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HomeMy WebLinkAboutBuilding Permit #243-14 - 295 REA STREET 9/18/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO ` 41 Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION 2 ?5 PROPERTY OWNER , 0� --T- PrI�J QC Print 100 Year Old.Structure yes n 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 Jil Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other 4 ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESrJPTION OF FO BE PEFORME M 634 ce IF A OAJE) Identification a se y e or Print Clearly) 478 �� 73oflZ OWNER: Name: O Phone: 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: $ D 0 OO FEE: $ �;0 - Check No.: l ' b `3 –P— Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner .Snature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Plans Submitted ❑ Plans Waived'❑ Certified Plot Plan ❑ Stamped Plans ❑ TYP"-,0 -SEWERAGE DiSP0SAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco.Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ I THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM -.:. .DATE REJECTED DATE.APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS a .CONSERVATION Reviewed on Signature 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 Tows! Engineer: Signature: Located 384 Osgood Street FIRE-DEPARTMENT -!Temp' Dumpster on site yes no Located-at 124 Mair Street- Fire Departinerit signature/date t 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 El Notified for pickup - Date I Doe.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 ❑ 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 y ❑ 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 I Hydraulic Ca culationslicable If Applicable) pp ) ❑ 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 apw al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.+ted with the building application Doc: Doc.Buil ing permit Revised 2012 Location r " ,T Date . - TOWN OF NORTH ANDOVER . Certificate of Occupancy $ Building/Frame Permit Fee $� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# r_ Building Inspector i Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 20,000.00 m $ - $ 240.00 Plumbing Fee $ 30.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 30.00 Total fees collected $ 400.00 295 Rea Street 243-14 on 9/18/2013 Kitchen Remodel The Commonwealth ofMassachusetts Department of IndustriqlAccidints Office of Investigations 600 Washington Street Boston,MA 02111 www.mas.s gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electriicians/Plumbers Applicant Information Please Print Legib Name(Business/Organization/Individual): ©Q CMZ l 0 q, o� Address: 29 sr,- - City/State/Zip: q ,q �Jf' (bi�yrphone#: C 7 Z7 7 3 Are you an employer?Check the appropriate box: Typo of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).' have lured the sub-contractors 2111 am a sole proprietor or partner- listed on the attached sheet.+ �• E]Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. El Building addition [No workers'comp.insurance 5. El We are a corporation and its , _fequired.] officers have exercised their 10.E]Electrical repairs or additions 3. I am a homeowner,doing all work right of exemption per MGL I L ]Plumbing repairs or additions myself.[No workers'comp. c.152,§1(4),and we have no 12.❑Roof repairs insurance .re uiredemployees.[No workers' required.)� 1311 Other comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. #Contractors that checkthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the,policy and job site information. Insurance Company Name:. Policy#or S elf-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensationTolicy declaration page(showing the policy number and expiration date). Failure to secure coverage as required.under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of 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 fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of 'Investigations of the DIA for insurance coverage verification. Ido herebyc t rider h p ns a penalties ofperjury that the information provided aabo/e is T andcorrect.Si afore Date: L [ Phone#: T78 S(b7 3 0 O2— 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): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - !'nn4a�f.PPrenn� Phone#: Information and Inst °cholas 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 anindividual,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 employes." 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 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 LL C or LLP does have employees,a policy is required. Be advised that this affidavit maybe 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 Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensationpolicy,please call the Department at the number listed below. Self-insured companies should eater 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 an any given year,need only-'submit one affidavit indicating current Policy information(ifnecessary)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 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 GoMxaa onwealth of M-assachusetts - Departmeut ofladusbial Accidents Offzee ofI1westigations. 600 Washingtall Street Bosfu MA 02111 TQL#617-727_-4900 ext 406 or 1-877:MASSAFE Revised 5-26-05 Fax W 617-727-7749 MW IiTUR Q4 t�eo r 'S 1 0 OF TH ANnoVER ° OFFICE OF BUILDING DEPART • � MENT 71600 Osgood Street Building 20,-Suite 236 Paust North Aiidover,Massachusetts 01845 Gerald A.Brown Inspector ofBuildings Telephone(978)689-9545 HOMEOWNER•LICENSE EXEMPTION Fax (978)688-9542 'LIDINGG PERMIT APPLICATION ATI ON Pleas._ eyrint •. DATE: l l , JQB LOCATION;4db: er Sfreet Address Map/Lot ' 978 6' Name. 0 7 3 0 2 Home Phone Work Phone PRESENT MAILING ADDRESS Zip Code T a current exemption for"homeowners"was extended to hichide owner-occupied dwellings to ttivo units or less and to allow such horn.state to engage an:n- hire who does nntpossess a license,provided that the owner acts as supervisor). Slate Building (Code Section 108.3.5.7 DEFINITION OF HOMEOWNER Persons)who gwns a parcel of land on which he/she resides or intends to reside on whit be,a one or two farr�ily structures. A person Who constructs mote thatone h there is,or is intended to considered a homeowner. ne home in a two-year Period shall not be, The , undersigned homeowner"assumes responsibility for compliances with the State Building Code and other Applicable codes,by-laws,Mles andregulations. The undersigned"homeowner"certifies That he/s understan minimum inspection procedures and requireme s nd at he s e wze.T omply w th 0 North wild overBPro uilding and Department requirements, HOMEOWNERS SIGNATURE AlPP.ROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 FORTH own of 2 1 E 1, ndover 0% o h , ver, Mass, Q �� coc"Ic NlWKN �7' 't1,9 A°R.tTen �`Pp,��y S V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT BUILDING INSPECTOR nn Foundation has permission to erect ................. buildings on � Rough to be occupied as .....K.j�. ....... .............. .•........................................................................ Chimney provided that the person accepting this permit shall in every respect conform 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 l i a�D UNLESS CONSTRUCTIONA T Rough Service 1 ..................... ............ ............................................. 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 Street No. Smoke Det. SEE REVERSE SIDE I