HomeMy WebLinkAboutBuilding Permit #739-14 - 30 DAVIS STREET 4/22/2014TOWN OF NORTH ANDOVER
/;APPLICATION FOR PLAN EXAMINATION
Permit NO:_:N ( Date Received
Date Issued:
_
IMPORTANT: Applicant must complete all items on this page
LOCATION -,,?
_.
Print _
PROPERTY OWNER (�
Print 100 Year Old Structure
MAP NO: PARCEL ZONING DISTRICT: Historic District
Machine Shop Villa
yes
Dk]
.TYPE OF IMPROVEMENT.
PROPOSED USE
Residential
Non- Residential
❑ New Building
9 One family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
4 Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septic 0 Well
❑ Floodplain ❑ Wetlands
0 Watershed District
❑ Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Identification Please Tvne or Print
OWNER: Name:y��( U /�Lp
Address: /� l 1 A V
CONTRACTOR Name: Phone:
Address:
Supervisor's Construction License: Exp. Date:
Home Improvement License:
Date:
ARCHITECT/ENGINEER Phone:
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: $_ FEE: $��
Check No.: Receipt No. e
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Own Sigpature of contractor ]
Plans Submitted [] PI ns Waived Certified Plot Plan ❑ Stamped Plans ❑
Locatiort.. , U 1� /
No. Date
Check #fill/ ��
TOWN OF NORTH ANDOVER
Certificate of Occupancy ; $
Building/Frame Permit Fee $rte
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
6 --� -
Building Inspector
Plans Submitted ❑ Plans Waived ❑ . - ..Certified Plot Plan ❑ Stamped Plans ❑
:TYPE OF-SEWERAGEDISP_OSAL
Public Sewer ❑
Tanning/Massage/Body Art ❑
Swimming Pools ❑
Well ❑
Tobacco.Sales
Food Packaging/Sales ❑
Private {septic tank, etc:_- ❑..-- _ ,.
-permanent Dbrapster ori Site ❑
THE -..FOLLOWING SECTIONS FOR -OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
J
_:__-DATE REJECTED DATE:APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
-CONSERVATION Reviewed on __ �j �-) l �i Siar
COMMENTS
HEALTH Reviewed on Signature
t
COM ENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes .
Planning Board Decision:
Comme
Conservation Decision: :Comments
Water & Sewer Connectionisi_gnature & Date Driveway Permit
DPW Towo Engineer: Signature:
Located 384 Osgood Street
FIRE DEPAftTMJrNT. -."Temp Dunipster on site yes.. no
Located -at 124 Main Street
Fire Debar`tinef t ssignatu'r`eldate `'Y
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.Z®NE 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 2010
Building Department
-' `rhe foli-,zwing is'a-list of,the *uired,forms to be -filled outfor:the appropriate. permit to .be obtained.
Roofii,g, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Gr 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 cas<s 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-tted with the building application
Doc: Doc.Building permit Revised 2012
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TO" OF NORM ANDOVER
OBECE OF _ -
BgllLi ING DEPARTMENT
1600 Dsgood Street Building 20, -Suite 2-36
• North Andover, Massachusetts 01 845
Gerald A. Brown Telephone (978) 68S-9545
Inspector ofMiff dings Fax (978) 688-9542
HOMEOW NER'LICENSE tnNiPTiON
B17IDING I'ERMT • PPLICATION
Beampn:nt ,
DATE;
JOB LOCATION; ?0 �� �% / S 7
Number Shea Address Mapfx of
Name, Horne Phone Work Phone
PRESENT MAU MCI ADDRESS D Z)dlr`,S —5 / . .
I Tn,=m LfaP,ep .
Tp Code
The current exemption for"•homeowners" was extencied to
to allow subh homeo" � - t nchide owner occupied dwellings to UVO units •ox less and
ueas �o engage au i � idividual•forhire who does notpassess a 11cense, provided that the owner
acts as supervisor). State 3ulding (Code Section 108.3.5.1)
DEFINITION OFHOMEOWNER.
PeISOn(s) who awns aparceI of land on which he/she resides or intends to reside, on which there is, or is intended to
be, a one or two fam--'dY sfzuciares. A person who consiroets more that one home in. a two-yearperiod shall not be
considered a homeowner.
