HomeMy WebLinkAboutBuilding Permit #455-2017 - 27 WILSON ROAD 10/31/2016 � �oRrH q
BUILDING PERMIT �sLE�
32 yE ``• '6 0
TOWN OF NORTH ANDOVER J , ;A
APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received ATED
SSACHUS�
Date Issued:Z0 It c�,�
IMPORTANT: Applicant must complete all items on this page
LOEATION' 7_..W�IS4h �[ oar .; nAft 4
PROPERTY QINNER� _�._ ` - - � _ u � _ _._- - - _
.._ _. J Pnnt' _ - - f03'Year�Stucture
MAP T_ _ PARCEL-__.- _ _ ZONING,DISTRICT: Historic Dts_tnct yes; (25
Machine Shop Village yes-
1-TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑Addition Two or more family El Industrial
Alteration No. of units: a• ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others.
❑ Demolition ❑ Other
Septic 1Ne11 q Floodplain 0 Wetlands tershed District
gater/Sewer- - --- - _
DESCRIPTION OF WORK TO BE PERFORMED:
r
uAte AJib e "ire 4e(4-k..
�h C Ar
Identificati n- e se Type or Print Clearly
OWNER: Name: Tar Phone:4)k—k351—
r ,
N Muc
Address: W J�SAm� "
Contractor'Name - . _ . _. Rhone:-.
Email:
Address---
=7
Supervisor's Construction,License. ._ _. .. _. Exp_ Date
Hflrne*Improvement License` _ -.
_. _ __..__ Ex
p
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: $ 4 FEE: $ '
Check No.: �0/ Receipt No.: -3 l
NOTE: Persons contracting with registered contractors do not have access to the guaranty fund
- _. -- — --
Signature of Agent/,Own Signature of contrac or
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL,
Public Sewer ❑ Tanning/Massage/Body Art ❑ Swinnning Pools ❑
Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑
Private(septic tank,etc. ❑ Pennanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Siqnature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
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:
_ Located 384 Osgood Street
FIRE`DEPARTMENT -;TempDum'pste�.o_n,site
yes __� kno
Fice'Department{signature/date _ - g
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
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
❑ 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
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/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
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 2014
Location �r^�- llJ� ly
Date/,9
• • TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee
$ 41,
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check#� W- 1
�' Building Inspector
NORT01 '9
Town Of 2 ,t 6 ndover
0
h ver, Mass
o CO
COCHICHIW'CM ��•
ADgATED ok'r (5
s �
BOARD OF HEALTH
Food/Kitchen
PERMIT . D Septic System
THIS CERTIFIES THAT .....Z. .... 140. . .. J...:*, BUILDING INSPECTOR
p g ., .. �M� Foundation
has permission to erect .......................... b ildin s o .... .....
Rough
to be occupied as .. .�... ... ... ... .. ��......�. ..�........................................ chimney
provided that the person accepting this permit shall in every respect con orm 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 TION &BOUILDING
Rough
Service
. . ... . .. ..... Final
IN CTO
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.
cE NORTH TOWN OF NORTH ANDOVER
3a ,•'` .'•, �O` OFFICE OF
- . BUILDING DEPARTMENT
�D * 1600 Osgood Street,Building 20, Suite 2035
North Andover,Massachusetts 01845
Donald Belanger Telephone(978)688-9545
Inspector of Buildings Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
BUIDING PERMIT APPLICATION
Please print
Y7 I
DATE:
JOB LOCATION: 1
�Number 11 Street Ad ess Map/Lot
HOMEOWNER R` 6a�4,)Ov 14tho
Name Home Phone Work Phone
PRESENT MAILING ADDRESS A 1A11W Rod '6L
- 14a A A
City Town State tip Code
The current exemption for homeowners g was extended to include owner occupied dwellings of one or two family
Y
dwellings and to allow such homeowners to engage an individual for hire who does not possess a license, rop vided
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 110.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 wi 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
••The Commonwealth of Massachusetts
- Y. F Department of Industrial Accidents
M _ X Congress Sheet,Suite 100
Boston,lY.[l�n�� 02114-2017
www mass.gov/dia
7IQ�M SV�V
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE pERMITTiNG AUTi[ORITY- Please Print Le 'bl
A • licant Information ' & J A �r.,
eA
Name(Business/0rgar&ationlindividua1)1
Address-J) JAA I t r
City/State/Zip: ; ,�,A�n /f�� �l�' �4< Phone#:
ex a.
Type of project(required);
Are you an employer?Check the aPP appropriate riate box:
-}]r employees(full and/or parttime).* 7. New'constraaion
❑
1.[]I am a employer vn
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Remo deliiig
an capacity.[No workers'comp.insurance required.] 9, Demolition
Y P '
3.[:]1 am a homeowner doing all work myself,.[No workers'comp.insurance required]� 10❑Building addition
4$I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.❑Electrical re airs or additions
.. P:
ensure that all contractors either have workers'compensation insurance or are sole 12,[�Plumbing repairs or additions
proprietors with no employees.
51-11 am ageneral conhactorand Ihave hired the sub-contractors listed on the,attached sheet.
13•.0 Roofrepairs
These sub-contractors have employees and have workers'comp.insurance.* 14.❑Other
6.❑We are a corporation.and its,officers have exercised their right of exemption per MGL c.
152,§1(4),and'we have no employees.[No workers'comp.insurance required]
Aall work
ny applicant that checic§bbk#1 must also fill out the section below showing theirworkers'compensation policy information:
t homeowners who submit•this affil alttaclied indicew
ating
a e doing owing the_andname en of the sub contre outside actors and state wrs must hetht a e or npot fhoseen ties have such.
(Contractors that check this bo. P Policy
employees. Ifthe sub-contractors have employees,they must provide their workers'com olic number.
ensation insurance for my employees. Below is file policy and job Sit
X am an employer that is providingworkeYs'compe
information.
Insurance Company Name:
Expiration Date:
Policy#or Self-ins.Lic.#:.
City/State/Zip:
Job Site Address:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL alties2in.the form ocriminal OPrWORK ORDER olation and a fine of up to $250.00 a
and/or one-year imprisonment,as well as civil p
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
X do Hereby certify u pains an ties ofperjury that the information provided above is true and correct
Date:
Si ature:
Phone#:
Official use only. Do rcotwrite in this area,to be completed by city or town official.
Permit/License#
City or Town-
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Phone#-
Contact Person:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their ehlpldyges.
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 certiflcate(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
IndustrialAccidents. 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 lavestigations 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. 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 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-AIASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia