Loading...
HomeMy WebLinkAboutBuilding Permit #22 - 275 CHESTNUT STREET 7/8/2009 BUILDING PERMIT 01* NO �oORTHgtio TOWN OF NORTH ANDOVER o� 6t t° °�, APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received go,-Arno'���� � ��j� �SSACHUSE� Date Issued: IMP RTANT:Applicant must complete all items on this page LOCATION Print PROPERTY OWNER ��r �C�1' Sf j ©C //� Print ' MAP NO PARCEL: ZONING DISTRICT: Historic District yes no 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 Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED:. Identification Please Type or Print Clearly) OWNER: Name: fi>Xilf¢_S l ��6�� /i4R� Phone: J' �o Address: CONTRACTOR Name: Phone: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: 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: $ FEE: $ 3n �— Check No.: Receipt No.: a- l NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund r Signature of Agent/Owne12 ix�dfufret-occntractor Location -42 r6-eX±AA1—I �/ No. z 7 `�' Dateo �a�TM TOWN OF NORTH ANDOVER O • Ow ` ( l Certificate of Occupancy $ • s, a MusEBuilding/Frame Permit Fee $ (� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check #�v Building Inspector 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 H1=^aLTH 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 - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date 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 - Date Doc.Building Permit Revised 2008 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/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 The COMMOnwealth of Massachusetts k j ii Department of Industria!Accidents Or _ ( Office of.[ Mew kations 600 Nl ashingtan Street ell Boston, MA 02111 www mass gov/din . Workers, Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeQibl Name(Business/Orpniration/fndividual): Address: 7— CiiylState/2:ip: ,� ' 6 , Phone k . 8� � Are you an employer?7Check.tbe appropriate box: I.❑ I am a employer w 4. [] I am a general contractor and IF7. ject(�ai�'employees(full anart-time).* have hired the sub-contractorsconstruction 2.�] I am..a.sole proprietor or ptvlzier- listed an the attached sheet delnrg ship and have no employees These sub-contractors haveworking for me in arty opacity. workers' comp.insurance. lition [No workers con . insurance 5. ng addition P ❑ We are a corporation and itsaired] officers have exercised their ical repairs or additions 7. 7insurance m a homeowner doing all work right of exemption per MGL 11.0 PIumbing repairs or additions self [No•workers'comp, c 152, §I(4},'and we have no required.]t Q12. ]Roof repairsPIYees. [No workm-s' !3. Omen COMP. insurance required_] 'Any appiicatrt that checks bot}�l must aito fill out the stolon beiow showing their workers'compensation poiicy information t Homeowners who submit this affidavit indicating they are doing all work and then h&s outside contractors must submit a new affidavit indi ;Contractors that check this but rnrtstrtieelr�an additiossi sheet showing.the name of the sub. mi*such. cotrtraetors and their workers'ca mml`- fnm iration. 1 ant an enrpfnyer thX is prouiaung:workersI compensati6n insurance or information f �'entployee� Below is the policy and job site . Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/Statelzip: Attach a copy of the workers'compensation policy diaration page(showing the policy numband expiration dat?ej, Failure to semre coverage as required under Section 25A of MGnumber L c. 152 can lead to the imposition er fine up to$1,500,00 and/or criminal penalties of a one-year imprisonmM 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. 1 do reby c fy under the pains a r*7 that 01F)Wformadon provided above is true and coned Phon #: ial use only. Do not write in tills area,m be co»tpleted by city or town ofc iaL City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Cierk 4. Electrical Inspector fi.Otbe'r S. Plumbing Insprxtor Contact Person• Phone#: 1 Information a. nd- Instructions `^ Massachusetts General Laws chapter 152 requires all emp 3oyers 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'fbmgDing engaged in a joint enterprise,and includirzg the legal representatives of a deceased employer,or the receiver or trmstee of an individual,partnership,associatiorn or other legal entity,employing employees.*However the owner•of a dwelling house having not more than th=apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair wdrk on.such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an empioyer." 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 *o construct buildings in the commonwealth for any applicant who has riot produced acceptable evidenceai7 compliance with the insurance coverage required." Additionally, MOL chapter 152,§25C(7)states"Neither t3he commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public woric until acceptable evidence of compliuinc a with the insurance requirements of this chapter have been presented to the corttracting 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 numbers)along with their certificates)of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not requiredito carry workers'ccwrnpensafion insurance. If an LLC or LLP does have empioyees,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 cityor 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 if you are required to obtain a workers' compensation policy,please--call the Department at the numberlisted below. Self-insured companies should enterimir self-insurance'license number on dw'appropriate line. City or Town Officials Please be sure that the affidavit is compie a 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 furtive 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 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 Department's address,telephone and fax number. The Cofnmonwes;-tlth of Massachusetts Department of bndimtiai Aacidmts Office of LmestigatEions 600 Wad rngton Street Bosfon, MA 62111 TeL #617-7274900 ext 406 or 1-9.77-MA.SSAFE Fax 4161 7-727-7741 Revised 5-2645 www'.ma c.gov/dia t gORTM TOWN OF NORTH ANDOVER •�'_ ^ • ow OFFICE OF 41 BUILDING DEPARTMENT f . 4�•'« 1600 Osgood Street Building 20, Suite 2-36 North Andover Massachusetts 01845 Gerald A Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION Please prim DATE:_ ��—q--Q. 17 . JOB LOCATION: JA 5— 0,8E 7y T Number Street AddressmalilLot — HOMEOWNER Name Home Phone work Phone PRESENT MAILING ADDRESS `. City Town . State Zip Code The curruit exemption for-h0 meownerC was Wdended.;o dude.; -o.,vied dwe'l,ngs to tm unit or less and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) DEFINMON OF HOMEOWNER Person(s)who owns a pared of land on which helshe resides or intends to reside,on which there is,or is intended to be,a one or two family structures. A Person who constivcts morn that one home in a two-year period shall not be considered a homeowner. The undersigned"homeowner"assumes re$Ponsibflity for cOmpliances with the 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 Proms and requirements and that he/she will comply with said procedures and requinneMr HOMEOWNERS SIGNATURE A APPROVAL,OF BURRING OFFICIAL, xinind 10.2005 Form Homwwn=Ez=ption is BOARD OF TPE:u_S 699-95 41 CO.NSERV-MON Fgg-953Q HEALTH 689-95 40 PLANNING hgg_9535 V40RTH '9 Town of4Andover . No. -_ ]( C, -_ = dover, Mass., T O — LAKE COC MICNE.C. V 2 -I 77 ,9S RATED BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR . THIS CERTIFIES THAT �N! ..... ............ ................. ....... ...��1..1 .......................... Foundation . . a' has permission to erect . ........ ........................ bu�din s on . ♦�.... ... A.A0 � I✓T............... Rough • c.�'...J................................ Chimney to be occupied as...... .. ... ....... /... ../........ provided that the person a cepting this permit shall in eve respe conforterms of the application on file in Final 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 PERMITT EXPIRES IN 6 ONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU ST S Rough .......... . ................................................. ................................................ Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. SEE REVERSE SIDE Smoke Det.