The URL can be used to link to this page

Home My WebLink AboutBuilding Permit #103-14 - 329 Middlesex 7/30/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION I �i-I 6� Permit N0: Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION . Print PROPERTY OWNEROYEf`//2F Print 100 Year 01 tructure yes. 0 j MAP NO PARCEL, ZONING DISTRICT: Historic District yes no Machine Shop Village. yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition XTwo or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well' I Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: fattmp &ollh T-u ba 7. 12-2 qb3 Identification Please Type or Print Clearly) OWNER: Name: Phone: ?&q3 Address: sQq ma&l _Y _ CONTRACTOR Name: _ -_. Phone: Address: Supervisor's Construction License: _ Exp. Date: Home.Improvement License: _ _ _ Exp. Date: 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 Cost: $ 1 4�' FEE: $ I Check No.: ( o y Receipt No.: �� NOTE: Persons contracting w' nre red tractors do not have access to the guaranty fund Signature•of Ag! naOOwn 1ature of contractor _ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Building Department The fol:owing is a list of the required forms to be filled out for the appropriate permit to be obtained. i Roofing, Siding, Interior Rehabilitation Permits o Building Permit Application Li Workers Comp Affidavit Li Photo Copy Of H.I.C. And/Or C.S.L. Licenses E, Copy of Contract u Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks u Building Permit Application o Certified Surveyed Plot Plan L3 Workers Comp Affidavit L3 Photo Copy of H.I.C. And C.S.L. Licenses L, Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o 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) Li Building Permit Application o Certified Proposed Plot Plan u Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit u Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) u Copy of Contract o Mass check Energy Compliance Report u 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 apw-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.tted with the building application Doc: Doc.Buhding Permit Revised 2012 I J Plans Submitted ❑ Plans Waived❑ Certified Plot Plan ❑ Stamped Plans ❑ I TYPE OF.SEWERAGE:DISPOSAL Public Sewer ❑ Tanning/Massage/BodyArt ❑ 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 I DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS L CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Siqnature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes I Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW'yowl! Engineer:g neer: signature: , i Located 384 Osgood Street FIRE DEPARTM =fiIT =Temp Dump'ster on site eyes_. no Located at 124,Main Street Fire Departmert�siginature/date 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.$10041000 fine NOTES and DATA— (For department use f I :c3 Notified for pickup - Date Doe.Building Permit Revised 2010 r Location No. 1 D�> ,y' Date 1 � J . - TOWN OF NORTH ANDOVER s 9 , Certificate of Occupancy Building/Frame Permit Fee $ --- - Foundation Permit Fee $ ' I,Nv�, ' Other Permit Fee $ TOTAL $ Check# 26681 ` Buhing Inspector FORTH own of 2 t ndover - to h , ver, Mass, v L 10 a 2A111 COCHICHIWICK A- E 0 .E0 S V - BOARD OF HEALTH Food/Kitchen PER T LD Septic System THIS CERTIFIES THAT .. . �: .. 1 .��. �. BUILDING INSPECTOR THIS Foundation has permission to erect .......................... buildings on ... �.......... .. ...... ... ..... ..... Rough - to be occupied as .....uwyft... ...... . . at.... ................................................ Chimney provided that the person accepting this permit sha every respect 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI TARTS Rough Service .......... ... .. .... ......... ........ ...... ..................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Reguired 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. SEE REVERSE SIDE The Commonwealth of Massachusetts Department of Industrlgl Accidents Office of Investigations 600 Washington Street Boston,MA 021I1 www.mass gov/ilia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers .Applicant Information Please Print Legibiy Name(Business/Organization/Individual): .D-e�/2.,,P—Z Address: 3r)q M/dn rJ/_"J_�( 1T. - City/State/Zip:&�tl"/ one#: 7 alp? 7t'�93 Are you an employer?Check the appropriate box: Typo of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have Hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet.x ❑Remodeling ship and'have no employees 'These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp,insurance. g, E]Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3. ( I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions / myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roofrepairs insurance required.]t employees.[No workers' comp.insurance required.] 13.�Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T Homeowners who submit this affidavit indicating they 2're doing all work and then hire outside contractors must submit anew affidavit indicating such. !Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees, Below is the policy and job site information. Insurance Company Name:- Policy 4 or S elf-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 requiredunder Section 25A of MGL c.152 can lead to the imposition of criminal penalties of 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. Do advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido Hereby ce under thepains andpenaltie erjury tit file informationprovided above is true and correct. - Si ature Date: Phone#: � Official use anly. .Do not write in dais 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 CIerk 4.Electrical Inspector 5.PIumbing Inspector 6.Other - - Contact Person: Phone#: Information ion and Aust ruefl®ns 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 j oint 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.aceeptable 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 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 notrequired to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Do advised that this affidavit maybe submitted to the Department of Industrial Accidents fox 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 andprinted legibly: The D epaitm erit 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 permithicense 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 Office of investigations would no to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: Tho GQMj]:AOnvd(aXth of l assa.,chusetts Department Offadustdat Accidents Office of Iavestigatiio.m 600 Washington.Street Boston,MA02111 `QL#617-7.274900 eyt 406 or 1-877:M'ASS.AFB Revised 5-26-05 k`a 4 617"727-7749 • �oRTy p4�tno,a�y TOMW OF 1NORT�H AND ovER �= 6E, . `••�a� ft OFFICE OF BUILDING DEP • �a� ,.^.� ,I600 Osgood Street Building 20, �s a�Hus cis • North Andover,Massachusetts 01845 te 2-36 Gerald A.Brown Inspector of Buildings Telephone(97g)688-9545 HOMEOWNER-LICENSE EXEMPTION Fax (978)688-9542 BUIDING PERMIT.APPLICATION Please mint DATE- JOB LOCATIbN.• Number Street Address • . ' . N[ap/Lot IMIO MOWNER Name. Home Phone �Q Work Phone 3 PRESENT MAILINGADDRESS at,_. _ip Code The current exemption for"homeowners"was extended to include owner-occupied dwellings to t4vo units z- ss a fo allow such isor). State u engage an dividua"for hire who does:lot Possess a 7 cense,provided that the owner rj acts as supervisor). State 3uilding (Code Section 108.3.5.1) DEFINITION OFHOMBOWNER Persons)who Qwns 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 atwo-yearperioO shall not e considered a homeowner. The undersigned"homedwner"assumes responsibility for compliances with the State Building Co Applicable codes,by-laws,rules andregulations. de and other The undersigned"homeowner"certifies that e/she understands the Town of North AndoverBu' minimum inspection procedures and re uemen and that he/she will comply 'th,said Procedures and Department pment requirements, HOMEOWNERS SIGNAT APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Porro Homeowners Exemption )30ARD OFAPPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-953 i