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HomeMy WebLinkAboutBuilding Permit #412 - 34 CHURCH STREET 1/6/2009 r10RTF/ BUILDING PERMIT Olt "O o h TOWN OF NORTH ANDOVER cr '° �°„, APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received T.o �SSACH�1`��� Date Issued: _ ` IMPORTANT: Applicant must complete all items on this page LOCATION jZ A 3`4 Print PROPERTY OWNER <fZoz— €�E 3oN wH�r r,,, -ca � , Pt�i+r� Mc•:.�C2��� t Print MAP NO: y Z PARCEL: ZONING DISTRICT: Historic District no Machine Shop Villageyes no 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 ssessory Others: Demolition Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: a Pty 2© P rz� ram Z;:yz-7 oc,(Z4 Ck� Identification Please Type or Print Clearly) OWNER: Name: iEF� mc, Phone: Z'11a -'f7Co Address: ,a �--\-\y CZ`N 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: $ i I00 C, • FEE: $ CS Check No.: /n-1— Receipt No,;27 :2 ?,,?- NOTE: Persons contracting with unregistered contractors do not have accessT guaranty fund Signature of Agent/OwnerSignature of contractor Location No. Date NORTh TOWN OF NORTH ANDOVER 1- 9 • ; ; Certificate of Occupancy $ + O ...• 4 � I Building/Frame/Frame Permit Fee $ swcHust 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # Building Inspector Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPEOF 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS l .> t CONSERVATION Reviewed on / 0 Signature) Y.U-7,�—p COMMENTS Lo 11i Al J-zn��� 1 i J ' HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments i Conservation Decision: Comments t Water& Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT -Temp Durnpster 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 t ❑ 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 o 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:Building Permit Application Revised 2.2008 MORTM TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT +` 1600 Osgood Street Building 20, Suite 2-36 •�+ne � North Andover,Massachusetts 01845 SSACNUst� Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION Please pdpt DATE: ' �-- 15 ' 6 70B LOCATION: �2_ _ 3`A C kAO CLC\-A SS Z Number Street Address Map/Lot HOMEOWNERC— gtRl781 - yG5-ct(ocj Name Home Phone Work Phone PRESENT MAILING ADDRESS Z A C-A y R sH ST (moo • l� Npbv C<L N� .A G1�'1 S City Town State 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 Person(s)who owns a parcel of land on which helshe resides or intends to reside,on which there is,or is intended to be,a one or two family structures. A person who constricts more that one home in a two-year period shall not be considered a homeowner. The undersigned"homeowner"assumes responsibility for compliances with the State Building Code and other Applicable codes,by-laws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. ,� C HOMEOWNERS SIGNATURE �� L � ,CCT J n APPROVAL OF BUILDING OFFICIAL Revised 10.2005 Fame Honv ownmts Exemption TIOARD OF \PPEA1.S 6XK-9541 CONSERVATION 688-9530 ITEAL11i 688-9540 PL.L\KING 688-9535 The Commonwealth of Massachusetts Department of 1-ndustrial Accidents K; e D Office of.fnvestiQ600W mshinaton Street -' Boston, MA 02111 :- www'.nzass.gov/die Workers' Compensation Insurance.Affic}avit: guilders/Contractors/Electricians/Plumbers APPlicant Information Please. Print Legibly Name (Business/Organization/individual): Address:_ Z C u CL City/State/Zip: WO fl t, O 6"J_ 1,,t A 0 �''Phone#: q Are you an employer?Check the appropriate box: 1•❑ I am a employer with 4. ❑ I am a to A Type of project(required): ..neral contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.❑ I am a sole proprietor or partner- listed ori the attached sheet 7. ❑ RcmodeIing ship and have no employees These sub-contractors have working for in an capacity. workers S. ❑ Demolition g Y P t'• ' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its 9. Building addition equired-] officers have exercised.their 10.'[1Electrical repairs or additions ``\\ 3 am a homeowner doing all work right of exemption per MGL 11. Plumbi Q A / myself [No workers' comp. C. 152, §1(4),and we have no ❑ na reg or additions insurance required.] f employees. [No workers' 12.❑ Roof repairs comp. insurance required.] 1.3kfTOther/icc-osso(�,; E n `Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit•ibis affidavit indicating they art;a Gir:_ _v t;: $Convectors that check this box must attached an additional shwt showing the A"r'him outside eontrac(ors"'us'submit x ncu-affidavit irdi�nn�such. elite c• he sub-con—.actors and their workers'comp,poi icy information. I am an employer that is providing, workers'compensation insurancefor ,e Ptoinformation. yees. Below is the Policy andIob site Insurance Company Name: Policy#or Self-.ins. Lic.9: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration datel. Failure to secure coverage as required under Section 25A of MGL c. 152 can Iead 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 in e. to 5250.00 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 herebjj certify under the pains and penalties of perjury tfzat the information provided above is true and correct + Siortature: lC_ `Pc --�5 that �Z ( � Phone#: 7 56— LS _ Ff onlp. Do not write in this area, to be completed by city or town official n: Permit/License 4 hority(circle one): Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector son: Phone t": 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 d--ceased 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 m r local licensing agency shall withhold the issuance or renewal of a license or permitto operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptabie evidence o.f 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 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 compi-etely,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 Liabiiity Partnerships(LLP)with no employees other than the members or partners,are not required to cant' workers'compensation insurance. If an.LLC or LLP does have - employees, a policy is required. Be advised that this afiiclavit maybe submitted to the Deparnnent 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 re_-'zrding the-iaw or if you are required to obtain a workers' compensation policy,please call the Department at the nmmbzr.lis+.ed below Self insw,:d 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 permitricense number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in arty 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 a(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 Iicenses. A new affidavit must be filled out each year. VVhem a home owner or citizen is obtaining a license or permit not related to an),business or commercial venue (i.e. a dog license or permit to burnleaves etc.)said person is NOT required 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 and fax number: The Commonwealth of Massachusetts Department of Lridust ial Accidents Office of Investigations Y 600 Wast-ington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-977-MASSA-FE Revised $-26=05 Fax#617-727-7749 WWW'Mass.gov/dia NORTK 0 Of 6 Andover , No. �` over, Mass.p_/ o o d > COCMICKEWICK �1. RATED vv `` BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR 31 - .4ko.3. . ...... ............ .THIS CERTIFIES THAT.... ........ ... ........ .h4 Foundation has permission to erect.. ......... buildings on .. ... ...... ..... .v*.4.`.a.......0'7T ..... Rough to be occupied as........ X ....5. .... ....................................................................................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final 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 3 V PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONS TR ST S Rough Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. SEE REVERSE SIDE Smoke Det. NAV AIAX we ' et CROSS I I . 5TREl1 r f I n/\RFDrr ft. . - 51.. LrXU-Pf?C_RJ