HomeMy WebLinkAboutBuilding Permit #779-2016 - 30 SARGENT STREET 1/5/20167 BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: -� 19 --24 (,p Date Received
Date Issued: 1 1
IMPORTANT: Applicant must complete all ,items on this page
LOCATION �� 0 SSC-
Print
PROPERTY OWNER —6kyj�S
Print 100 Year Structure yes DnoMAPPARCEL:3 ZONING DISTRICT: Historic District yeMachine Shop Village yes
TYPE OF IMPROVEMENT
PROPOSED USE
Res' ential
Non- Residential
❑ New Building
ne family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
0 epair, replacement
❑ Assessory Bldg
❑ Others:
emolition
❑ Other
0 Septic []Well
❑ Floodplain [I Wetlands
p Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
LA_1Z_47(
d ct
Identi ication - Please Type or Print Clearly
OWNER: Name: `I -,Oq Z Phone:
Address: s3 J
Contractor Name: T)4 v7 Phone:
Email:
Address:
Supervisor's Construction License: Exp. Date:
Home Improvement License: Exp.. Date:
ARCHITECT/ENGINEER Phone:
a
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: $ FEE: $��'
Check No.: Receipt No.: 2-c1
NOTE: Persons contractu{g nth %u)iregistered contractors do not have access to the guaranty fund
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
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 m U FORM
PLANNING & DEVELOPMENT Reviewed On
COMMENTS
Signature
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH
COMMENTS
Reviewed o
Sianature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Cpnservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
w
.qPW Town Engineer: Signature:
LOcatea M4 Usgooa Street
DEPARTME�NT=Ternp,Dvumpsteron se'yes.i
tLocat d' at11�2,4 Main Streets, ;: z ,' 777
4
�Fi„re Dep IH16 tis gnatur�e/date _ y
±c, �',.wc� -a:�.o to _ - {t�,•... ., �� ._ t �, ., ,t
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)
❑ Notified for pickup Call Email
Date Time Contact Name _
Doc.Building Permit Revised 2014
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
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
TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
Building Permit Application
4 Certified Proposed Plot Plan
6 Photo of H.I.C. And C.S.L. Licenses
4 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 I ECC 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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NORTH TOWN OF NORTH ANDOVER
6�'. °0 OFFICE OF
A BUILDING DEPARTMENT
a ; * 1600 Osgood Street, Building 20, Suite 2035
.o North Andover, Massachusetts 01845
Gerald A. Brown Telephone (978) 688-9545
Inspector of Buildings Fax (978) 688-9542
HOMEOWNER LICENSE EXEMPTION
BUIDING PERMIT APPLICATION
Please print
DATE: A—
JOB
LOCATION: SW
Number Street Address Map/Lot
HOMEOWNER
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,rop vided
that the owner acts as su erp visor.
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 110.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. N
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
Name __--
Workers:, Compensation Insuran,ce.Affzdavit: Builders/ContractorslElectxicians/PXumbexs.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Address: -3 (b S1
City/State/Zip: N r-" 0"/_`
Are you an employer? Checkthe appropriate box:
Phone #:
1. ❑ I am a employer with • , .: employees (full and/or pari tune).`
2. I am a sole proprietor or partnership and have no employees working for me in
y capacity. [No workers' comp_ insurance required.]
(am a homeowner doing all work myself [No workers' comp. insurance required.] t
4am 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-C] I am a general contractor and I haye, hired the sub-coitractors listed on the attached sheet.
These sub -contractors -fade employves and have workers' comp- insurance-'
6.F1 We are a corporation and ifs offigers have exercised their right of exemption per MGL 0-
152,
.152 § 1(4), and we have noemployees. [No workers' comp. insurance required.]
Type of project (Tg4uired):
7. [] New construction
8. [] Remodel]rig
9.UDemolition Com`
10 ❑ Building addition
11.❑ Electrical repairs or additions
M [J Roofiepairs
14. [] Other
xAny applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
4 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
#Contractors that check this box musk attached an additional sheet showing the name of the sub contractors and state whether or not those entities have
employees. If the sub -contractors fiave employees, �tiey rimet provide their workers' comp. policy number.
