HomeMy WebLinkAboutBuilding Permit #71 - 33 MAPLE AVENUE 7/24/2009v
Permit NO:
Date Issued:
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
11 IMPORTANT: Applicant must complete all items on this page 1
LOCAT
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PROPERTY OWNER_ *A
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MAP NO: PARCEL: ZONING DISTRICT Historic District yes
Machine Shoo Villaae ves
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One family
Addition /
Two or more family t-�
Industrial
Alteration
No. of units:
Commercial
Repair, replacement.
Assessory Bldg
Others:
Demolition
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
K TO BE PERFORMED:
OWNER: Name:
Identification Please Type or Print Clearly) / �, �" 0 —4-
, D
Phone
Address:
CONTRACTOR Name: Phone:
Address:
Supervisor's Construction License:
Home Improvement Licen
ARCHITECT/ENGINEER
Address:
Exp. Date:
. Date:
Phone:
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: $ � C>�� FEE: $ ,:�
Check No.:
Receipt No.: 7 —Z --'Z
NOTE: Persons contracting wAunregL
Wred contractors do not have access to the guaranty fund
Signature of Agent/Owner
Plans Submitted Pla s Wa
contractor I
Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/Massage/Body Art
Swimming Pools
Well
Tobacco Sales
Food Packaging/Sales
Privafe-(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 Reviewed on Signature
COMMENTS
h
ZoniAg 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
FIRE DEPARTMENT - Temp Dumpster on,site yes no
Located at 124 Main Street;
Fire Department signature/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.$100-$1000 fine
NOTES and DATA — (For department use
❑ Notified for pickup - Date
Doc:.Building Permit Revised 2008
"BBuilding 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
Doe: Doc.Building Permit Revised 2008
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TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
1600 Osgood Street Building 20, Suite 2-36
North Andover, Massachusetts 01845
Gerald A Brown
InspecW of Buildings
HOMEOWNER LICENSE EXEMPTION
Please aril
DATE: ,LL-�-o%
JOB LOCATION:
Street Address
PRESENT MAILING ADDRESS
Telephone (978) 688-9545
Fax (978) 688-9542
�b7�57J
Work Phone
City Town Stm Zip Code
The eureerit memPWn for "homeownerb" was wMerded to iudu& oWnEr-xupied dwellings to two units or less
and to allow snch homeowners to engage an individual for hire who does not possess a license, provided that the
owner acts as supervisor). State Building (Code tion 108.3.5.1) .
DEFINITION OF HOMEOWNER .
Person(s) who owns a parcel of Ind 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"pspmm responsilAlit for conqfliances with the State Building Code and otherAphelicable m1m by rules and regalatim
The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department
inTmbon P and Gramm ments and that he/she will comply with said procedures and
HOMEOWNERS
APPROVAL OF BUILDING OFFICIAL
Rid 10.2005
Fam Homoo m Exemption
130ARD OF TPEALS E99-9541 CONSERV-MON Egg -953 TiE.lLT1i /;xg-9540
PLANNING bKg-9535
The Commonwealth of Massachusetts
kj
1k.
DePartment of Industrial Accidents
Office of Investigations
.
sl r
°pt
600 Nlashirceton Street
9aBoston,
`r
MA 02111
} www mums gov/dia .
Workers' Compensation Insitrance Affidavit: Builders/Contractors/E1ectriciattstpiambers
A Iicant Information
Please Print LeQibl
Name (Business Cthwizationllndividual):
Address:
City
Phone
-----------------
Are yo�,R, mployer? Cb=k.the appropriate boz:
1.[]F employer with
4. ❑ I am a general contractor and I Type prole (regnrr.
employees (full and/or part-time).*
2. ❑
issue Dred the ss[frcosstractors 6 ❑Naw construction .
I sill .a.sole proprietor or partner-
ship and have no employees'
listed on the attached sheet 7. ❑ Remodeling
These su&contractoss have 8. Q Demolition
workingfor mem any capacity.
atri
[No workers' comp., insurance,.
workers' comp. insurance.
5. ❑ We arc a corporation and its 9' Q Building addition
required.]officers
3. I illi a homeowner doing all work
have exercised their 10.0 Electrical repairs or additions
right of exemptionper MGL 11 -El PIumbing repairs
myseIt [No -workers' comp.
insurance fired, t
�N ]
or additions
c, 152, § 1(4), and -we have no 12.❑ Roof repairs
.employee;s. [No workers'
WIMP. insurance required ] I3.❑.Other
*ArY aPPli=M that checks bo)t # l must also fill out the section below showing theirworkers' compensation Policy information
i liomeown* who submit this affidavh indicating
mpetisconmi
they are doing an work and then hire outside tors
- 4Contracton; that check this box mustatiscbed an additional sheer she must submit a new affidavit indicating such.
wire the name of the sub-concraetors and their
workers' cat.c. Rcli� irf ah„n
� � :� er�saiyer tFrat is proviaurg:workers' comperrsmtiori insurance for nry. empoyees: Blow is the -- _-----
inforrrratlom lpolio!' cud job site .
Insurance Company Name:
Policy # or Self -ins. Lic. #:
Expiration Date:
--------------
Job Site Address:
City/State2ip:
Attach a copy of the workers' 'compensatiom policy declarationshowia
page ( ab 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
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOpenahies of a
P WORK ORDER and a fine
of up to $250.00 a day against. the violator. Be advised tat ha copy of this statement may be forwarded to the Office of
Investigations of thePIA for insurance coverage verification.
! c"undirtheopaiwd penalties of perjury that the in orrnation Pr '
f p luded above is trae and corred
Si tur'e..
Date:
Phone #:
Eof
only. Do not write in this area, to he conrple gl, by �Y or town. official
n: Permit/License #
hority (circle one):
Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
son: Phone #.
Information a nd Instructions
Massachusetts General Laws chapter 152 requires all emp 3 oyers 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." r `
An enrlayer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the'fomgoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver ortrvstee•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 shat not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state ow- local licensing agency sw withhold the issuance or
renewal of license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence -of compiiance with the insurance coverage required."
Additionally, MOL chapter 152, §25C(7) states `Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public worse until- acceptable evidence of compliI with the insurance
requirements of this chapter have been presented to the coritracting aufhority."
Applicants
Please, fill out the workers' compensation• affidavit compicn-tely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es): at7d 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 orpariners, are not required,to carry workers' cc rnpensafion insurance. Ifan LLC or LLP does have
employees, a policy is require. 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 t"m that the .application for the permit or license is being requested, notthe Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
oompensation policy, please call the Departanent at the number listed below. Self-insured eorizpani- should enter their
self-insurance'iicanse number on dw'appropriate tine.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department hiss 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 appli=t.
Please be sure to fill in the permit/license number which w-ilI be used asa 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 (cityor
town)." A copy of -the affidavit that has been officiaily starnped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file fur fsitare 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 flog license or permit to bum leaves etc.) said person is NOT.reyuired to complete this affidavit
The Office of Investigations would dike 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.
The Commonwealth of Massachusetts
DepaMment of Industrial Accidents
Office of Investiptions
600 Washington Street
Basfon, MA 02111
TeL # 617-72.7-4900 Ext 406 or 1-977-MASSAFE
Fax # 617-727-774
Revised 5 -26 -QS w'w'w'mass.gov/dia
Location
C
No. Date �� •� ?
TOWN OF NORTH ANDOVER
p
Certificate of Occupancy $
��S'•""'t�'
Building/Frame /Frame Permit Fee $
s+cMust 9
Foundation Permit Fee $
or
Other Permit Fee $
TOTAL $
Check #
22246
Building Inspector