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HomeMy WebLinkAboutBuilding Permit #802 - 33 BEAVER BROOK ROAD 5/7/2012BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Issued: IMPORTANT: Applicant must LOCATION i✓7YL' nt PROPERTY OWNERS r Pint MAP NQ �� }IPARCEL:O?3 ZONING-DISTF Date Received TYPE OF IMPROVEMENT 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 Septic Well Floodplain Wetlands` ` ' : Watershed District' Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: ✓L f Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: A. 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: $ 6'��O O FEE: $ &0 Check No.: t2 0 o F9 1 a�6 � Receipt No.: NOTE: Persons contracts g with u egistered contractors do not have access to the guaranty fund Signature of Agent/Owner­—Signature of contractor Location :1 D Vet 0130yoa lC No. 0 ;.— Date IvL • • I TOWN OF NORTH At�OVER Z Certificate of Occupancy $ Building/Frame Permit Fee $&Q. Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check Oo-3AI j & 66 3 3> 25275 Building Inspector Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/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 PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH Q COMMENTS .o Reviewed on Reviewed on DATE REJECTED DATE APPROVED Sianature Sianature 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 DPW Town Engineer: Signature: Dimension Number of Stories Total land area, sq. ft.: Total square feet of floor area, based on Exterior dimensions. 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 de ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 ent use 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 �d­­­­­�x----� Date....... ... G f „_.- 1 ?°.,�".;•.,,"o,� TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .................. ' - has permission to perform ........ N w U .................................................................... wiring in the building of .....?...�........... . .......... .: `'�.................................... L f 1,4 l dJ QOrth An Over S. at..................... .........!.................. ee... Z�... UJ Lic. No. ....5.5!! ............. .. .......... . I„/... .. .. - .. ..., f....... /ELECTRICAL INSPEC'�OR C � ” � �(-)'02/116/99 12:21 262.00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 0 �I W Cd z x O ca o w v v v) OH U a � O A o u. o w G U G u. OH U w 05 � O a a o w G iw a OH w a w w o c� cn G w" O H o w co w H w a w w w c4 z cn o cn c c m c C N • C2 C Q O _vV d C c CD i 0 CD 0 C • do N NEE :tsc 0.m c E � L C �• m O N L O N CD = N y"' �o s � H C C W O Em CLCD m N m ; J. = :t= O C! "a C m p m V N O. C Z O O.� Cf Z..:. � c a o c N m y- m C 'c Q L L L p = m d H -S N o $ ~ m W CO +. c •N CL=R C Z co •N Cs V 3 Q�Q COD a. Oom= co cm i O y C 'E mCD 0 CD CD m 0 Cc o a CL CMQ ca o Cc� C C CD ca C � � C..3 co � c C E _cc �. CO2 W D N LU U) W W W C4 as N oxU � J 0�8� aCL 3 anl 0, HEW Cl U. H IL O id �° tr c 108 41m 43 m CO IS ce` r m o� on o m a o macs � *2 a w C) c a o aN n. Ron. -m g a 0 c mid ;a � mo aof->0 p O m m a m 0 Cq 0 Y U �m V- 0 V(OCQC c V if .� E m 'moo x D cQ G z O 0 Q 4 00 z z a tC W N Y O V W N OC Ul 0 Q Wa W2 J1 d Sa >a W Z LU � mtWg�C Q a.o<r,z a a z 00 SS w � � N 10 N N �.. v a �2a�vM b E ii c �. Q77 - U ��¢E-a w>-C7C�ad� O � QO»Na-N�� N rX NN WLL W cc(0 Z M �U`` z $ ta � �C'1 2 in co Zo O �_' t 0 IL 00 V ONZoo Q� 0 -10 0tV=1 U Q U. Z -N —W _ Z t0 Y � = ti (a -LU tL ti CU UO CD ' L1 4 S A �.y 4-' ..-.. �.-. LU m soca O SO .._.-_.- A >z Y �c wco m a0 0— x N w . 0 CL z� va a z V- o w � � N is < �.. O a �2a�vM b E Za CO Ca Q77 MU-M Ir7!c% QQ z [s a 8M N a N O eidm�� a� La m� o Z u- Cly cic-t Ca `�a.vvcm�c� U ��¢E-a w>-C7C�ad� � N QO»Na-N�� N rX WLL W cc(0 oW M �U`` $ ta � �C'1 2 in co � N �mQ FaMtiS cooIu'S V 0 -10 0tV=1 U 10"Z NN E .N.1 o �$Q t0 A � = ti (a -LU tL ti CU 0 N CL m N N V ri � N � � N V NN .N.1 m Q CD A N 0 N CL The Commonwealth of Massachusetts Department oflndusirialAccidents Office ofInvesiigations 600 Washington Street Boston, MA 02.111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/ContrcactorisXlectriciansfPlumbelrs .Apulicant Information Please Print Lesribly Name eO� ee,., d C s- Address:3 VJCa✓r es -,-a/c /?o City/State/Zip:_ 0 Phone #:, 9;r.5" 71 � / Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/orpart-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- ship and. have no employees working for mein any capacity. [No workers' comp. insurance required.] 3)��,I am a homeowner doing all work myself. [No workers' comp. insurance required.] t listed on the attached sheet. x These sub -contractors have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and wehave no employees. [No workers' comm. insurance reauired.1 Type ofproject (required): 6. ❑ New construction 7. ❑ Remodeling 8. Q Demolition 9. ❑ Building addition 10.Q Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.Q Roofrepairs ME] Other 'Any applicant that checks box61 must also fill outthe section below showingtheir workers' compensation policy information. 