HomeMy WebLinkAboutBuilding Permit #730-2017 - 29 ROCK ROAD 1/20/2017TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: % 3 O DateReceived d I
Date Issued:
IMPORTANT:
nplicant must complete all items on this page
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
l One family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
epair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
Septic `' M Well 3 F F �
Dry Floodp a nj Vlletlantls v
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DESCRIPTION OF WORK TO BE PEKr-UKMtU:
S
or Print Clearly)
OWNER: Name:
(,S W Vlh
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BOLDING PERMIT. $12.00 PER $9000.00 OF/THE TOTAL ESTIMATED COST BASED ON -7 $9�?,5.Q0 PER S.F.
Total Project Cost. $ f,(/�K/?�W�L_ � 4f � l _FEE: $ ' ///
Check No.: % �Lf �^ Receipt No.: 1 yS`r"l
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
signature ofi Agent/.Qwner .,.. << ". Signature of contractor : .
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
Building Department
Tine fonowing is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
o Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
o Copy of Contract
❑ Floor Plan Or Proposed Interior Work
o Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
o Building Permit Application
o Certified Surveyed Plot Plan
o Workers Comp Affidavit
o Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Mass check Energy Compliance Report (If Applicable)
a Engineering Affidavits for Engineered products
VOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
o Certified Proposed Plot Plan
o Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Copy of Contract
o Mass check Energy Compliance Report
o Engineering Affidavits for Engineered products
ROTE: 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 Torun Clerks office must stamp the decision from the Board of Appeals
that the apn•,al 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: Doc.Building Permit Revised 2012
Plans Submitted ❑
Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE:OY SEWERAGE DISPOSAL
Public Sewer N
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
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
tP,"arii:-ing Board Decision: Comments
Conservation Decision:
Comments
Water & Sewer Connection/Signature bate Driveway Permit
DPW Tow;-, Engineer: Signature:
Located 384 Osgood Street
a-iKt 1DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Mair., Street
Fire Departmerit 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
NU I t5 anc( DATA — (For c(eaartment use
El Notified for pickup - Date
Doc.Building Permit Revised 2010
Location
No. -7 3 0 -;,ot-7 Date t -O/ S Ot 7
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ '7
Foundation Permit Fee $
Other Permit Fee $�
TOTAL $
4 _
Check
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Donald Belanger
Inspector of Buildings
Pleaseprint
DATE: r` J-6//
TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
120 Main Street
North Andover, Massachusetts 01845
HOMEOWNER LICENSE EXEMPTION
Building Permit Application
Telephone (978) 688-9545
Fax (978) 688-9542
JOB LOCATION: jq
Number Street Address Map/Lot
HOMEOWNER a&Mgr(jr,?,3A,0w �5U
Name 'Home Phone Work Phone
PRESENT MAILING ADDRESS oZq / OC.K_. ",
% k, &k yef MA 0/9�5
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 9/16
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
File Commonwealth of M'assachusetts
- Department of IndustrialAccidefats
- I Congress street, stj to 100
02114 -2017
2017
Boston, MA
www mass.gov/dza
.� b'M .• rya:
Workers' CompensationInsurance.Affidavit.- Builders/Contra
GA17'[ OsltilX�.fxiciaxzs/'lmmbers.
TO BE MED WITHTHEP � v,o��Aper+ 1
Nal] G (BMInesslOrgaf&aCion/individual :.
Address: Q
city/state/zip: /V 0 , Hyt_f v u
Are you an employer?eck trio appropriate box:
X.❑ I am a employer with employees (mull. and/or part time)•;
2.� I am a sole proprietor oz panne b P and have no employees VVOA dng forme in
any capacity. Ego workers' comp. insurance required.]
3.� I am ahomeowner doing all work myself. w
jNoorkere comp. insurancerequired] i
❑I amahomeownerandwillbbiringconiractorstoconductallworlconmyproperly. iw,l%
e
ensvrethat all couhactois eifherhave, workers' compensation insmance or are sole
proprietors with. no employees.
5 T am a general contra fpr and Thrive hiredthe sub -contractors listed the atiached sheet
These sub -contractors have employees andhaveworkers' comp. instTrnce.?
b.❑ We are a corporation and lis -of kers have exercisedtbeir rigbt o£exemPtin per MGL c.
