HomeMy WebLinkAboutBuilding Permit #641 - 326 CANDLESTICK ROAD 5/22/2009BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: `+ I
Date Issued:
IMPORTANT:
LOCATION ,.ion 6
PROPERTY OWNER.-
MAP
WNER_MAP NO,/&,f,.1 PAF
Date Received
pplicant must complete all items on this page
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;Print
L: 1 ZONING DISTRICT. ___._ Historic District
Shop'�i
yes
TYPE OF IMPROVEMENT
PROPOSED USE
Res - -
Non- Residential
New Building
One family—
Additi�
Two or more family
Industrial
C Alt - -
No. of units:
Commercial
Repair, repIacem6
Assessory Bldg
Others:
Demolition
Other
Septic Well -
Floodplain l Wetlands
-Watershed District
Water/Sewer
a
DESCRIPTION OF WORK TO BE PREFORMED:
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Identification Please Type or Print Clear
OWNER: Name: /Marlp-ne- EVf�S Phone: Qq9' O�
61r16
Address: 5 C_ n�l�s }1 [ 0 � 6-611 bill- 5Q�-'_CNeD
2
CONTRACTOR Name t )1� i /,� �1C'�� Lt�tL1� `Phone:
.Address;
Supervi:sor's Construction 'License; �. �__ _ : _ _ Exp. "Date
Home =Improvement License, :Exp'. pate:
ARCHITECT/ENGINEER 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 Cgost: $ /OC O- CrO FEE: $
Check No.: l f Receipt No. a C�
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
t1- n
Location s G
Date_
MOw7N TOWN OF NORTH ANDOVER
O• . 1 • O�
F 9
i49
W
certificate of Occupancy $
Ss�CHU Building/Frame Permit Fee $ v
Foundation Permit Fee $ _
Other Permit Fee $ _
TOTAL $
check #
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/MassageBody 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 Reviewed on Signature
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
Comments
Water & Sewer Connection/signature & Date Driveway Permit
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
NU I t5 antl DA fA - (For department use
❑ Notified for pickup - Date
Doc.Building Permit Revised 2008
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 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 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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2008
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Njashington Street
Boston, MA 02111
I www nzassgov/dia .
Workers' Compensation Insurance Affidavit: Builders/ContractorsXlectriciane/Plumbers
nniieant Tnfn,.mn,"__
Nanne (Business/Organiza6on/individual):_
Ades
Citystate/Zip:
C
EVu
M
Phone #A 1 V - lG o, - q r ri
Type of project (required):
6. ❑ New construction
7. Remodeling
8. Q Demoiition
9. ❑ Building addition
10. ED Electrical repairs or additions
11.Q Plumbing repairs or additions
12.M Roof repairs
13.5a�ther
Homeownt ra who submit this atiidavit indicating they ora tieing all worts land then hits outside contractors MUM pnmst Submit a ��y affidavit indicating such
4Cont►actors that check this box must attachedsn adrfitioast shca showing• the items of the sub-contrttctars and their workers' camp. affidavit
imfin esus
I ane an employer that s providing workers' compensation insurance for my. employees: Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lie. #:
Expiration Date:
Job Site Address: City/Staie/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 penalties of a
fine up to $1,5o0.00 and/or one-year imprisonment, as well as civil penalties in the farm 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 of
Investigations of the DIA for insurance coverage verification.
I do hereby cert under the pains and 1kno& tk_s ofPerjury that the infnrmadon provided above is rue and correct
z
ficial use only. Do not write in this area, to be completed by city or town ofcid
City or Town;:
Permit/License #
Issuing Authority (circle one):
L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
t?MMe=
!' Contact Person:
Phone #:
Are you an employer? Cheek.the appropriate box:
I. ❑ I am a employer with
4. ❑ 1 am a general contractor and I
employees (fulland/or part-time).*
2. ❑ I am a:sole proprietor or
have hired the sub -contractors
listed
partner-
on the attached sheet, t
ship and have no employees
These sub -contractors have
working for me .in any capacity.
[No workers' comp. insurance
workers' comp. insurance.
