HomeMy WebLinkAboutBuilding Permit #280-2017 - 27 MARBLEHEAD STREET 9/14/2016 %0RT1{ q
BUILDING PERMIT
I � TOWN OF NORTH ANDOVER o
APPLICATION FOR PLAN EXAMINATION * T _
OpA n 1
Date Received BOATED c5
Permit No#: gSSAC"US
Date Issued: 114 Z646
IMPORTANT: Applicant must complete all items on this page
LOCATION
1 Print
PROPERTY OWNER an) I�� �(fkf
Print 100 Year Structure yes no
Historicistrict yes no
MAP PARCEL: ZONING DISTRICT: Machine Sh p Village yes no
TYPE OF IMPROVEMENT PROPOSED USE Non- Residential
Residential
[INew Building ❑ O e family
El Addition VWo or more family ❑ Industrial
❑A teration No. of units: ❑ Commercial
epair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
4 '� ® Flood F lain ®1111en,ds aterhistr
T
DESCRIPTION OF WORK TO BE PERFORMED:
Y herd d -hUjy-S ak ee
�� sheer 6ki hills u nem 3) lou G in
�r n ,v -es
IdentificatiPIease Tyne`or Print Clearly
OWNER: Name: �Yl\V?l� ��`n'� �Tv�' Phone��-$I�1a�7�-�'�-f�-
Address: �� _e C 1 Ma j'1doo� �Y1®l d ( (?Lf 5-
Contractor Name: Phone:
Email:
Address:
Supervisor's Construction License: - Exp. Date.
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT.--$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
Total Project Cost: $ 0 , FEE: $
Check No.: Receipt No.:
5OU99
NOTE: Persons contra g wit regi er d con ctors do not h ve access to the guaranty fund
Building Department
The following is a list of the required forms to be filled outlfor the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
Building Permit Application
Workers Comp Affidavit
Photo Copy Of H.I.C. And/Or C.S.L. Licenses
Copy of Contract
Floor Plan Or Proposed Interior Work
Engineering Affidavits for Engineered products
OTE: 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/Cross Section/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
OTE: 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
2012 I ECC Energy code
Engineering Affidavits for Engineered products
OTE: 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
Doe:Building Permit Revised 2014
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
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
c
CONSERVATION Reviewed on Signature
COMMENTS
WEALTH Reviewed on Signature
COMMENTS
i
Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
i
Conservation Decision: Comments
Water & Sewer Connection/signaure ®ate Driveway Permit
]DPW Town Engineer: Signature:
-Located 384 Osgood Street
FIREiDEPARTIVIEIVT - Temp,Dumpster on site yes,
L'ocated at-A 24 Main Street �.c f
Firet`Department sgnatiare0clate
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
NOTES and DATA— (For department use)
® Notified for pickup Call Email
Date Time Contact Name
Doc.Building Permit Revised 2014
Location1 � Itl%!
No. 2,, (,? " Date O 1 z016
r
• - TOWN OF NORTH ANDOVER'S
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
,
TOTAL $
Check# � "
%` Building Inspector /"
tAO R TF{
own o ? _ �� e ndover
No.
h ver, Mass,
'P
COCNICHEWICK
A0R�TED
S U
BOARD OF HEALTH
PERMIT T LD
Food/Kitchen
Septic System
THIS CERTIFIES THAT ..., l �.�!.' ....,� c , ,� BUILDING INSPECTOR
.... .............................
has permission to erect „� ��� Sration
.......................... buildings on .... ......... .. .......
Rough
tobe occupied as .....mo`•..�.... .. .. ..�........... ... ..................................................... Chimney
provided that the person accepting this permit shall in eve 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 CONST TIO Rough
Service
... . ... ... ... ..... .. ....... Final
BUI G INSPECTOR
GAS INSPECTOR
Occupancv Permit Reguired 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.
TOWN OF NORTH ANDOVER
- OFFICE OF
BUILDING DEPARTMENT
f 1600-Osgood Street,Building 20, Suite 2035
+b North Andover,Massachusetts 01845
Gerald A. Brown Telephone(978)688-9545
Inspector of Buildings, Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
BUIDING PERMIT APPLICATION
Please print
DATE: I-)
JOB LOCATION: oq_� ��h����' � IF I 2
Number Street Address Map/Lot �
HOMEOWNERan I n s
Name Home Phone Work Phone
PRESENT MAILING ADDRESS
0 njol4w rn 0
City Town State Zip Code
The current exemption for"homeowners"was extended to include-owner-occupied dwellings of one or two family
dwellings and to allow such homeowners to engage an individual for hire who does not possess a license,provided
that the owner acts as supervisor.
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 dwelling,attached or detached structures accessory to such use and/or farm structures.A
person who constructs more than one home in a two-year period shall not be considered a homeowner.(780 CMR
Section I IO.R5.1.2)
The undersigned"homeowner"assumes responsibility for compliance with 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 SIGNAT
APPROVAL OF BUILDING OFFICIAL
Revised 8.2015
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
Sales: 800.448.3636
Phone: 804.271.2363
NEXT GENERATION Fax: 804.743.7779
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�^. n8 Coommonvealth ofMassgchuseffs
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Department ot'"industrtal Aceldents
1 Congress Street,Suite 100
!�d Roston,MA 02114-2017
7
yvww.mass.gov1dia
Worke.&,Compe'nsationInsurance Affidavit:BuUciers/ContxactorsfBlggiTiciamiTInnbers.
