HomeMy WebLinkAboutBuilding Permit #564-2017 - 34 SAUNDERS STREET 11/23/2016 I BUILDING PERMIT F "oRTH
TOWN OF NORTH ANDOVER h�''` •=6 {
-
APPLICATION FOR PLAN EXAMINATION w
permit No#: ,5(gY-";L067 Date Received
7 ADRITED hQA,.(C
RSSACHUS��
Date Issuedj / ' a3 ' I
LVIPORTANT:Applicant must complete all items on this page
- 3 _ Crs
LOCATION, - _
Pnnf _ 1 DD Year Structurenn�_ ,Z®NINGtD1STRICT _.'HistonclDistncti yes:PAREL. . aeM e Sh �Uill ge_ yesachm op
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑Addition Vwo or more family ❑ Industrial
❑Alteration No. of units: 0 Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
emolition ❑ Other
ti
O Septic ❑ Well' -'' ❑ Flood'=lairi ❑Wetlands ❑Watershed District-,
❑,Water/Sewer. ._ - - -
DESC IPTION OF WORK TO BE PERFORMED:
LOQ vv�
Identific4tio - Plea e or Print Clearly
OWNER: Name: Z .n Phone: -2cD8'�8�3
Address:
•Contractor Name: Phone: .�. _ - -
Address - - -
Supervisor'ssConsfruction License# :Exp. Dateti�
Homellrnp oveentLicerise .- M Exp; Date K _ _
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.
.notal Project Cost: $ I ,. 0 00 FEE: $ ®'
Check No.: 30 9 Receipt No.. 3�
NOTE: Person4 contracting witli unregistered contractors do not have:access to the guaranty fund
Signature o _entLOwner Signature of contractor,
-t
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
IYPE 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 Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
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
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
COMMENTS
limension
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
®ANGER 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 Call Email
ate Time Contact Name
Doc.Building Permit Revised 2014
Building Department
artment
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
r . . i
Roofing, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
Li Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ 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
o Building Permit Application
o Certified Surveyed Plot Plan
Li Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o 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)
o Building Permit Application
❑ Certified Proposed Plot Plan
o Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Copy of Contract
o Mass check Energy Compliance Report
o Engineering Affidavits for Engineered products
40TE: 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 Revised 2014
Location SA v it kf--�
No. 5' +J - �U-17 Date i i - 13
• - TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $3
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check#
r � ?� Building Inspector
r 1 V NORTty -
W" '. . : . . 2 ; , At .c . : ver
0
No.
A Z
, h ver, Mass, - on ®�
coc NIc Ml WICK 1'
'OATED "'*' '(y
U BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
THIS CERTIFIES THAT ..,LY.. ,ft d.......CJ..fir. V �,,,,,,,,,,,,,, BUILDING INSPECTOR
has permission to erect .......................... buildings on .... ............�. ........ .. K Foundation
.Rx.rh-w f. .� Rough
tobe occupied as ...... ..... ... ....... ................................................... Chimney
provided that the person accepting this permit shall in every respect c form 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 CONSTRUCTIO T RT Rough
_,_ - __ Service
.. ... .. ....... .. . .................. .
..............
BUILDING. . . INSPECTOR. .. Final
GAS INSPECTOR
Occupancy Permit Required to Occupy Buildinz 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.
