HomeMy WebLinkAboutBuilding Permit #949-14 - 30 MARBLEHEAD STREET 6/30/2014BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: 1114 � -- I � Date Received
Date Issued:
RTANT: ADDlicant must comi)lete all items on this
LOCATIOU �?o
PROPERTY OWNER
Print Year Structure y es
x Q4� 0
MAP M� PARCEL: ON ZONING DISTRICT! Historic District 0
'Machine Shop Village yes n
TYPE OF IMPROVEMENT
0
0(, 6
IE
Residential
PROPERTY OWNER
Print Year Structure y es
x Q4� 0
MAP M� PARCEL: ON ZONING DISTRICT! Historic District 0
'Machine Shop Village yes n
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
'&�ne family
[I Addition
0 Two or more family
11 Industrial
[I Alteration
No. of units:
0 Commercial
lid<epair, replacement
El Assessory Bldg
0 Others:
11 Demolition
11 Other
11 Septic OWell
0 Floodplain [I Wetlands
11 Watershed District
0 Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Pepnqc 6- " bFzK(,VQ R,91 " PC eX U rV1 A�C ori Iry CW -r '06 M#4
OWNER: Name:
Address: '30
Contract,
Address:
IdentificAtion - Please Type or Print Clearly
08
Supervisor's Construction License:
Exp. Qa.,.
Home Improvement
ARCH ITECT/ENGI NEER 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: $ %K 2e FEE: $
z0j—
Check No.: " ti � D-7 D -7 (P- 6 Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund
LSignature f Agent/OwneEa*,:��—)V/,�_
Signature of contractor
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
L3 Building Permit Application
L3 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
u Building Permit Application
Lj Certified Surveyed Plot Plan
u Workers Comp Affidavit
Li 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
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
u Building Permit Application
Li Certified Proposed Plot Plan
ij Photo of H.I.C. And C.S.L. Licenses
Lj 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
Doe: Building Permit Revised 2014
Plans Submitted 11 Plans Waived 0 Certified Plot Plan El Stamped Plans 11
TYPE OF SEWERAGE DISPOSAL
Public Sewer El
Tanning/Massage/Body Art
Swinuning Pools 0
Well El
Tobacco Sales E]
Food Packaging/Sales El
Private (septic tank, etc. El
Permanent Dumpster on Site El
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On
COMMENTS
CONSERVATION Reviewed o
COMMENTS
HEALTH
COMMENTS
Signature
Sianature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: -- Zoning Decision/receipt submitted yes
Planning Board Decision:
Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date DrivewaV Permit
DPW Town Engineer: Signature:
Locatea jo4 usgooa z>treet
FIRE� bEPAkT'-MIENT � T r Mp QU
e mpster on site yes- no -
Located at 124 Main,Street
Fire Department signature/date
COMMENTS
Dimension
Number of Stories
Total land area, sq. ft.:
Total square feet of floor area, based on Exterior dimensions.
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes
MGL Chapter 166 Section 21 A —F and G min.$100-$l 000 fine
NOTF-5 and DATA — (For department use
I ON re
I LJ Notified for pickup Call Email I
Date Time Contact Name
Doc.Building Permit Revised 2014
Locatiot2 C4
Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee
TOTAL
Check #(A,��fA-Nm 1(p
27726 Building Inspector
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The Commonwealth ofHassachuseiffs
Deparbuent qf1ndusMq1Acc1d&fs
0 e ofluvesfigations
ffle
600 Washington Street
Boston., MA 02111
www.mass.govIdla -bers .
Worke]r$, Compewation Imurance Affidavit: BadersIContractor$Mlectriciang/PlOm
A Please FrktLegibl-y
TO
kant lhfo. m
Name (BusinesslorganizationMadNidud): ��oAwei-
Address: '30
I
City/;Stat01Zp: Wo 0^-)oa t)ei�- Phone#: '-70(, 091- 3008..
Are yoU an ex3aployer? Check the appropriate box-
Type of project (req&ed):
i El i am a employer vith
4. F1 I am a general contractor and 1
6, Now cOnstructioa
-
employees (fun andJcxpart:-t1mo).*
have Wred the sub -contactors
listed on the attached shoot. T
7. Remodelling
2. El I wn a sol() proprietor or partner-
ship aad-lavono-omployeos�
These sub-contraotors have,
S. E] Demolition
woxldng formo im any capacity.
workers 2 comp. insurance.
