HomeMy WebLinkAboutBuilding Permit #75-11 - 31 BRIDGES LANE 7/20/2010Permit NO:
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received '712ZI tb
TYPE OF IMPROVEMENT
DESCRIPTION
PROPOSED USE
Residential
Non- Residential
New Building
One family
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
Repair, replacement
Assessory Bldg
Others:
Demolition
Other
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OF WORK TO BE PREFORMED:
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Identification Please Type or Print Clearly)
OWNER: Name: Phone:
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: $412 ^ FEE: $
Check No.:1 2 Receipt No.:_93
NOTE: Persons contracting with registered contractors do not haveaccess to the guaranty fund
LocationO v 2 l G
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No. Date / ,�q
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TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #�
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Building Inspector
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410,01
10
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/Mas-sage/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 - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH-
C01MMENTS
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Com
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIREDEPARTMENTTemp bumpsfer on site :yes
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Lot a ute�''� `74 �rt=�- �`'rs,;`
�Fire,'1Department�si nature/datet �, rV.�;'��str
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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 - Date
Doc.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 Per 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 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 2008
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toRTH TOWN OF NORTH ANDOVER
o`"t�eD �o OFFICE OF
BUILDING DEPARTMENT
�o 1600 Osgood Street Building 20, Suite 2-36
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: -� I Z-0 ( lc:5
JOB LOCATION:
(Number
HOMEOWNER "P,
Name
PRESENT MAILING ADDRESS
City Town
v Vo,
q ? � v� -3 &
Home Phone
SCiXh2 Cc zs c9 two
State
Map/Lot
Work Phone
Zip Code
The current exemption for "homeowners" was extended to include owner -occupied dwellings to two units or less and
to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner
acts as supervisor). State Building (Code Section 108.3.5.1)
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 structures. A person who constructs more that one home in a two-year period shall not be
considered a homeowner.
The undersigned "homeowner" assumes responsibility for compliances with the 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 requireir and that he/she will comply with said procedures and
requirements. ,
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Revised 7.2009
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 685-9530 HEALTH 688-9540 PLANNING 688-9535
The CommOnwea4th of Massachusetts
ifDepartment o f rl2dustr ial ,accidents
Office of lnvesz gations
600 Washin,,mn Street
BOStOPZ, M4 02111
�-i7t4SS.bOV�dta
Workers' Compensation Insurance Affidavit: Buders/Contractors/Electrilicant Information cians/Plumber
s
T
Name (Business/Organization/Individual):
r lease rrint Lembly
Address: b Yid,
City/State/Zip:
Phone #: j 2t5
(9
X23 3
Are you an employer? Check the appropriate box:
—�-
1 • ❑ I am a employer with
--
4. ❑ I am a a
f project (required):
employees (full and/orpart-time).*
2. ❑ I am a sole
general contractor and I
have hired the sub -contractors
77N v,construction
F7.D
proprietor or partner-
ship and have no employees
listed on the' attached sheet $
Remodeling
working for me in any capacity.
These sub- contractors have
'
workers com insurance.
g• ❑ Demolition
INC)eqworkers' comp. insurance5.
P•
❑ We are a corporation and its
9. ❑ Building addition
'required.] ]
3.7.1am a homeowner doing all work
officers have exercised their
right
gh
10•❑ Electrical repairs or additions
m sel£
Y [No workers' comp.
of ��mption Per MGL
c. 152, § 1(4); and
.11-0 Plumbin g reP or matron,
insurance required.] t
we have no
employees•
'
12•❑ Roof repr,.,,.VJ
*A-ny Iir ±±y� bfl:: �, m, s comp. insurance required.]
Homeowners .• i ^SO 11t: C!:!' the 3eC'CZ'J^.. C:lQI': £'.2CY,^•• r
who submit •"a �� wCr–Ms
13.[1 Other
this affidavit indica CQSL`r,.,_„`"'C^.
+Contractors ting ^, a - dQmg all •.;.erk and wen hue o
that `h W^ this box must. a ached an additional sheet showing the idE contractor - 16= submit a new amdavit
7,"— .. _r�--- _
name of the sub -c indicating such.
onactots and their workers'
-- - - E yG' uuu w proviaing workers' coinPensaio---.Y .mon.
information. insrsrancefor
my employees. Below, is theoli ,
P cJ and job site
Insurance Company Name:
Policy # or Self -ins. Lc. #:
Expiration Date:
Job Site Address:
City/State/Zip:
Attach a copy of the workers' compensation policy 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 )
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form imposition
a STOP WORK ORD
Of up to $250.00 a da against Penalties of i
Y ainst the violator. Be advised that a co ER and a fine
Investigations of the DIA for insurance coverage verification.Py of this statement may be forwarded to the Office of
I do herecertify u er
tieS of perjury th4rr the information. provided above is true and correct
Si>�atvre•
Official use only. Do not write in this area to be completed by city or town offtciaL
City or Town:
Permit/License #
Issivina Authority (circle one):
L Board of Health 2. Building Department
6. Other
City/Tgwn Cleric 4. EiectricaI Inspector 5. Plumbinb Inspector
Contact Person:
Phone #:
Information an d Instructions
Massachusetts General Laws chapter 152 requires all employs to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every pe=rson in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, parmership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including tie 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 apartmL eirts and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintemiance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not be=cause of such, employment be deemed to be an emplpyer."
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 C enstruct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of co=npffimce 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 utter 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-contractor(s) 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' comp cation 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 for confirmation of inmirance coverage. Also be sore to sign and date the affidavit. The affidavit should
be returned to the City or town that the ap-whcauon for the perr3aft Or license in f,,
being requested, not a .D epa*tvt of
Industrial Accidents. Should you have any questions regardin g the law, or if you are =4 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 stampe=d 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 pert 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
ffidavitThe Office of Investigations would Iil<e to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department7.s address, telephone .and..fag.number—.
The Commonwealth. of Massachusetts.
Department of Industrial Accidents
Office c f Inrestic,ans
600 Washington Street
Boston, MA 02111 ,
Tel. # 617-72.7-4900 exrt406 or 1-877-MASSA.FE
Revised 5-26-05 Fax # 6.17-72.7-7749
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