HomeMy WebLinkAboutBuilding Permit #737 - 27 BRADSTREET ROAD 6/26/2009BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: t Date Received
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TYPE OF IMPROVEMENT
PROPOSED USE
Reside al
Non- Residential
New Building
Onefamily
Addition
wo or more family
Industrial
Alteration
No. of units:
Commercial
Repair, replacement
Assessory Bldg
Others:
Demolition
Other
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OWNER: Name:
UtbUKIF I ION OF WORK TO BE PREFORMED:.
Please Type or Print Clearly)
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: $ �I �(� e �� FEE: $ O !� ,
Check No.: Receipt No.:—J
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
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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 Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
1
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 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 - Date
Doc -Building Permit Revised 2008
Building Department
The following is a Fist of the required forms.to be filled out for the appropriate permit to be.obtained.
Roofing, Siding, Interior Rehabilitation Permits
o Building Permit Application
Workers Comp Affidavit
4�Copy
Photo Copy Of_H.I.C. And/Or C.S.L. Licenses
of Contract
❑ r Proposed Interior Work
❑J 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
❑ 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 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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2008
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The Commonwealth of Massachusetts
l� Department of Industrial Accidents
Oifice of Invest igatiolts
606 Washington Street
Bosiort, MA 02111
www.nzass.gov/dia ,
Workers' Compensation Iasurance.Affidavit: Builders/Contractors/Eiectriciants/Piumbers
Applicant Information
Naini (Business/Orgeoizafiom4ndividual):
Address:
Citystate/Zip:
Phone #..
art employer? Check.tbe appropriate hoz:
FA8ou
I° ELM aemployer with
4. ❑ I am a general contractor and I
p (requites:
employees (foil $nd/orpert-time).*
have hired thosub-contractors
construction
I am .a.sole proprietor or partner-
listed on the attached sheet 3
odeling
ship and have no employees'
workingfor mein
These suis -contactors have
olition
F7O
arty opacity.
workers' comp, insurance .
workers' comp. insurance.
5. ❑ We are a corporation and itsnS
i[No addition
required ]
I am a homeowner doing all work
officers have exercised their
right of exemption per MGL
trical repairs or additions3.❑
bing repairs
myself (TIO workers' comp.
insurance required.].t
r 152, § 1(4),' and we have no
•emPto ces. [No workers'
or additions
12.[] Roof repairs
COMP. ►nsuraace required.]
`tiny applicant that checks bob # t must also fill out the section below showing their workers' 'compensation
r Homeowners who submit this affi'rtavit indicating they are doing an work
;Corttraetnts
13.❑.Other
policy information.
mad then hie outside connactots must submit a new affidavit indicaiiag such
that check this box MAT Attached an additions) I;hw,, showing Ihte name of the sub-eonnactoisAnd their workers' cer„M" .s:—.
F�••�, infomiedon.
I am an employer that is providMX:workers' co ematiori - r
inforrnafion. n+P insuraaee for my employees: Below is the policy andjob site .. .
Insurance Company Name:
Policy 4 or Self -ins. Lic. #:
F.zpiration Date:
Job Site Address:
. City/StateJZip.
Attach 8 copy of the workers' Com usation
Pe Policy deciaration page (showing t`he policy Dumber and ezpiratioa 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 andlor 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 copyy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of pedi., that the information provided above is [rue and eotrsed
Signature:
Phone #:
�ciat use only. Do not write in this area, m be completed or town or '
.ff`t�
City or Town. Permit/Licease #
Issuing use
(circle one):
1. Board of Health 2 Building Department 3. City/Towu Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Pers(
Phone #:
Information a nd 1110tructions-
MassachuseM
General Laws chapter 152 requires all emp Ioyen 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%mgoing engaged in a joint enberp'rise, and includirig the legal representatives of a deceased employer, or the
receiver ortrvstee of an individual, partnership, associatioin or other legal entity, employing employees. 'How -cm 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 Ceensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or *o construct buildings in the commonwealth for any
applicant who has not produced acceptable avidence air compliance with the insurance coverage required."
Additionally, MOL 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 insunmce
requirements of this chapter have been presented to the carttracting 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), adCh=(es); acid phone nuinber(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members orpartners, are not requiredlo cant' workers' ccbrnpensation 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'1he 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
seit-insurance"lieense number on the'appropnate 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/liceme 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 :infonnafion (if necessary) and under ".fob Site Address" the applicant should write "all locations in (city or
town)." A copy of•the affidavit that has bem.officially sta=nped or marked by the city or town may be provided to the
applicant as proof that a valid affids6t. is on file for futrae 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 bum leaves etc.) said person is NOT.required to complelt this affidavit.
The Office of Invest►pations 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
Departmnnt of Industrial Accidents
Office of mvestti ations
600 Washington Street
Boston, MA 02111
TeL # 617-7274900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7748
Revised 5-26-05 www.mass.gov/dia