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Home My WebLink AboutBuilding Permit #123-14 - 268 REA STREET 7/6/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Z Date Received Date Issued: • IMPORTANT: Applicant must complete all items on this page LOCATION' �'- Print PROPERTY OWNER �AtAIS 5 Print ��,,�� 100 Year Old Structure yes no MAP NO PARCEL:��'ONING DISTRICT:K"�3 Historic District yes o Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Res' ential 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: �Jellt a0 U� I ��ti 1^ a� Identification Please Type or Print Clearly) OWNER: Name: .�AAMZ6 �*Jck+ Phone: � Z3 Address: Z1 y -c.f- ST, Agotie.-L (M CONTRACTOR Name: Phone: Address: Supervisor's Construction License: Exp. Date: i 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: $ (ZOO, 0-o FEE: $ �o • Check No.: Receipt No.: NOTE: Persons efontracting with unregistered contractors do not have access to the guaranty fund 14 Signature.of Agent/Owne �--- Sig nature of contractor Plans Submitted ❑ PlansWaived ❑ Certified Plot Plan ❑ Stamped Plans 0 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 INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on t5- /3 Sig nature OL f�Q�; COMMENTS J V�,CC l �q — (.yc7 1-� V\Q)�- HEALTH Reviewed on Signature COMMENTS f Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Todt;! Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster on site yes no Located at 124 Mair, 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 I NOTES and DATA — (For department use �I Q Notified for pickup - Date I i Doc.Building Permit Revised 2010 l I Building Department The fohowing is-a list of the required forms to be filled out for the appropriate permit to be obtained. Roofip,g, 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 o Copy of Contract ❑ 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 o Building Permit Application ❑ Certified Surveyed Plot Plan Li Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses Li Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) D Mass check Energy Compliance Report (If Applicable) Li 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 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 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 that the apw-al 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: Doc.Bui!ding Permit Revised 2012 Location No. L, Date • - TOWN OF NORTH ANDOVER • � �7' ' Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ wx TOTAL $ Check# 6 1% Building Inspector NORTH Town of � o No. L3iqZ yC, h , ver, Mass, �p T O LAM! COC NIC Nl WICK V AOR�TEO ►.P�`'�J S BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THATLllBUILDING INSPECTOR Foundation has permission to erect .......................... buildings on .4a..10.4 ........ ....................... . . ................. _ Rough 0 I , to be occupied as ..................... .1,: ..1. -:.....9�::�:�%1�r_11. :.........��..�.: ...tn.- .......... 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 CONSTRU A 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 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 The Commonwealth of Massachusetts Department ofIndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: ZGS`- City/State/Zip: Klba_rL-� APA 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- listed on the attached sheet. [J Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition o workers'comp.insurance 5. ❑ We are a corporation and its officers have exercised their 10.❑Electrical repairs or additions required.] 3.dI 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.❑Roof repairs insurance required.]r 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. i Homeowners who submit this affidavit indicating they a're 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 their workers'comp.policy information. 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:_ 2 G� �C C` 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 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. Ido hereby ce ify under thepains andpenalties ofperjury that the information provided above is true and correct. - Signature: �{ Date: l S` 2013 Phone#: 1 f-5-Z- �6 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.PIumbing 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 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. Ane w 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 bum 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 an questions, lease do y y q stions, p not hesitate to give us a call. . g The Department's p s address,telephone and fax number: The Conu4onwealth of Massachusetts Department of Industrial Accidents Office of Iuvestigal!i,ons 600 Washington Street Boston.,MA 021 It Tei,#617-727-4.900 ext 406 or 1.-877,MASSAFE Revised 5-26-05 Fax##617-727-7749 www.Mass,govfdaa =ct�oKry nw OF NOR fit,.�o k6�Syo - T� T$AND OVER Tn OFFICE OF BUILDING • ' �y�a�°R,,,°�4� ..5'°.� DEPARTMENT :1600 Osgood Street Building 20 -Suite 2 3 6 sSA�sus�c North Andover,Massachusetts 01845 Gerald A.Brown Inspector of Buildings Telephone(978)688-9545 •� - HOMEOWNERLICENSE EXE1V1pTION Fax (978)688-9542 GUIDING PERMC[T•APPLICATION - Please print DATE: 13 ' JQB LOCATION: N7-A Number Street Address Map/Lot I MEOWNER . Name. Home Phone - Work Phone PRESENT MAILING ADDRESS � /� 3T OA- AC 'T°,7m StSL'-. Zip Code- The current exemption for"homeowners"was extended to include owner-occupied dtvellinas t less allow subb homeov"Ders to engage an i,dividual for hire wag does notpossess a i Ce ° v0 units or.Gss and acts as supervisor). Slate Building (Code Section 108.3.5.1) license,provided that the owner DEFINITION OFHOMEOWNER Pe rson (s)who Qwns a parcel of land on which htends ' be,a one or two fan,iIy structures. A person who/constru e s more that one hometo a two-On year Cher eriodr is intended to considered a homeowner. Y p shall not be The undersigned"homedwner"assumes responsibility for compliances with the State B Applicable codes,by-laws,rules and regulations, Code and other - The undersigned`homeownez"certifies that he/she minimum inspection procedures and requirements ap understands the Town of Forth Andover Building Department requirements, nd that he/she will comply with,said procedures and HOMgOWNPRS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption ''gDARD OF APPEALS 688-954] CONSERVATION 686-9530 HEALTH 688-9540 PLANNING 688-953i