HomeMy WebLinkAboutBuilding Permit #102-2016 - 32 LINCOLN STREET 7/24/2015 BUILDING PERMIT o� No DrH q�
TOWN OF NORTH ANDOVER 32 y�yt` 646 0
APPLICATION FOR PLAN EXAMINATION
Permit No#: f � 0 � Date Received
r gSSACHI)
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION ' L free)/tn
Print
PROPERTY OWNER 1'
�l + Print 00 Year Structure yes no
MAPPARCEL: Dtq 1 ZONING%DISTRICT: Historic District ye no
Machine Shop Village ye no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building Ywo
e family
El Addition or more farrlilv ❑ Industrial
❑Nteration No. of units: ❑ Commercial
Repair, replacement ❑Assessory Bldg ❑ Others-
❑ Demolition 0 Other
0 Septic 0 Well ❑ Flgodplain ❑Wetlands ❑ Watershed District,
0 Water/Sewer `
DESCRIPTION OF WORK TQ BE PERFORMED:
I
Identificatidh- Pease Type or Print Cle y n,
OWNER: Name: -owe Phone: `1
Address: J
Contractor Name: ` Phone: 7
Email: 1on C' r.--
Address: t .-.
Supervisor's Construction License: Exp. Date:
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Phone: t
Address: Reg. No. ,
FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. y ^`
Total Project Cost: $ 8 ®0 v= FEE: $
Check No.: 3�z Receipt No.: � 0 9 7
NOTE: Persons contractin ith ' tered contractors do not have access to the guaranty fund
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Taming/Massage/Body Art ❑ SwinUDing Pools ❑
Well ❑ Tobacco Sales ❑ Food Packaging/Sales 11
Private(septic tank,etc. ❑ permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF e U FORM
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
_.' . COMMENTS
Zoning Beard of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning BOEird Decision: Comments
s
Conservation`Decision: Comments
Water 9 Sewer Connection/Si nature Date Fn)rh/1nXAM1 Permit
DPW Town Engineer: Signature:
. rT Located 384 Osgood
_ART�MENT pu -�'�" Street
R;FYIRE DEPa _Tem m ster on s '
tQ cate�d at F1 -jMain St�eet�
r
_F ireiD'epartmentsignature/date° t t
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 ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA— (For department use)
i
El Notified for pickup Call Email
3 Date Time Contact Name
Doc.Building Pennit 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
i
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 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
Location
No.
Date�O 5
• TOWN OF NORTH A jDOVER.
•
• b,Y c ,>-
Certificate of Occupancy $
Building/Frame Permit F U�
Fee
Foundation Permit Fee $
' '* > Other Permit Fee $
TOTAL
4
S2
Check# t.
Building Inspector
251:0 9 7
00 R T!1
Town of t E 1., ndover
h ver, Mass
o ^K* > >
COC MI C41WICK y1.
�d AOOATEO
S u
BOARD OF HEALTH
Food/Kitchen
PERMIT T Septic System
0 'rj , h BUILDING INSPECTOR
THIS CERTIFIES THAT .............e......... ................................................ ... ................... . ...........
+ ....
has permission to erect buildings on .. .-. 2,1 �� Foundation
......................... ........ �.1�►.....
Rough
tobe occupied as ......... .. ...... ..... ........ .. . ............................................................. Chimney
provided that the person.:cceptin his permit shall in every res t conform to the terms of the application Final
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and
Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR
Rough
VIOLATION of the Zoning or Building Regulations Voids this Permit.
Final
PERMIT EXPIRES INt6WNjTfHELECTRICAL INSPECTOR
UNLESS CONSTRUCTSRough
Service
............. ... ........ .......... Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
TONVN OF NORM ANDOVEP,
b£t" =a° OFFICE OF
lit
:1600 QsgoDdStreOfBu1Iding20,•Svite236
NofthAndovor,Massaoh-.set#d 01845
• �s�ACfli35�'r` -
Gerald A.Brown Teleplbna(978)699-954-.5
InspectorofBIAldings . Fax (97-8)689-9542,
,. • o EOWNERTICENSE 13XM& r
PLICATION • .
