HomeMy WebLinkAboutBuilding Permit #880-16 - 296 BERRY STREET 2/11/2016BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: & 0 r ��
Date Received
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION
y �t L¢✓ 16\
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Print
PROPERTY OWNERG?f?!c°/
Print 100 Year Structure yes no
bt
MAP I PARCEL:— ZONING DISTRICT: Historic District yes 7ir62
Machine Shop Village yes o
TYPE OF IMPROVEMENT
PROPOSED USE
Resi ntial
Non- Residential
❑ New Building
rVbne family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
epair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
I ❑Septic: ❑Well
❑' Floodplain. Wetlands
¢ ❑ Watershed Di tract:
f Wafer/Sewed
DESCRIPTION OF WORK TO BE PERFORMED:
C)
Identification - Please Type or Print Clearly
OWNER: Name: �;� �v,l �2C, �n Phone: &Z %- I -3 Q
Address: 2Q
Contractor Name: Phone:
Email:
Address:
Supervisor's Construction License:
Home Improvement License:
P+
Date:
Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE. BULDING PERMIT. $92.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ DO() FEE: $ -t36 -
Check No.: :] /_ 3 Receipt No.: 3 C200---
NOTE: Persons contractiyff with unregistered contractors do not have access to the guaranty fund
J
Location
No.
Check #-71.5
Date `7 A // - -
TOWN OF NORTH ANDOVER
Certificate of Occupancy $-
Building/Frame Permit Fee $ t;K
Foundation Permit Fee
Other Permit Fee
TOTAL $
Ar
1301cling Inspector
Plans Submitted [I Plans Waived [I Certified Plot Plan 11 Stamped Plans 11
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
Tanning/Massage/Body Art ❑
Swimming Pools ❑
Well ❑
Tobacco Sales ❑Food
Packaging/Sales 11
Private (septic tank, etc. ❑
Permanent Dumpster on Site El
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
Reviewed On
Signature.
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
I Conservation Decision:
Comments
Comments
', Water & Sewer ConneGUOWS!gnature & Date Driveway Permit
DPW Town Engineer: Signature:
LOcatea M4 USgOOCI Street
in
,IR�-_ DEP e fl
""'burnb -r,
T �te nsi e- .qesz.,_ e�zZ
.Fir p.
-4 t T 'j-,
COMMENTS,,
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Deter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
NOTES and DATA — (For department use
El Notified for pickup Call Emai
Date Time Contact Name
Doc.Building Permit Revised 2014
Fel
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
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
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
Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
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
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Gerald A. Brown
Inspector of Buildings
Please print
DATE: Z
TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
1600 Osgood Street, Building 20, Suite 2035
North Andover, Massachusetts 01845
HOMEOWNER LICENSE EXEMPTION
BUIDING PERMIT APPLICATION
JOB LOCATION: V -,A
Number Street
Telephone (978) 688-9545
Fax (978) 688-9542
Map/Lot
HOMEOWNER _W0�C
Name Home Phone Work Phone
PRESENT MAILING ADDRESS
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 proceduresa uirements and that he/she will comply with said procedures and
requirements.
I .1/� dA
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
Tlae Commonwealth oflMMassachusetts
_ .Department ofindustrialAecidents
_ y X Congress Street, Suite 100
.Boston, HA. 02114-2017
www.rnass:gov/dia
Workers, Compensation Insurance Affidavit: Builders/Contractors/Electx zcians/PXumbexs.
TO BE FMED WITH TEE PEP—MTT1NG• AUTHORITY•
Name (B isiroess/Oxganizaiion/Xndividual):
Address:
city/State/Zip: IV • � VY,I �V kx
Ase you an employer? Check the appropriate box:
1.❑ I am a employer with . employees (full and/or pari time).4'
2. I am a sole proprietor or partnership and have no employees working forme in
capacity. [No workers' comp. insurance required.]
3. ! am a homeowner doing all work myself [No workers' comp. insurance required.] t
4. E] I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
5.n I am a general contractor and T have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance.
6.❑ We are a corporation and its of gers have exercised their right of exemption per MGL G.
152, §1(4), andwa have nQ emplciyees. [No workers' comp. insurance required.]
Type of project (required):
7. New construction,
8. [] Remodelhig
9. ❑ Demolition
10 [( Building addition
11.Q Electrical repairs or additions
13. El Roof repairs
14. [] Other
*Any applicant that checks box 41 must also fill out the section below showing their workers' compens ation p olicy information.
T 73omeowners who subrriit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this boxmust-attached an additional sheet showing the name of the sub -contractors and state whether or not (hose entities have
employees. if the sub -contractors have employees, they const provide their workers' comp. policy number.
I am an employer that is pi'ovidirzg workers' compensation insurance for my employees ' .Below is the policy and job site
information.
Insurance Company
P V # or Self ins Lic #:
Expiration Date:
o Gy ,
fob Site Address: car RPS < , 5 City/Stale/Zip:XP {
Attach. a copy of the workers' co,mpensation 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 fine 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.
lydo rer eby cer fnder+trie�ains and penalties ofperjur�� tliat the information pr ovided abova j str'ue and correct.
official use only. Do not write in this area, to be completed by city or toren of
zcia%
City or Town:
Permit/License
Issuing Authority (circle one): i
1. Board of Health 2. Buildingpepartment 3. City/'Town Clerk 4. Electrical Inspector 5. Plumbiuglnspector
6, Other
Contact Person: Phone
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 "...evexy person in the service of another under any contract 61 litre,
expxess or implied, oral or written." '
An employer is defined as "an individual, psrtnership, association, corporation or other legal entity, ox 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. Hovrever 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 commola"Yealth, 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 fll'out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-'contractof(s) name(s), address(es) and -phone number(s) along with their certificate(s) of
irxsu se inti#ed Diabiliiy�omparries (LLC}orBimitectL abiiyiy Part r lu (LDP wz no emp ogees other than e-
members or partners, are not required to can. 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 Depaztment of Industrial
Accidents fox confinnation ofinsurance coverage. Also be sure to sign and date the aifidavit. The 'affidavit should
be returned to the city or town that the application fox the permit or License is being requosted, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you'are required to obtain a workers'
compensatioil policy, please call the Department at the number listed below. Self iir'sured companies should'enter•their
self insurance license number on the appropriate Tine. -
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 size to fill in the pennit/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. Anew 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.a. 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 o£. ZndustrialAccidenis
1 Congress Street, Suite 100
Boston, MA 02114-2017
TeX. # 617-727-4900 ext. 7406 or 1-877-MMSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