5. We area corpora�on and its
9, El Building addition
!No work -ors' comp. insurauc()
officers have oxorcJs ed their
10. U Electrical repairs or adations
3. P'fam, a Roxeovmer Aing all work
right of exemption p or MOL
11.[] Plumbingrepairs or additions
Myself Lw0workeys"Comp.
c. 152, § 1 (4), and we have no
12.P Rooftepairg
insuraacerequRed-1 I
employe6s. [No workers'
13.E] other
comp. insurancorequired-1—
1!Anyapplicautthat checks bDX#1 MustalsO M 6uttho section below showingtheir Workers'coMPGnsatIOUPOROY intolmall0n.
,11-Honleownerswho submit ihig affidavit indicatingthey ka doing allworX and then hire outside contractors must submit a new affidavit indicatifig sitch.
Tcontractors that cheAthis box must attached M gdditional shoot showhigtho, name of the suh-contraotors and1heir-workers' comp-Polloywolmation.
-1 am an em e T 2 e1,T oy S of w 1 thep lie andjoh Me
ployer that isprovidilig WOMeTs' c0muellsafiffl 11'suran Oft ry I ee' B 0 s 0 Y s
Nformallon.
Insurance Company
policy # or Self -ins. UG.
ExplraflortDato;
Yob Site Address, Pity/statelzip:
Attach a copy of 0e, worker,%' cOmPensation-policy declaration page (showing-thepolicYnMberand expiration date)
Faffirato, secure ooverago.as reqy6dunderSoction25A of MOL o. 152 can leadto thaimposition of erhninalPanaltles of a
one. om of a STOP. WORK ORDER and a fma
flue up to $1,500.00 and/or year Mpnsqmont, a wellascivi[ponalflosinthof
of up to $250.00 a day against1ho Vloktor. Be advised ffiat a copy of this statementmaybo foxwardedto the Office -of
investigations oftho DIA for ffisurance coverage verification.
Ales ofperjuly triat t1le informationprovidecl above fs true and eorrect.
X do 11 CeAMY Uniter filepains andpen
Mone 4. "
OfJi-elal use only. Do not -Wirite in this area, to he eonWleted by cli�y or town offidaf
City or Town: Permit/Licenge 9
Issuing Authority (circle line):
1.)30ard of Health ,),.)3u1ld1ngDepartment 3. CifyMoym Clerk 4. Blectrical Inspector 5. Numbing Inspector
6. Other
'Dy'- .9.4
Information and Instr
Uctions
Massachusetts Geueral Laws chapter 152 reqalres all employers to 1daworkers, compensation for Moir employeegg.
FTOVI
-Ptirsua�ttotMgstatate,aner,lployeeisde, ed as'�..evaryparson k the service of ano r d yco a to
,xpress or implied, oral Or Wx1ttGn.,,
I e fm the im er an iitr c fbira,
AneMTIOYq�js definedas "anindividualparfuership, association, coVoration or other legal entity, oranytwo ormore
of the f6r6jo'iftj engaged in ajoint enterprise,
red and includingthO 16gal-Telnesentatives of a:decoased emplo
eiver or Ustee"O anindividuaLparfnership, askciation or other legal entity, employing en�pjoyp or the
91�e,, the
Owner of a dwelling househavingnotmoro thanthree apartments and who resides therah- o t . ocoapantofthe
,r who em in ct! repair work on su6h dwelling house
dwolling house of anothe ploys persons to do ma tananceconstra onor � r he
or on the grounds or building appurtenaut thereto shall not because of such employment be deemedto be an employer.,,
MGL chapter 152, §25C(6) also states that "every state or 101cal Re-ensing agen . ey shall withhold the issuance or
renewal of a license or p ermit to operate a business or to const"ruct buildings in the commonwealth for any
applicant who has not produced -acceptable evidence of compliancewith tILO insurance coverage require.d.11
Additionally, MaL chapter 152, §25C(7) states'Wolther the commonwealth nor any of its p olitical sub 6visions shall
cuter into ally contract for the p arformaace ofp ablic work until '
acceptable evidence of complipco with theinsuranco
requirements of this chapterhave, beenpresentedta thb cQntracting, au.thorjty�-
Applicants
Pleas-0cfill out the workers, compensa*Uou affidavit completely, by checking e, boxes that applyto, yours! ationandif
th ta
ji 6ccdsa*� supply sub-contractor(s) name(s), addrCss(03) andphone number(s) along with their cerecate(s) of
insurance. LimitedLiability Companies (LLC) orLimitedLiabilitypa-inerships (LLP)withno employees otherthanthe,
members or P�rluars, are, notrequired to cart7 workers, compensation insurance. I-Ean L—TC OrLLP does have
6MP1OYeP5,apol1qy!srequired. Be advised tfiattfil� affidavit maybe submitted to the Department of Judustrial
Accidents for conffimationof insurance coverage. Also be suXe to sign and (late the affidavit. The afff davit should
'he laturadd.to the city or town thatth� application forthe pamit or license is being reqaateq, not the Dq'
parlmant of
Ind-astrialAccidents. Shouldyouhavo any questions regardhig the law orif you are xcqufredto obtain a*orkers'
con�pensatlonpollqy-, please call the Department at thq number listed below. Self-insured companies should enter their
B01-C-Insmanco license number on the appropriate line.