Please rinf .. - ,
DATE: `7 Zt,-/j-
SOB LOCA tN-,
Numbez �treetA.cldress ' � • /�
Map)Zot
. �7'az�.e. . �iozne I'3zone �ozlt�'hone .
PRESENT MADDRESSAl A, �
j o-r
`to Tem ,���.
- . Z%g Cods
The current e empfzon dor"homeowaaers"was extended to?nelttde owner occti ied v f-
di�e1u�s to i�.o units o�,js:.a—
an
an
to aT1ow s�bl,homeo:rersto engage aur.;"dua. ' ' .
g UVd I forhire who does nod assess a BcDma provided
acts as su aw sor•. 9 ato 3 ; • p ,P z d that the owuez
.P � u.ldang (Coda�ectior.IOS,3.5.� ,
DEFMITzON•ORHOMEOVMFI
Persons)who gwus aparcel of land on which,'LEAD reslaes or intends to reside,on which fhere is,or is infended to y
Tie,a one or tt�o aznzly siructuras. A person Who con fMots mom that-one homy inatwoyearp i,d d shall ztot'be
comsidered a homemner. ,
Tha uudersigaad"lzonZeowuer"assumesresponsibility forcbznplianceswith the StateBuil&ag Code aztd outer
.Applicable codes,by-laws,zules and-iegalatiom.
The,rtndersigned"homeoWnez"cexti,$es t
mildmum ins hat Itelsheundersfauds the Town of North AndoverBuildingDr,&f neat
pection procedures and recluirezaeuts and that to/slza+ill comply withv,a!d procadmm and
recluirerrteztts,
ROAMOWN`3RS SICNATME ,
APPROVAL OF J3WDWG OFFICIAL
Revised 7.2009
1~oxm TlomeownerS EXemption ,
30ARD(TA.PE.EATS 688-9541 CONSERVAUON 588-9534 -
23EALTff6$5-9548 PLA.T2NLiV'G 58S}535 .
The Commonwealth ofMassachusetts
. Department of IndustrialAccidents
X Congress Street, Suite 100
Boston,MA.02114-2017
www mass.gov/dna
yJ♦
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORI'T'Y.
Applicant Information Please Print LeFAly
Name(Business/Organization/Individual):
Address: 3a-
City/State/Zip:
a-City/State/Zip: ml� Phone#: g 7?'3 21 `V5'
Are you an employer?Check the appropriate box: Type of project(xequired):
1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction
2.F]I am a sole proprietor or partnership and have no employees working for me in 8. []Remodeling
any capacity.[No workers'comp.insurance required.]
3..0I am a homeowner doing all work myself[No workers'comp.insurance required.]t
9. Demolition
/ 10 0 Building addition
4.❑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 11.❑Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
❑ 13 Roof repairs
• These sub-contractors have employees and have workers'comp.insruance.t (—- p
6.F1 We are a corporation and its officers have exercised their right of exemption per MGI,c. 14.El Other
152,§1(4),and we have nu employees.[No workers'comp.insurance required.]
*Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit•this affidavit indicating they are doing all work and then hire outside contractors must s4bmit a new affidavit indicating such.
TContractors that check this box must•attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub'con1rac6s have employees,ley must provide their workers'comp.policy number.
d am an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site
information.
Insurance Company Name:
Policy#or S elf-ins.Lie.#: 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 MGL c. 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 Iuvestigations of the DIA for insurance
coverage verification.
Ido hereby cer fy_ nd z 'ns andpenalties ofperjury that the information provided above is true and correct.
Signature: ----- Date: 7 la
Phone#: — 75 � S
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 Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their empoyees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written." '
An employer is defined as"an individual,partnership,association,corporation or other Iegal entity,or 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. 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 of public 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 the'boxes that apply to your situation and,if
necessary,supply sub-contractors)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'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 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 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
Tel. ## 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax 4 617-727-7749
Revised 02-23-15 www.mass.gov/dia