X am an employer that is piovI019 workers' compensation insurance for my employees.' Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins, Lic. ##:
Expixaiion Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' comapen ion polucy declaration. page (showing flee ]Policy number and expiration date).
Failure to secure coverage as required under MGL e. 152, §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.
X do hereby certify under' a pains a penalties ofperjur",� that the information provided abo a is true and correct
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 Ifealth 2. Building Department 3. City/'Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6, Other
PhoneContact Person'
The Commonwealth ofMassrxchusetts
.
Department oflndustr^ial Aceldents
z.
M
1 Congress Sheet, Suite 100
A
4 ' r.
Boston, MA. 02114-2017
www.mass.gov/dia
Name __--
Workers:, Compensation Insuran,ce.Affzdavit: Builders/ContractorslElectxicians/PXumbexs.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Address: -3 (b S1
City/State/Zip: N r-" 0"/_`
Are you an employer? Checkthe appropriate box:
Phone #:
1. ❑ I am a employer with • , .: employees (full and/or pari tune).`
2. I am a sole proprietor or partnership and have no employees working for me in
y capacity. [No workers' comp_ insurance required.]
(am a homeowner doing all work myself [No workers' comp. insurance required.] t
4am 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-C] I am a general contractor and I haye, hired the sub-coitractors listed on the attached sheet.
These sub -contractors -fade employves and have workers' comp- insurance-'
6.F1 We are a corporation and ifs offigers have exercised their right of exemption per MGL 0-
152,
.152 § 1(4), and we have noemployees. [No workers' comp. insurance required.]
Type of project (Tg4uired):
7. [] New construction
8. [] Remodel]rig
9.UDemolition Com`
10 ❑ Building addition
11.❑ Electrical repairs or additions
M [J Roofiepairs
14. [] Other
xAny applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
4 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
#Contractors that check this box musk attached an additional sheet showing the name of the sub contractors and state whether or not those entities have
employees. If the sub -contractors fiave employees, �tiey rimet provide their workers' comp. policy number.
X am an employer that is piovI019 workers' compensation insurance for my employees.' Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins, Lic. ##:
Expixaiion Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' comapen ion polucy declaration. page (showing flee ]Policy number and expiration date).
Failure to secure coverage as required under MGL e. 152, §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.
X do hereby certify under' a pains a penalties ofperjur",� that the information provided abo a is true and correct
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 Ifealth 2. Building Department 3. City/'Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6, Other
PhoneContact Person'
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 "...every person in the service of another under any contract U' lure,
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
ofthe foregoing engaged in a joint enferprise, 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. 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 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 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 ofpublic 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 !ha -boxes that apply to your situation and, if
necessary, supply sub -'contractors) name(s), address(es) and -phone number(s) along with their certificates) of
msur-ance.—L-ixnmitedViabihty-C-ompamos fl -L -C) -or Limited L abxlityFartnemlu (LL��ith no emp oyees o er "an the
members or partners, are not required to carry 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 Department of Industrial
Accidents fok confirmation of insurance coverage. Also be sure to sign and date the affidavit. The •affidavit should
be retuned to the city or town that the application for the permit or license is being requested, not the Deparknent of
Industrial Accident's. Should you have any questions regarding the law 0'r 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 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 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. 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 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
1 Congress Street, Suite 100
Boston, MA 02114-2017
TeX. # 617•-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 w.ww.mass.gov/dia
NORTH ANDOVER BUILDING DEPARTMENT
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
at: is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c11,S150A.
Also, note Permits are required under Fire Prevention laws Chapter 148 Section
l OA.
The debris will be disposed of in:
(Location of Facility)
Ll igna re o Permit Applicant
20
Date
D h
V --Mel 642Y 4 ree.
Location
No. 261 Date j
Check # J
f
Gi 8- 0 1
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ +
P
Buildi4in-spector