E KORTH 1 TOWN OF NORTH ANDOVER
° ''`I° OFFICE OF
BUILDING DEPARTMENT
+ :+ 120 Main Street
North Andover,Massachusetts 01845
,SSACHUs�t
Donald Belanger Telephone(978)688-9545
Inspector of Buildings Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
Building Permit Application
Please print
DATE:
JOB LOCATION: 3S— �C�,cJ✓��21�� S '
Number Street Address Map/Lot
HOMEOWNER ��1 ✓1 � �g '�n8'
Name Home Ph e Work Phone
PRESENT MAILING ADDRESS ::��a pr:qj
City Town State Zip Code
The current exemption for"homeowners"was extended to include owner occupied dwellings of one or two family
dwellings and to allow such homeowners to engage an individual for hire who does not possess a license, rop vided
that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns 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 dwelling,attached or detached structures accessory to such use and/or farm structures.A
person who constructs more than one home in a two-year period shall not be considered a homeowner. (780 CMR
Section I IO.R5.1.2)
The undersigned"homeowner"assumes responsibility for compliance with 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.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Revised 9/16
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
•,7'he Commonwealth of Massachusetts
"Department of IndustrialAccidents
~ r 1 Congress Street,Shite 100
3- tl ��A 021142017
F - oston,if
9�< www mass.gov/dia
Wa3:kersCompensation Insurance Affidavit:Bmilders/Co ��sMie ricians/Plnmbers.
TO BE FILED WITH TEE PE�T� ABlease Print Le 'til
A �licant Infor oration
✓1 J
Name(Business/Oigatiization&dividud): .
Address:
n2 LOU P� Phony#:
City/State/Zip:
Are you an employer?G7'eck the appropriate box:
Type of project(Tecluired);
em io es full and/or part-time)." 7. E]N&vW constriction
1.0 I am a employer with P y
2.E]I am asole proprietororparinership audhaveno employees Working forme in 8. E]Remodeling
arty capacity.[No workers'comp.insurance required.] 9. ❑Demolition
3.L?'a-la ahomeowner doing all work myself'[No workers'comp.insurance required.]t 10 Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property- I will p
I l.❑Electrical re airs or additions
ensrsethat all contractbis either have workers'compensation insurance or are sole Plumbin repairs or additions
proprietors with no engioyees. �•g~' • g
5.F1 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13•, Rbof repa7rs
Thesesub-contractors have employees and have workers'comp.insurance.t
14. ether
6.❑We are a corporation and its,offic6rs have exercised their right of exemption per MGL c.
152,§1(4),and We have no employees.[No workers'comp.insurance required]
*Anyappiicantthatchecksbb 41 must also fill.out the section below showingtheirworkers'compensationpolicyinfommation"
t Homeowners vrho submit•this affidavit mdtcaimg they are doing all work and then hire outside contractors must submit
a new affidavit indicating such
Contractors that check this tiok must attache additional sheet showing the name of the sub-contractors and state whether or not those entiq shave
must rovide their workers'comp.policy number.
empkoyees. If the sub contractors have employees,they p
X am an employer'that is providing7vorX�eNs'compensation inszcr�ance for°my employees. Below is the policy andjob site
information..
Insurance Company Name:
Expirationl)00'
Policy#or Self-ins.Lic.#:.
City/State/Zip:
Job Site Address:
Attach a copy of the woxkers' compensation policy declaration page(sho•wing the polzcy number and expiration date).
e by a ffib
Failure to secure coverage as required unde�realties i the form o5A is a f aaSSTOP W0�ORDERal-violation anda fine of up to $250.00 a
and/or one-year'imprisonment,as well as p
may be forwarded to the Office of Investigations of the DIA.for insurance
day against the violator.A copy of this statement
coverage,verification.
X do Hereby certify under'tliepains andpenaltres ofperjury that the information provided move s true and correct.
.• �Si ature;
Phone#:
Official use only. Do not Write in this area,to be completed by city Ortown offaciax
City,or Town'
Permit/License#
issuing AuthoYity(circle one): i
X.Board of Health 2.Building Department 3.Cityffown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.other
Phone#-
Contact Person•
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 d'efiued 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 trastee 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 to cal 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(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
Pleasb fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub=contractors)name(s),addresses)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 not required to carry workers'compensation insurance. If an LLC or LLP d6e's have
employees,a policy is required. Ba advised that this affidavit maybe 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 town that the application for the permit or license is being requested,not the Department of
Industrial-Accidenis. 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/Iicense 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 fature 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 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