5. ❑ We are a corporation and its
required.)
officershave exercised their
3 • I am a homeowner doing all work
right of exemption per MGL
myself. [No -workers' comp.
c. 152, § 1(4), and we have no
insurance required.].t
.employees. [No workers'
comp. insurance required_]
*Any applicant that checks botF # t must also fi11 out the section below showing their workers' iio
Type of project (required):
6. ❑ New construction
7. Remodeling
8. Q Demoiition
9. ❑ Building addition
10. ED Electrical repairs or additions
11.Q Plumbing repairs or additions
12.M Roof repairs
13.5a�ther
Homeownt ra who submit this atiidavit indicating they ora tieing all worts land then hits outside contractors MUM pnmst Submit a ��y affidavit indicating such
4Cont►actors that check this box must attachedsn adrfitioast shca showing• the items of the sub-contrttctars and their workers' camp. affidavit
imfin esus
I ane an employer that s providing workers' compensation insurance for my. employees: Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lie. #:
Expiration Date:
Job Site Address: City/Staie/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 penalties of a
fine up to $1,5o0.00 and/or one-year imprisonment, as well as civil penalties in the farm 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 of
Investigations of the DIA for insurance coverage verification.
I do hereby cert under the pains and 1kno& tk_s ofPerjury that the infnrmadon provided above is rue and correct
z
ficial use only. Do not write in this area, to be completed by city or town ofcid
City or Town;:
Permit/License #
Issuing Authority (circle one):
L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
t?MMe=
!' Contact Person:
Phone #:
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 of hire,
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
of the'foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or bustee of an individual, partnership, association or other legal entity, employing employees. 'However the
owner. of a dwelling house having not more than three apaa-tments 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 shaU 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 insumnce'coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither gide 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 cordracting authority."
Applicants
Please fill out the workers' compensation. affidavit compimtely, 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 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, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage.. Aliso 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 nuraiberlisted below. Self-irsured companies should enter their
self -ins c license number on the appropriate dine.
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 permittlicense number which will be used as a reference number. In addition, an applicant
that must submit multiple permiMicense 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 ofthe 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 bum leaves etc.) said person is NOT.required to complete this affidavit
The Office of lnvestig�lions would hike to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give as a call.
The Department's address, telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington street
Boston, MA 02111
TeL # 617-727-4900 ext 406 or I-8.77-MASSAFE
Fax # 617-727-774
Revised 5 -26 -QS www.mass.gov/dia
Gerald A Brown . .
Inspector of Buildings
Please mint
TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
1600 Osgood. Street Building 20, Suite 2-36
North Andover, Massachusetts 01845
HOMEOWNER LICENSE EXEMPTION
DATE: —o q
JOB LOCATION: JA C an d It s h ck
Number r Street Address
HOMEOWNER Margo e,
Name Home Phone
PRESENT MAILING ADDRESS -
W0,
City Toon
Telephone (978) 688-9545
Fax (978) 688-9542
M%"
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
Pawn(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 comglian= with the State Building Code and other
Applicable codes, by-laws, rules and regulations.
The undersigned "homeowner" certifies that helshe »>�rsfands the Town of North Andover Building Departmeut
minimum inspection procedures and raprements and that he/she will comply with said procedures and
�• n A _
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Revised 10.2005
Form Homoownen Exemption
ROARDOF \PPF.\I.1S(,88,)541 CU.NSERV.1TIpVFS8-9j;4
HE.UXIi G8&9544 PLANNING 688-9535
l.rll 1Lf\UIY DICUJ. IN%.,.
171 MI. JUL CX;1 .7e- 117;'iJ
REGISVKY:
TITU RFXERENCE:
PLAN REFERENCE: P41W
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This plan was not prepared from an instrument survey.
Offsets and distances shown should not be used to
establish property lines.
This plan is intended for mortgage purposes only.
X certify that the structure-- --shown on this Plan
INA S in conformance with zoning setbacks
in effect at the time of construction.
structure
I certify that the pmad shown is Nbr located within
a flood hazard area as depicted on HUD Flo4d Insurance
Rate Maps for Community No- d "09
MORTGAGE PLOT. PLAN
LOCATION A SAN D
SCALE / 6� _DATE;
CERTIFIED 70:
CAMERON BROS., INC. rob No.
MALDZR MASWHUSEM •
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