HomeMy WebLinkAboutBuilding Permit #987-15 - 327 MIDDLESEX STREET 5/29/2015BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#9 �11+ — ( r — Date Received
Date Issued: 6.
1 PORTANT: Applicant must complete all.items on this pa I ge
LOCATION
Print
PR NER, if 1)17 C
OPERTY OW
Print 10 Year Structure yes-, no
MAP PARCEI ZONING DISTRICT: Historic District yes no
Machine Shop, Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
El New Building
0 One family
D Addition
NKrwo or more family
0 Industrial
El Alteration
No. of units:
D Commercial
0 Repair, replacement
0 Assessory Bldg
0 Others:
D Demolition
11 Other
0 , epti [I Well
S 0'
FloodpJain C]'Wetlands
atershed Dist ,t
11 W ri
0 YVater/Sewo - r
DESCRIPTION OF VVUMM I U t5t 1-t=Mt-UM1V1r-U;
OWNER: Name:
ILVEM UF K I III I %-IVUII-Y
F.Avne "m OIL,
7�
4
ARCH ITECT/ENGI NEER
Phone:
Address: Reg. No,
FEE SCHEDULE: BULDING PERMIT: $1Z00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ FEE: $ q
Check No.:-/(-�- Receipt No.:
NOTE: Personls contracting hit"h u�registerej co
ptrq^rs do not have access to the guarantyfund
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
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 IECC Energy code
Engineering Affidavits for Engineered products
JOTE: 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 0 Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/Massage/Body Art
Swimming Pools 11
Well El
Tobacco Sales
Food Packaging/Sales El
Private (septic tank, etc.
Pennanent Dumpster on Site El
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On Signature,
COMMENTS
CONSERVATION Reviewed o
COMMENTS
HEALTH
COMMENTS
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 Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
E e i
jj§ne es%
lylgiff efi,
_j_
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 rnin.sloo-si000 fine
NU I t5 ancl UATA — (For department use
U Notified for pickup Call Ema
Date Time Contact Name
Doo.Building Permit Revised 2014
Location
No Date
�015hci // r
Check #
28853
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Building Inspector
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Datum: MA Stateplane Coordinate System, Datum NAD83,
Meters Data Sources: The data for this map was produced by Merrimack
Valley Planning Commission (MVPC) using data provided by the Town of
North Andover. Additional data provided by the Executive Office of
Environmental Affaim/MassGIS. The information depicted on this map is
in
for planning purposes only. It may not be adequate for legal hounclary
defin n or regulatory interpretation. THE TOWN OF NORTH ANDOVER
M S
AKiEtio NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING
THE ACCURACY COMPLETENESS, RELIABILITY, OR SUITABILITY
OF THESE DATA� THE TOWN OF NORTH ANDOVER DOES NOT
0 41
ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF
THIS INFORMATION
The Commonwealth of Massachusetts
(.4 Department ofIndustrialAccidents
1 Congress Street, Suite 100
Boston, AM 02114-2017
www-mass-gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/El - ec ' tricians/Plumbers.
ADblicant Inforina TO BE FILED WITH THE pERMTT . ING AUTHORIiY. Please PriaL_Lggi�h
f
Name (Business/Organization/Individual): F��S_Irce mcjcbCA�A'aA
J,
Address:
ff
f)rV41, Ancla/ev-
0,---)
e A 3 / Q0_LJ10q_�)__
Are you an employer? Check the appropriate box:
1. n I am a employer with ____�..�IIIPIOYees (full and/or part-time).
IF] I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3.FJ I am a homeowner doing all -work myself [No workers' comp. insurance required.] t
4.FJ 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
proprietors with no employees.
5.n I am a general contractgr and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors h�ve employees and have workers' comp. insurance.t
6.FJ We are a corporation and its office rshave exercised their right of exemption per MGL C.
152, § 1(4), and wehave n * em quired.]
o . pl6yees. [No workers' comp. insurance re
—1— their workers' compensatic,
Type of project (required):.
7. E] Ne,�V'd6nstr�ction
1
8. El Remodeling
9. n Demolitio�i
10 E] Building addition -
ME] Electrical repairs or additions
12. .J Plumbing repairs or additions
_F.
11F] Roof repairs
14.F] other—,
n policy information.
*Any applicant that checks box 41 Must a1SU JW UUL U� 0-1-11
t 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 must attached an additional sheet showing the name of the sub -contractors and state whether or not those, entities. have
comp. policy number.
employees. If the sub-conLetors have employees, they must provide their workers'
I am an employer that is providing -workers' cOMpensation insurancefor my employees. P�low is thepolicy andjob site
information.
Insurance Company Name:
Policy # or Self -ins. Lic.
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
well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a
and/or one-year imprisonment, as I
day against the violator. A copy of this statement may be forwarded to the office of Investigations of the DIA for insurance
coverage veri
I :: d : o :::: h :: e : r : e : by certi penalties ofperjury that the information provided above is true and correct.
fy under thepains and _ I — — I —
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): i
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 employees.
1. -
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 defmed 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 trustee of an individual, partnership, association or other legal entity, employing employeeg. 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(l) 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
nece9sary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate('s) of
insurance. Limited Liability Companies (LLQ 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. 1�e 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 pr 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
elf-insuran
____Lii inst ce 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 I (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 permitnot 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 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 # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
TOWOMORTRANDOYM
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OFFICE OF
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.1600 DgkODd Street Buffft 20, -Svite, 2-3 6
- Nofth Anbvea; Massadhus otta 01945
Gerald A. Drown TOIGOone (979) 6S 9-9145
InS
pector of Bildffigs -Fax (978) 689-9542,
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person(s) who-9wasapare,01 oflaad DflatcudSto reside, Mwhichfhere, is, oxis jofaudedfo
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requirenients,
HoAfflowXBRS SIGNAIM
APPROVAL O:F 33MD)NO OFFICfAL
RBY19ed 7.2009
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3DARD OF APPEATS 688-9541 CONTSERVAEON 689-9530 BBALTH6�8-qS40 PLANN)NO 689-9535