ;ass and
vers to engage an Ldiv; dual•forhire, who CIO as Rotpossess a licealse, provided that the ownez
acts as supervisor). RataBu?lding (Code Soo tion ID8.3.5.i) -
DEFMITION OF HOMEOWNER
Persons) who Awns a parcel of land ou which he/she resides or intends to reside, on which fhare, is, or is infended to +
be, a one or two family structures. A person, who constructs more tliat one home in. a two yearpe. 91 shall not b e
considered ahoaneownez ,
The undersigned "homeowner" assumes responsibilityforcbmplianceswith the StateBuilding Code and other
Applicable codes, by-laws, n&s andregulations.
The undersigned "homeowner" cent fes that he/she tmderstauds the . own f North AndoverBuilding Deparfinent
minimum inspection procedures and requirements and that he/she co Iy tyith,said pzocedures and
requirements,
Pi0ME0)?V2,TER5 SIGNATURE ,
APPROVAL OF BMD)NG QFFICIAL
Revised 7.2009
FOnn EOMCOwIl@g Exemption
'BOARD OFAPPEArS 688-9541 CONSERVATION 688-9530
HEALTH 688-9540 PLANNING 688`9535
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The Commonwealth of Massachusetts -
Department oflndustriqlAccldiints
Office ofInvestigations
600 Washington Street
.Boston, MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Conn°actors/EleciiriciansIPlumbers
Applicant Information Please Print Ledbly
Name (Business/Organi'zation/Xn.dividual): �.J�V.5 ,/
Address: -2-6`P-554-27 �J
City/State/Zip:
��r/ems /d /�i.�, Phone #: g� • ��
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. 0 I am a general contractor and I
employees (full and/or pmt -time).*
have hired the sub-contractoys
on the attached sheet.
2. ElI am a sole proprietor or partner -listed
These sub -contractors have
ship and'have no employees
working for me, in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ElWe are a corporation and its
r ed.]
officers have exercised their
3. am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
Tiemployees.
c. 152, § 1(4), and we have no
[No workers'
insurance required.]
comp. insurance required.]
Type of project (required):
6.. E]
Nowo-upintc
'i'tion
. L�
8. emolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.Q Roof repairs
13.❑ Other
"Any applicant that checks box41 mustalso fill outthe section below showingtheir workers' compensation policy information.
i Homeowners who submit this affidavit indicating they lire doing allwork 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.
.1 am an employer that is providing workers' compensation insurance for my employees: Below is the policy and joh site
information.
insurance Company
Policy## or S elf ins. Lic.
Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensatioupolicy declaration page (showing the policy number and expiration date).
Failure to secure coverage as requixedunder 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
ofup 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.
X do Hereby c ti under the pains nd aMe ofperjury ffiat Me information provided above is true and correct.
�.
Si ature Date; Z.
•�'
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License 0.
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Towa Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:.
Phone M
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 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 wdeceased 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 producedacceptable 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, apolicy 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. he 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 Departmenthas 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, anapplicant
that must submit multiple permit/license applications in any given year, need only submit one afffdavit 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 of-Rcialty stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is ou 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:
Tho Commonwealth ofMhssa.,dhwett4
Department Off dw-Wal Accidents
Omeof Tnyestigaliona
6.00 Wadiingtoa Slut
Boston, MA, 021 t I
TO. # 617-227-4900 eyt 406 ox- 1-877-MASSAk'B
Revised 5-26-05 Fay, 0 617-727-7749
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