City or Town Officials
Please be sure thattho affidavit is complete andprintedlegibly. The Department has provided a space attho bottom
ofthe affidavitfaryou to fill out in the event the Office of Investigations has to contactyou regarding tho applicant.
Please'be-sm` to ffll in the Pumlit/RcOnsO number Whichwill be used as a referenco number, 1h. addition., ail applicant
that J�Ust submit multiple. permit/licanse applications in any given ye'ar, need On1Y s ubmit one, affidavit indicating curr6nt
PORGY infomiation (if necessw) and under "Yob Me Address" the applicant should write "all locations ln---�(cfiy or
to-Wlr)!'�A: �Opy ofthe affidavit that has b eon officially sta�nped or marAed by the city or town may be provided to the
applicant as Proof that a valid affidavit -18'011 fdc�[bx filtInD Penuits Orlicenseg. Anew affidavitmu'stboffileLd but each
year. Mere a homeowner or citizen is obtaining a licanse oipjermit -not related to any business or commercial vautura
(i.e. a dogliGense orietmitto, burnleaves etG.) saidperson is NOTxeqpfredto complete this affidavit.
TILD Office of Investigations . wouldliko to thankyou in advance, for your cooperation and shQuldyqU have any.questions,
please do not hesitdta to give us a call.
The D ep arfmont's addres s, talephona ah.d fax numb er:
Tho CQm
mon
Do,partment QfjirLcTV&jaj Apoldorta
Office dhavestfgAvana
a 0 Wa4k&n S�:o a
Boston, MA 02111
T01 0 617-72Q-4900 W406 Qr- 1-877�M
Revised 5-26-05
TO" OF NORTH ANDOVEp
Otto.
D OFFICE OF
I- IBMDING I
10 IDE
�0 -P"Tlv"NT
160 0 Uqg'o C)
d Street Bifflding 20, -Suite 2-36
North Andovar, Massadhusatts 01845
Gerald A. Bro-wn Telephone (97�) 688-9:5.4.5
Iaspectorof.Badiugs F47-
(978) 689-9542
ROMMENER ICENSE P-XEMP
�33MING PFIRMT AIPLICAT10N
:n
DATE-_TtjjC �3�001i4
:JOB LOCATION. -
Numb or StreetAddress
ffap)�ot
I�OAMM�R, POLVEgs. _791,9,31-:3E50b
Homo
Phone,
workphone
-PP,B'SP,NT MAM1�4CTADDPRss---SA,,, c As AE.0
--------------------
rz- M 09 01 b'4S-
01, ty T o w n stAe -
The current exempgon fbr'1omeo',?V—,a-rs1v was oxtenaed to iuojude ownpr-oc,
tO allow Rulbh homeoviiners to engage alin- dividual-f�r hire -who cloes dpied 6"Vellil-c's to tV0 units -Qr loss and
acts as SL11)erV'sor)- g'late DO' ding (Code Section 108.3.5. 1) - 11otpossess a limnse, provided that fh�, owner
D13FMITION OF ROMEOVMER
POMOR(-9) who _pns aparcel of land on which he/she, resiaes or intends to reside, on which there j orisjute
nde
be� a one or two fam- -dY straCtures. A person. who constmets more S, 'd to
at ne ho u a _Ye
.considered a homeowner, th -0 me i two 'arpeii6d shall not be
T'Omdar'igned"homcdwnce'assumesrespDnsibilityfo cOmPliances With the State Building Code a -ad other
Ap T
_pTicabla codes., by-laws, Mes and-regalations.
The undersigned "fiomeowne3?, certiges that he/she !MdOlstands the Town of gorth Andover Building I)e
Minimum inspeDtion procedures and requirements and that helsho vjU coluply with'saidprocedIlres and
.requirements,
ROAMOWMERS SIG-XATr)]?,,Fl
A�PPROVAL OF BUILD)NG OFFICIAL
ROVised 7.2009
Form liomeowners Exemption
'13DARI) OF APPBALS- 688-9541 CONSERVATION 698-9530
DBALTH 688-9540
PLANNING 689-9535