7 Homeowners who submit this affidavit indicating they ere doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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 thepolicy and job site information. Insurance Company Policy # or S elf -ins. Lic. #: Expiration Date: rob Site Address: City/State/Zip; Attach a copy of the workers' compensation policy tleclaration 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 civilpenalties 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 ceriffil uNfer tag pains andpenaldes ofperjury that the information provided above is true and correct. Phone#: Z "r- %/_�,/ O, ffccial use only. Do not write in this area, to be completed by city or town offrcial. City or Town:. Permit/License # Issuing Authority (circle one): 1. Board of Health 2. wilding 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. Pursuant to this statute, an employee is defined as "...everyperson in the service of another under any contract ofhire,- 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 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 shalliot because of suchemployment be deemed to be an employe" MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license orpermit to operate a business or to consiruct 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 beenpresented 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) andphonenumber(s) alongwiththeir 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. Iran LLC or LLP does have employees, a policy is required. 13 a advised that this affidavit may be submitted to the Depart . ment 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 thathas been officially stamped or marked by the city or town maybe provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each year. Where a homeowner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license orpermit to burn leaves etc) saidpersoa is NOTxequired to complete this affidavit. The Office of Investigations would like 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 anal fax number: The Commonwealth of MQssachvsotts Dep.ariuicat ofDidustdalAccidents offibe ofIu estig iQus 60G Waftgto a Street Boston? MA 021 X I TO, # 617-727,4900 at 406 ox 1-877,MASSAFE Revised 5-26-05 Fad # UW727-7249 TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT 1600 Osgood Street Building 20, Suite 2-36 North Andover, Massachusetts 01845 Gerald A. Brown Telephone (978) 688-9545 Inspector of Buildings HOMEOWNER -LICENSE EXEMPTION Fax (978) 688-9542 BUIDING PERMT APPLICATION Please print DATE: JOB LOCATION:_ 3 3- Number Street Address HOMEOWNER 7 (OA r - Name �9 Map/Lot dome Phone PRESENT MAILING ADDRESS �3 at,�,r Work Phone Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings to itivo units or less ant to allow such homeot,,�rers to engage as 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 , Persons) who Awns a parcel of land on which he/she resides or intends to reside, on which there is, oris intend be, a one or two family structures. A person who constructs more that one ed to considered a homeowner. home in a two-year period shall not be e The undersigned "homeowner" assumes responsibility for compliances with the State Building Code and other Applicable codes, by-laws, rules and regulations. 0''7F .fit/ ��y�. The undersigned "homeowner,, certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requiremen he/she will comply with said procedures and requirements, HOMEOWNERS SIGNATURE APPROVAL OF BUILDING Revised 7.2009 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 •\ 7B+ cW0AffE+ L2710FM1 LHV= Office Use only DEPARTMFIVTOF'PUBLK&IFM Pernift No. BOARD OF"FMPREYEM70NRE,GUTATIOA 55210 1Z�fJ0 9A4 Occupancy &Fees Checked PPUCATIONFOR PERMIT TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 )✓I�' /, — (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street � Owner or Tenant Owner's Address To the Inspector of Wires: Is this permit in conjunction with a building permit: Purpose of Building Yes © No El (Check Appropriate Box) Utility Authorization No. '977 Existing Service Amps / Volts Overhead Q Underground a No. of Meters New Service _� Amps 1Zj / 1/d Volts Overhead Underground No. of Meters 1 _ NL'�, -)of Feeders and Ampacity v Location and Nature of Proposed Electrical Work L✓ No. ofir.ighting Outlets No. of Hp( Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA ground ground No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets / No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total Pum s Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Heating Devices KW _ No.1�oryers Local Municipal Connections a Other No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER — OWNER'S llvStJRANCEWAIVER IamawatetltattheLrase tk>eamrX=amq aodthxrrrysigt=(ntwparnkTpfratiatwdiaesttztomererx (Please check one) Owner F7 Agent a Telephone No. 10 •r :• • •: J:n v. 1 •: • _ AIL Tel. Na m#rdbyMassxfase Ca ai PERMIT FEE $ �/