HomeMy WebLinkAboutBuilding Permit #722 - 27 MEADOW LANE 5/18/2010r►vR � BUILDING PERMIT o�H ts�eD 06,"tio
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received 4 '
TYPE OF IMPROVEMENT
New Building
Addition
Repair, replacement
Demolition
2
PROPOSED USE
Residential
One family
Two or more family
No. of units:
Assessory Bldg
Other
Non- Residential
Industrial
Commercial
Others:
Setrc. - Wel) Floodplain Wetlands 1%tehed L�.istr�cf
Wdterieuve ,
gESCRIPTION OF WOR ( TO B� PREFORMED:
d
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
Address:
CONTtAGTORName Phone:
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: $_ �2) FEE: $`�—
Check No.: Receipt No.: r J I
NOTE: Persons contracting with unregistered contractors do not have acc e a anty fund
ignature of Agent/Owner Signature of contract _
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
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE REJECTED DATE APPROVED
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
Comm
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
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
NOTES and DATA — (For department use
No
dV D ,n) • � C �
(C
❑ Notified for pickup - Date
Doc.Building Permit Revised 2010
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
Building Permit Application
o Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
Copy of Contract
❑ F Interior Work .
❑-E--R� nn id its -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: Building Permit Revised 2008
Location rr IeAd(JVj
No. -2 .- Date v
TOWN OF NORTH ANDOVER
r
Certificate of Occupancy $
Building/Frame Permit Fee $ 3
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # 1 J ? 0
23, bk/' ,
Building Inspector
CONTRACTORS INVOICE
WORK PERFORMED AT:
All Material is guaranteed to be as specified, and the above work was performed in accordance with the drawings and specifications
provided for the above work and was completed in a substantial workmanlike manner for the agreed sum of
Dollars^� ),
This is a ❑ Partial ❑ Full invoice due and payable by:
Month Day Year
in accordance with our ❑ Agreement ❑ Proposal No. Dated
Month Day Year
NC3822 CONTRACTORS INVOICE
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The Commonwealth of Massachusetts
Department o f Industrial _,accidents
Office of LnVes7ie ations
600 Washington Street
Boston, MLa 02111
1vWw•m9zsS-gov/dia
Workers' Compensation insurance Affidavit: guilders/Contractors/Electricians/Plumbers
�plicant Information r.
Name
Address:
City/State/Zip:
e
t`
Are you an employer? Check the appropriate boa:
r
1. ❑ I am a employer with
4. ❑ I am a general contractor
employees (full and/or part-time).
2.V I
and I
have hired the sub -contractors
am a sole proprietor orartner_
P
ship and have no employees
listed on the attached sheet I
These sui>-contractors have
working for me in any capacity.
[No workers' comp, in ranCe
workers' comp, insurance.
5. 11We are a corporation
required.]
and its
officers have exercised their
I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
C. 152, § 1(4), and we have
insurance required.] t
no
employees. ,
� [No workers
comp. insurance
Type of project (required):
6• ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9• ❑ Building addition
10.❑ Electrical repairs or additions
11.0 Plumbing repairs or additions
12•❑ Roof repairs
eauued ] I 13.❑ Other
`-.ny �iicrl that chi box e? must s!so BU out the sem
i..+'Lw�7np. g',n_�.nworkers' co'S`^�.4�^.�^
Homeowners who suhmitthis affidavit indicating }til' a . dog al word and Then hire outside contractors must submit a new affidavit indicating such.
'Contractors that sheds this box must attached an additional sheet showing the aame of the sub-eontractors and their wmk-, _r
ormation, uR empeoyer that is providing workers' compensation
infoinsurance for my employees. Below is the policy and job site
Insurance Company Name:
Policy # or Self -ins. Lic. #:
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 required under Section 25A of MCL C. 152 can lead to the imposition of criminal penalties of a
fine up t$ $1,500a d 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 statement maybe forwarded to the Office a
Investigations of the DIA for insurance coverage verification
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Official use only. Do not write in this area, to be completed by city, or town official
City or Town: Permit/License #
Issui � Authority (circle one): -
1. Board of Health 2. Buildinb Department 3. CilvITown Clerk 4. Electrical Inspector 5. Plumbinb
6. Other Inspector
Contact Person:
Phone #,:
Information an- d 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 inaividual, 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 be cause 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 c onstr-uct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of coampliance 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 un -1 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 store to sign and date the affidavit The affidavit should
be returned to the City or to n that the auuiicEdon for the perrmtor license IS Being requested, not fne.De-E.*T�";e It OT
Industrial Accidents. Should you have any questions regarding the v, 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 permnits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or pest 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
allThe Department's address, telephone and.fax.number.
The Ccmmonwealtll of Massachusetts
Department of Industrial Accidents
Office of fnrestibations
600 Washington Stre: t
Boston, MA 0.2111
Tel. # 617-727-4900 east 406 or 1-9 77-MLkSSAFE
Revised 5-26-05
Fax -4-617-72.7-7/7/49
u<rVri 7 rna&s-gov/Glia.