HomeMy WebLinkAboutBuilding Permit #672 - 262 PLEASANT STREET 4/1/2014Permit NO� ?
Issued:
LOCATION,- . -
PROPERTY OWNER._
MAP NO: �t PARC
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
0
ORTANT: Applicant must complete all items on this page
not
Print 100 Year Old Structure yes nb
;EL:� ZONING DISTRICT:. Historic District ye no
Machine Shop Village ve no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One 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:
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
Arlrinnec•
CONTRACTOR Name: _ _ .. _ Phone:
Address:
NY leowoft L10
Supervisor's Constructio7Uicelrn'
s P. t:x! - - . ,
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: $ 144QDQ FEE: $
Check No.: �� Receipt No.:
NOTE: Persons contracts c unr istered contractors do not have access to the guaranty fund
'^s r
Signature of Agent/0 ' er Ig_�ature. of'contractor
Plans Submitted Li Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
- Plans Submitted ❑ .`Plans Waived ❑.: ;.Certified Plot Plan ❑ Stamped Plans ❑
TYPE 0E-.SEWERAGE_D1SP0_SAL
Public Sewer ❑
Tanning/MassageBodyArt ❑ ..
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
DATE REJECTED DATE:APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
_CONSERVATION Reviewed on - Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS ¢
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes -
Planning Board Decision: Comme
Conservation Decision: :Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Tow;! Engineer: Signature:
Located 384 Osgood Street
FIRE 'DIEPAKTMENf.--,7er4ip Dumpster on site yes_ - no
Located: at .124 �Mair, Street.-
-'Fire Depar"tme►]t signature/date a j t: �• r w
t '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, rust 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
® Notified for pickup - Date
Doc.Building Permit Revised 2010
Building Department
The foh wing is a list of the required forms to be=filled out-forthe appropriate. permit to .be obtained.
Roofirr�g, Siding, Interior Rehabilitation Permits
❑ l Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H-.I.C. And/Or G.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/Crossection/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
o 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 Clerks office must stamp the decision from the Board of Appeals
that the apn•�al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be subm-tted with the building application
Doc: Doc.Building Permit Revised 2012
Location 77 -
No.
Check # A�-
2 i -,, ; , I
Z) " U
Date 4
TOWN OF NORTH ANDOVER
Certificate of Occupancy $-
Building/Frame Permit Fee $
Foundation Permit Fee $-
Other Permit Fee $-
TOTAL $
Building Inspector
�w
Enter construction cost for fee cal -
North Andover Fee Cakulation
Construction Cost
$ 10,000.00
m
$ -
$
120.00
Plumbing Fee
$
15.00
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
15.00
Total fees collected
$
250.00
262 Pleasant Street
672-14 on 4/2/2014
Kitchen Remodel
gORTH R TOWN OF NORTH ANDOVER
OFFICE OF
° , I p BUILDING DEPARTMENT
1600 Osgood Street Building 20, Suite 2-36
North Andover, Massachusetts 01845
SACHUSY
Gerald A. Brown
Inspector of Buildings
HOMEOWNER LICENSE EXEMPTION
Please print
DATE: ( t'
JOB LOCATION: ::�6 cQ 7— A/b 4/,
HOMEOWNER
Number
Name Home
PRESENT MAILING ADDRESS a& a PXSQ Az�o(
City Town
State
Telephone (978) 688-9545
Fax (978)688-9542
Map/Lot
'� 6 Y13
Work Phone
Zip Code
The current exemption for "homeowners" was extended to include owner -occupied dwellings to two units or less
and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the
owner acts as supervisor). State Building (Code Section 108.3.5.1)
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to
be, a one or two family structures. A person who constructs more that one home in a two-year period shall not be
considered a homeowner.
The undersigned "homeowner" assumes responsibility for compliances with the State Building Code and other
Applicable codes, by-laws, rules and regulations.
The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Revised 10.2005
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
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The Commonwealth of Massachusetts Print Form
r Department of Industrial Accidents
ry. Office of Investigations
1 Congress Street, Suite 100
a. Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Paula Caselden
Address:262 Pleasant St
Citv/State/Zip:North Andover MA 01845 Phone #:978-697-5563
Are you an employer? Check the appropriate box:
. ❑ 1 am a employer with 14. ❑ 1 am a general contractor and I
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3.'�Q I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
have hired the sub -contractors
listed on the attached sheet.
These sub -contractors have
employees and have workers'
comp. insurance.*
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑✓ Remodeling
S. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13. ❑ Other
*Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
,Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. if the sub -contractors have employees; they must provide their workers' comp. policy number.
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-.:I6fzs"a cam(! City/State/Zip: IPA -
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).Q�
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.
I do hereby cepAunder the pAins and penalties of perjury that the information provided above is true and correct.
978-697-5563
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
.w
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-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 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 of Investigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 7-2010 www.mass.gov/dia