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Home My WebLink AboutBuilding Permit #442-14 - 265 SUMMER STREET 11/18/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: Date Received Date Issued: f Am IMPORTANT: Applicant must complete all items on this page LOCATION' 1�S 5VLM ,Pn t PROPERTY OWNER ,1C'v 'y i 8 . C`+ � SS J Print" 100 Year Old Structure yes rio MAP NO: W'+,A PARCEL: 1 ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT. PROPOSED USE Residential Non- Residential ❑ New Building ' One family ❑Addition El Two or more family El Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other El Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District, 0 Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: AAAauk, �, ✓; �� Identification Please Type or Print Clearly) OWNER: Name: �. �c�i' Phone: 5��+ Address: utyl,619 CONTRACTOR Name: Phone: Address:,-- C�2r�� 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: $ a a.` FEE: $ 10,00 Check No.: t� Receipt No.: �� 13 NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund gnafurexof Agent/Qvvner- Slgpature_of contractor. Plans Submitted ❑ Plans Jaived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Plans Submitted ❑ . -.Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE-OR-SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑. . Swimming Pools ❑ Well ❑ Tobacco.Sales ❑ Food PackaginglSales ❑ Private(septic tank,etc.._ ❑. Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR-OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE:APPR.OVED PLANNING &'DEVELOPMENf ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS d F Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Server Connection/Signature& Date Driveway Permit bPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT, Temp Qumpster on site yesno Located at X124 Mair Street g ff Fere D , �, epartmer�t signature/date r•- COMM.ENTS ` . r �•.,. : . -y. ,. :, 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-$1000fine NOTES and DATA— For department use El Notified for pickup - Date t E Doc.Building Permit Revised 2010 Building Department "rhe fol swing is'a1" t of the required forms to be filled out for the approp riate:permit to.be obtained. Roofivg, Siding, Interior Rehabilitation Permits oBuilding Permit Application ❑ Workers Comp Affidavit Li Photo Copy Of H.I.C. And/Or C.S.L. Licenses o 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 o 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) 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 ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o 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 apical period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm:ited with the building application Doc: Doc.Building Permit Revised 2012 Location 2ioc5 -S(AVAVN_Q^ No. Date t. • • TOWN OF NORTH ANDOVER Certificate of Occupancy $ • Building/Frame Permit Fee $ ' Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# 27113 Building Inspector r -i NORTH _ . W. 1 : :. .c ver 0 No. 44z.. Iq it A. - �` rh ver, Mass, O COC NIC t#1WICK ��• �d A�RATEO PPa,`'�5 S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT � '� �. � ................... BUILDING INSPECTOR. has permission to erect buildings on 5 31A%**1VWt*e $+" Foundation .......................... .................................................... t�.... Rough to be occupied as �C .�..."!!1'Z �4 ......... Chimney ............ ....... ........ .................................................................. 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 CONSTRUCTION STARTS Rough ............ Service ..................... .... .. ............ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE it � _ n I i i t 4 �= r r , Iii • _ r a t �d Y y The Commonwealth of Massachusetts - Department oflndustriglAccidents Office of Investigations 600 Washington Street Boston,MA 02111 U1. www.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/In yid 1): i - U- � �� IS Address: _L(4 w&1 aj . 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. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- 7. Remodeling listed on the attached sheet.t 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.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.0 I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.[]Roof repairs insurance required.]t employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. T Homeowners who submit this affidavit indicating they Ere doing all work and then hire outside contractors must submit a new 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. lam 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.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 fins 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 ofthe DIA for insurance coverage verification. Ido hereby certify unferthep ins a penalties ofperjury that the information provided above is true and correct. Signature: i - Date: I U 1 Phone#: J — L e� --;'),),ts 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 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-contractors)name(s),address(es)and phone number(s)along with their certificates)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 fir Accidents for conmation 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 permithicense 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: Tho C=40awalth of Massachu.,so is Department ofzndustrzal.Accidents Offitce o�Iu�esti�al�ions 600 Washington Streit Boston,MA 02111 TO,#617-727,4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617"727-7749 'c�ww.n�tass,govfdza �asry rye yY1� O�` }OE�'�en k6 Sya A NORTH ANDOVER OFFICE OF Y ]BUILDING DFPARTMENT ` aP"" 1600 i0sgood Street Building 20,-Suite 2-36 A Ar b fffl North Andover,Massachusetts 01845 Gerald A.Brown Inspector of Buildings Telephone(978)688-9545 HOMEM-MR•LICENSE EXEMPTION Fax (978)688-9542 ]OMIN G PERMIT.AAPPLICATION Pleas---e print DAML—A kuj -1,0 1 JOB LOCAT1oN: I�S i� A, 1: I Number er Stre et Ad - dress . Mapl'Lot HOMEOWNER C.44r Rom y�� •c Name. - e Phone Work Phone PRESENT MAILING.ADDRESS eS 7ip Code The current exemption for"homeowners" to allow such homeoywas extended to include owner-occupied dwellings to two units•or less and �ners to engzge an;;idivadual•forhIre wno does not possess a h cense,provided that flee owner acts as supervisor). State Building (Code Section 108.3.5.1) DEFINITION OFHOMEOWNER Persons ()who Qwns a parcel of land on which he/she resides or intends to reside,on which there is,oris intended to be,a one or fwo fau�ily structures. A person who constructs more thatone home in a Iwo yeher eis,O shall not e considered a homeowner. The undersigned"homeowner"assumes responsibility for Applicable codes,by-Jaws,rules andregulationscompliances with the State Building Code and other , t The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Department requirements,minimum inspection procedures and requirements and that he/she will comply with,said procedures and IIOMEOWNBRS SIGNATURE .APP.ROVAL OF BUILDING OFFICIAL, Revised 7.2009 Form Homeowners Exemption ''BOARb OF APPEALS 685-954] CO]�SERtr T `r ATION 6SS-9530 HEALTH 688-9540 PLANNING 685-9535