The undersigned "homedwner" assumes responsibility forcbmpliances with the State Building Co
Applicable codes, by Jaws, rules andzegulatiom. de and other
The undersigned "homeownez" certifies that he/she understands the Town of North AndoverBuilding Dep�ent
xniniznum inspection procedures and requirements and that he/size will comply with+said procedures and
requirements, ,
HOMEOWNBRS SIGNATURE
A-PROVAL OF BUILDING OFFICIAL
Revised 7.2009
Form Tiomeownms Exemption
'EOARD OF APPEALS 688-954] CONSERVATION 688-9530
HEALTH 688-9540
PLANNING 688-9535
The Commonwealth ofMassachasetts , -
Department of lndustrigl Accidents
Office oflnvesiigations
640 Washington Street
Boston, MA 02111
www.mass govIdia
Workers' Compensation Insurance Affidavit: Builders/Conti°actors/Electxieiansl ffinbers
A.�pphcant Information Please Print Legibly
Name (Business/Organizaiionftdavidual):
.Address: -� 0 Dli U ! ,� S t
City/State/Zip: Alo & DL Phone
Are you an employer? Check the appropriate box:
Type of project (required):
1. C( I am a employer with
4. ❑ I am a general contractor and I
6. [] New construction
employees (fall and/or part-time).*
2. El am a sola proprietor or partner-
have hire dthe sub -contractors
listed on the attached sheet
`%• ❑Remodeling
ship and1aveno.employees
These sub -contractors have
8. ❑ Demolition
working forme in any capacity.
workers' comp. insurance.
9. Building addition
[No workers' comp. insurance
5. ❑ We area corporation and its
10.[] Electrical repairs or additions
required.]
3. RrI am a homeowner doing all work
officers have exercised.their
right of exemption per MGL
11. [1 Plumbing repairs or additions
myself. [No workers' comp.
c. 152, §1(4), and wehave no
12.E] Roofrepairs
in.suraucerequired-] t
employees. [No workers'
VIA
13. lOthex
comp. insurance required.]
KAny applicantthat checks box#1 must also fill outthe section below showingtheir workers' compensationpolicy information.
Homeowners who submit this affidavit indicatingthey k• doing all work and then hire outside contractors must submit a new affidavit indicating such.
TContractors that checkthis boar must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
f am an employer that isproviding workers' eomquensation insurance for my employees Below is the policy d job site
information.
Insurance CompanyN
Policy # or S elf -las. Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' comp ens ation•poliey declaration page (showing the polley number and expiration date).
Failure to secure coverage.as reguiredunder Section 25A of MGL o. 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 o£
Investigations of the DTA for insurance coverage verification.
X do Hereby cer . tler the pains anct penal es o penury h�aa`t t�ze ire joYynation Yovza a a/Dove zs truge ana correct.
nRP
Oficial use only. Do not write in this area, to be completed by city or town official
City or Town: PermitlLicense 0
Issuing Authority (circle one):
1. Board of Health 2. BuildingDepartment 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Juspector
6. Other - -
Contact Person: Phone U.
Information and Instrnctions
Massachusetts General, Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an ernployee is defined as "••.every person tri the service of another under any corifract ofhi m,•
express or implied, oral or written."
An employes is defined as "an individual, partnership, asso claiion, corporation ox other legal entity, or any two or more
of the Foregoing engaged in a joint enterprise, and including the legalrepresentatives of a•deceased employer, or the
receiver oxtnistee of an individual, partnership, association or other legal entity, employing employees. )Awevex the
owner of a dwelling house having notmore than three apartments and who resides therein, or the occupant oftile-
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 lie -ening 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 or any of its political subdivisions shall
enter into any contract for the performance ofpubiic work until acceptable evidence of compliance with the insurance
requirements of this chapter have b een 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) and phonenumber(s) 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 required to carry workers' compensation insurance, If an LLC or LLP does have
employees, apolicyisrequired. Be advised that this affidavit maybe submitted tothe, 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'
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 andprinted 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. 1'n, addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (ifnecessary) and under "lob Site Address" the applicant shouldwrite "all locations in (city or
town)." A copy of the affidavit that has b een officially stamped or marked by t.ha city or town may be provided to the
applicant as proof that a valid affidavitis on file Fox future permits or licenses, .A new affidavit must be tilled out each
Year. Where a home owner or citizen is obtaining a license ox p ermit not related to any business or commercial venture
(i•e, a dog license orpermit to burn leaves eta.) 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 aird fax number:
ThO Gatua zo.Uwcaxth of -
Dgpa .e,ut d1ndu*1al ,Accidenta
Wince ofJAVOStzga-don
600 Washigg o xee
E0*111 MA 021 if
e , 617-727,4900 ext 406 or X -877-
.V
Revised. 5-26-05 Fax 0 617-727-7749
749
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