HomeMy WebLinkAboutBuilding Permit #1232-2016 - 272 MASSACHUSETTS AVENUE 5/25/2016 u NORr
BUILDING PERMIT o� bgtio
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
12�2- �1�
Permit No#: Date Received �gssgcHUs���y
Date Issued: 2 ,
IMP RTANT: Applicant must complete all items on this page
LOCATION � 7
Print
PROPERTY OWNER �-eOL-f� ,(�
Print 100 Year Structure yes
MAP PARCEL: w� ZONING DISTRICT: Historic District yes
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑ Addition ❑ Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
Q Septic ❑Well El Floodplain El Wetlands ❑ Waters hedrDistrict
0Water/SeWer
DESCRIPTION OF WORK TO BE PERFORMED:
. . ti a d
f dentification- Please Typ or Print Clearl
OWNER: Name: Jt'. - Phone: C ��
Address:
Contractor Name: , Phone:
Email:
Address:
Supervisor's Construction License`.` Exp. Date:
Home Improvement License: Exp. Date:
ARCH Phone:
Y
t
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: $ a� �U . ; FEE: $
Check No.: 3�lk Receipt No.: 84Z°�
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
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
4 Building Permit Application
4. 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
:6 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
One To Be Returned Inc
Sprinkler Plan And
Jude
;rE Two Sets of Building Plans ( ) to
Hydraulic Calculations (If Applicable)
Copy of Contract
2012 IECC 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
Doc:Building Permit Revised 2014
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
I
Public Sewer ❑ Tanning/Massage/Body Art ❑ Sw mining 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 o U FORM
PLANNING & DEVELOPMENT Reviewed On Signature-
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
4
Z
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
i
Conservation Decision: Comments
Wa,,�er& Sewer Connection/si nature& Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
F E DEPART ppn to dye' s_ ' _ , no �-®'-
erne u sten si {
Lo ted at 1�24'MainSf`ree
Fire Depart�,men sgn_ure d,at�e �
r.
C�M' MENS%
L
Dimension
Number of Stories: Total square feet of floor area, cased on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL; Movement of Meter location, mast or service drop requires approval of
Electrical Inspector lies No
DANCER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$10o-$1000 fine
NOTES and DATA— (For department use)
❑ Notified for pickup Call Email
Date Time Contact Name
Doc.Building Permit Revised 2014
Location
r /
No. IZ Z" ;?Ok , Date
• - TOWN OF NORTH ANDOVER
y: Certificate of Occupancy $
Building/Frame Permit Fee $ �,..-
Foundation Permit Fee
Other Permit Fee
TOTAL
Check#
30 2
Building Inspector_
Enter construction cost for fee cal - North Andover Fee Cakulation
Construction Cost
2,50'0.0'0 m
$ - $ 30.00
Plumbing Fee $ 3.75
Gas Fee 100 comm. $: 100.0.0
Electrical Fee $ 3.75
Total fees collected $ 137.50
272 Mass Avenue
1232-2016 on 5/25/2016
Convert one half of garage to play room
� t1pRTH ndover
Town of
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�o h ver, Mass, C41
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BOARD OF HEALTH
PER LD Food/Kitchen
♦♦��__ Septic System
THIS CERTIFIES THAT ........ .��1[v.. — \.... .... BUILDING INSPECTOR
. . ..... . . ... .. ..
HQhas permission to erect .............. buildings on ........ Foundation
............ ... .... .... .. . .. .. ....... ..�-
Rough
to be occupied as ..... a kjw.a z .....etconior
. .. ...... .... �.ftr...... Chimney
provided that the person accepting this permit shall in every reo 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, Iteratin and
Construction of Buildings in the Town of North Andover. �,� �� r�1. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRU CTI? STARTS 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
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TOWN OF NORTH ANDOVER
® �•4°ate OFFICE OF
BULDING DEPARTMENT
1600 Osgood Street,Building 20, Suite 2035
+y North Andover,Massachusetts 01845
Gerald A. Brown Telephone(978)688-9545
Inspector of Buildings Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
B UIDING PERMIT APPLWATI+ON
Please print
DATE: -,z l
JOB LOCATION: p� �� 94
Number Street Address Map/Lot
HOMEOWNER 0I..1^ �-IJ�-�t f"-0 �.��-&�(� yOJ7 N %7 - 67141q
Name Home Phone Work Phone
PRESENT MAILING ADDRESS . -�S
4?M7,-
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 SIGNATURE_
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 Massqchusetts
Department of Industrial-Accidents
a d X Congress Street,Suite 100
Foston,MA
02114-2017
www.mass.govIdia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORI'T'Y.
Applicant Informationii Please Print Le •b
/lul
Name(Business/Organizationdividual): !
LL
Address:
City/State/Zip: Gl(/�'Y - UI�'y�Phone#: 9 7
Are yon an employer?Check&e appropriate box: Type of project()required):
1.❑Tama employer with employees(foll and/or part-time).'' 7. F1 New construction
2. ]I am a sole proprietor or partnership and have no employees Working for me in $• V Remodeling
any capacity.[No workers'comp.insurance required.]
3.1 1 am a homeowner doing all work myself.[No workers'comp.insurance required.]t
9. Demolition
10 ❑Building addition
4.L]I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees. • '
12..[]Plumbing repairs or additions
5. 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet.
❑ � 13.[�Roof repairs
These sub-contractors have employees and have workers'comp.insurance.t
6.❑We are a corporation anofficers d ifs ocers have exercised their right of exemption per MGL c. 14.❑Other
152,§1(4),and we have no.employees.[No workers'comp.insurance required.]
e
*Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who stbniif this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must•atfached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. if the sub-contractors have employees,they must provide their workers'comp.policy number.
Iain 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:
X16b Site Address:p� /� City/State/Zip: V' C /?Y.>
ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c, 1.52,§25A is a criminal violation punishable by 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 flue of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
f do hereby certi y under the pains and enalties ofpeijury that the information provided ab ve is rue and correct.
Si nature: `tDate:
Phone# 7k'32b - 6 I-U
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): i
1.Board of Health 2.Building Department 3.CitylTown Clerk 4.Electrical Inspector 5.PIumbing Inspector
6.Other
Contact Person: Phone#: t
i
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 contrdct of Hire,
expres's 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 enfsrprise,and including the legal representatives of a deceased employer,or the
receiver or trustde of an individual,partnership,association or other legal entity,employing employees. IloWdver the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant ofthe
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 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-'contractor(s)name(s),address(es)andphone number(s)along with their certificate(s)of
insurance. LimitedUability 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 Depat•tment 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,riot the Department of
Industrial Accidents. Should you have any questions regarding the law or if yol.'are reqiiredto 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. 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 1.00
Boston,MA 021.14-201.7
Tel.##617-727-4900 ext.7406 or 1-877-AIASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
I