1 4 and ate have no employees. [No workers' comp• insurnce required-]
B
Type oprof ect (required):
7. ❑ Nevi consirirciion
8. ] R..emodeap;
9. ❑ Damolition
10 [] Building addition
11.❑ Elecisical POP aaxs or additions
n2 I Plum'bYng repairs or additions
13•. []Roof repairs
14.Other
152, § O,
Any applicantthat checks bbit#1 Inst also ck out the are doing all work andthen hire )V,, showing o dinde cm ntrao�s pmust mbm i a nsw af5davit indicating such.
i Homeowners who submit this a f Mavit indicatingthey
ConttactorsthatcheckttrisboznusEathedanaddittonalsheetshowingthenameofthesnb-confractorsandsiniewhefiierornotfhoseentdies ave
mP Policy
employees. if the sub-coutractorshave employees, they mustprovidetheir workers' co oIi number.
Xcart an employer thatisproviding-nvorkers' compensation insurancefor'my employees BeZow is t7iepolicy aridjobsite
information.
Insurance CompanyNarne:.
ExpirationDate,
Policy # or Self -ins. Lic. #: .
City/Stale/Zip:
lob Site Address:
Attach a copy of the WCkers' coxapensation policy declaration page (showbag the policy number and exprratioxr date).
Q
pollute to secure coverage w required under M nalixes2m§he £ m ocriminal
TOTWOKK ORDER and a tine o£up to $250.00 a
and/or one-yeax imprisonment; as well p be forwarded to the Of$ce ofXnvestigdtions of the DIA for insurance
day against the violator. A copy of this statement may
o - r'.44-Nration
rdo Iter eby�ce��ify uradeY tliepains anper2ttlties ofperjury ilaai t7ie inforrrtatzort prUv�ue�
Official use only. Do riot write in t7iis carecy to be _-,gmpleted by city or tovn ofjzcicrb
is true and correct -
Peraazit/Licensa #
City or Town'
IssuiugAntho?dty (circle one):ector
1. Board of Eealth 2. Building Department 3. CitylTown Clerk 4. ElectricalXnspector �. Plumbing
6. Other
Phone
Contact Person-
Information and Instructions
Massachusetts General Laws chapter 752 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 hife,
express or implied, oral or written,"
An employer is d'ef'uied as "an individual; partnership, asso dation, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enierprise, and including the legal representatives of a deceased employer, or the
receiver'or trasiee 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 ofths
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 opdrate a business or to construct buildings in the commonwealttu for any
applicazntwl[d Iias 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 stub=coniractor(s) name(s), address(es) andphone numbers) along with their certiftcate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are notrequired to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised thatthis 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
I•adustrial=Accidents. Should you have any questions regarding the law or if you are required to obtain a workers,
comPonsati0ii policy, pleaso call t"ha Department at the number listed below. Self-insured companiessbotildenter their
self insurance license number onthe appropriate lino.
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 of aidavit for you to fill out in the event the Office ofluvestigations has to contact you regarding the applicant.
Please be sure to Min the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple pernit/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 fature permits or licenses. Anew affidavit must be filed 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
I 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 www.mass.gov/dia
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: 7 3 o Date Received
Date Issued:
IMPORTANT: Applicant must complete all items on this page
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TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
0 New Building
K One family
11 Addition
0 Alteration
El Two or more family
No. of units:
D Industrial
0 Commercial
I&Repair, replacement
0 Assessory Bldg
0 Others: V9 P
0 Demolition
0 Other
r, ❑Septic
'00 W-&tff
.-L
lain i�� &W
0 =afn ,_dtlands
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suare
DESCRIPTION OF WORK TO SE PERFOKMEU:
I ,-LAIL
Identifi Please Type or Print Clea r1y)
OWNER: Name:_(?,,,- M7PZ41 Phone:
1 0 ;y-50
41
ARCHITECT/ENGINEER Phone:,
Address: Reg. No.
FEE SCHEDULE: 13 ULDING PERMIT.- $12.00 PER $1000-00 OF THE TOTAL ESTIMATED COST BASED ON $9? 61 PER �5�.F
Total Project Cost: $ 60 &DW)L- --��FEE: -77
Check No.: -7 (?Ll Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
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