TO BE +PILED WPI'H TSE PERN:C!'TTING ATJTHORI�`Y.
A Iicant 7nfoxmation Please Pinot Ilearbl
Namo (Business/Organiaationadividual):
Address:_ Anl
GitylState/dip: �Y d �r (N d4517
4
Are ou an emPtoYom? Mecrthe a xo rime box: Type of project(m=' ).
1.�T am a employer s employees(hill andlarparC timej.* 7.- [(Nevi coA fr<.iction
2. I am a sole propdeto=or partn.ersyP and have no employees working for me in 8. Remo delirig
auy capacity.[No workers'comp.insurance required.] 9. ❑Demolition
ILMlam ahomeownerdoingaliworkmyselt[Nowmkers'comp.inenrancerequired.]' 10❑Building addition
¢.❑lam ahomeownerandv0behiringcoidractorstocondnctall-woikonmprpo
ropaty. Iwill 11.[�Elecfrzcalrepairsor.additions
tin
ensure that.all coniraciors either have workers'compensation insurance or
Proprietors withnno employees. 12' 0 Plumbing repairs or additions
$.❑I am a general contractor and Ihaye hired the sub contractors Listed on the attached sheet13. Roof
rep
airs
These sub-co�racinrshade employees and have workers'comp.mST MC'-T
14.❑Other
6.[]We,are acorporatiompd#gofficeshave exercisedthesrightof'exempiionperI
ernP IoYees.[No workers'comp.inuance regaked_1152 §14 and wsfiave no
-3ro ., 'on-
on h
--Any applicantthat checlssbox4l must also_frIl outthe see�onbelow showingthesworkers'compenatip olicy
t$omeowneswhogo6i '-4� affidavitmdicabngtheyaredoingallworkandthenhireouisidecontractorsmusisi7•bmitanearaffidavitmdicatmgsucb-
?Contractors that checkihis bow must-attaghea an additional sheet showing the name of the sob-contractors and state whether ornotthose entities Lave
' employees.Ifthe sub-coriiractors Tuve employees,tliey musE provide their workers'comp.policy number. '
I a�ri ora employer t1z at as providing rvorke�s9 compensation insal-ance for rrzy employees'Belo7v is thepoficy xidjob site
infotrnadon.
Insurance Company 2Tame:
Policy or Self-ins.Zic.#: Expira onDate;
Job Site AddressC"
. � �/State/Zip:
.Attach a copy ofthevvorkers' compeMationpolicy declaration.page(showing the policynumber and expiration.date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year ituprzsonrnent,as well as civilpenalties in-the form of a STOP WORD ORDER.and afire ofup to$250.00 a
day against the violator_A.copy of this statement may-be forwarded to't e Office of Investigations of the DIA for insurance
coverage verifccatiorz.
Ido heYeby uY1de pains d penal"ties ofpelftr y tlaat the infomationprovided ab v�&-me cid C07-,ed
Date: fl 1
(a
Si a e: r I
Phone#: y
Official use only. JI o not�vrzte in this area,to be completed by city or t0V official
Cray or Town: Perxnit/License#
fssuiug.Authority-(circle one): i
1.Board of Healffa 2.BuildingDepartiamt 3.City/' own Clerk fir'.Electrical Inspector 5_Plumbing lnspector
6.Other
Cow'act Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation fortheir employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract bf hire,
express or implied,oral or written."
Au employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregovlg engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver-or t mAde 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 anotherwho employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shalt not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or to cal Ucensiug agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings ha the commonffealtlx for any
applicautwho lias root 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 checkingle boxes that apply to your situation and,if
necessary, supply sub contractox(s)name(s),address(es)aud•phone numbers)along with their certiftcate(s)of
insurance. limited Liability Companies (LLC)or Limited Liability Partnerships(ILP)withnoemployeeso"therthanthe
members orpatuers,arenotrequiredto carryworkers'compensationinsurance. If an LLC or LLP doeshave
employees,apolicyisrequired. Be advised that this affidavit maybe submitted to the Depa�nentof-Industrial
,Accidents foi conftunation ofinsurance 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 ifyou•are required to obtain a workers'
compensation"policy,please call the Department at the number listed below. Self-insure_d companies should•enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affdavitis complete and printed legibly. The Department has,provided a space at the bottom
of the affidavit for you to fi11 out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/1i.cense number which will be used as areference 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"fob 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 maybe provided to the
applicant as proof that a valid affidavit is on file for fature permits or licenses. Anew affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit notxelated 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 Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel.# 617-727-4900 ext. 7406 or 1-•877-MASSAFE
Fax#617•-727-7749
Revised 02-23-15 wMv.haass.gov/dia