HomeMy WebLinkAboutBuilding Permit #625-2017 - 34 SAUNDERS STREET 12/8/2016BUILDING PERMIT
A11 _` TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXA� ' MINATION'
PermitNo#: Date Received
Date Issued:
LWORTANT: Applicant must complete all items on this page
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
0 New Building
`LOCATIONS
0 Addition
Erl wo or more family
0 Industrial
WN K__
6
0 Commercial
—0
11 Repair, replacement
0 Assessory Bldg
0 Others:
Demolition
.10 r, re yes.no
_y.'yea
PARCEL:. 0-V
ZONING DIST
ri., ri
*6:4
Yps no
a6fi6! -villa e
ih*
1p- no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
0 New Building
9e ami y
00�family
0 Addition
Erl wo or more family
0 Industrial
Alteration
No. of units:
0 Commercial
—0
11 Repair, replacement
0 Assessory Bldg
0 Others:
Demolition
0 Other
osb�pic veI
Flo6dplainWetlah 8
0 Watershed b"is ri 6f
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Identification - Please Type or Print Clearly
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OWNER: Name: CL
Address: � 11�_Unottrs
Cdritrpabtof, Ndffie; P.,-hbhe
Address:
Supervisor'si q- �e Exp- Dater,
Coh��trubfibnLiq_
H-E)Me Improvement icense E-xp,, potei.,
ARCHITECT/ENGINEER Phone:
* +- 1; UJ ^ -1 'root.–
oto 4^1^
one:
Address: Reg. No.
'FEE SCHEDULE. BULDINGPERMIT.' $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
total Project Cost:$ 1060 FEE: $
Check No.: 313 Receipt No..,, 313 17
NOTE: Persons contracting wit unregistered contractors do not have. access to the guaranty fund
Signature d contractor;-
Plans Submitted ❑
Plans Waived 0 Certified Piot Plan ❑ Stamped Plans ❑
iYPE'bF SEWERAGE DISPOSAL
Public Sewer ❑
Tanuing/MassageBody Art ❑
Swi r'a'ng 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
COMMENTS
Signature
CONSERVATION Reviewed on Signature
COMMENTS
IAEALTH_ Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Punning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Locatea 6M usgooq Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 MainStreet ;
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, roast or service drop requires approval of
Electrical Inspector lies No
®ANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
Doc.Building Permit Revised 2014
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/Cross Section/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
o Photo of H.I.C. And C.S.L. Licenses
a Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy o CCo! Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
DOTE: 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
-7 1( 4 Q-4
Location U
No. �r I o / -7 Date 4- C,
Check# 3 / �;
TOWN OF NORTH ANDOVER
Certificate of Occupancy
Building/Frame Permit Fee $
Foundation Permit Fee
Other Permit Fee
TOTAL
Building Inspector
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Donald Belanger
Inspector of Buildings
Please print
DATE: I l�
TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
120 Main Street
North Andover, Massachusetts 01845
HOMEOWNER LICENSE EXEMPTION
Building Permit Application
Telephone (978) 688-9545
Fax (978) 688-9542
JOB LOCATION: + �)Or, VNd_,R -_s
Number Street Address Map/Lot
HOMEOWNER
�n
- Z 99--)-273
Name' -1 Horne Phone Work Phone
PRESENT MAILING ADDRESS :�>S 3ayn d -z -✓S s A-�,,ee,
�-4 a r -I -k A ramu eI
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 regte f nts and that he/she will comply with said procedures and
requirements. 'I
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
The Commonwealth of Massaekllsefis
Department of IndustrfalAceldents
1 Cong-ress Street, Sulte 100
Boston, MA 02114-2017
www massgov/dra
Compeaiion Insurance Affidavit: Builders/Conixactors/Electriciaus/�lumbers.
TO BE FILED WITII TEE PERWHrl NG .A U ORIF .
bl..n nn Prtini'
NaMG (Business/Orgariizationllndividual):
� � 5Qz V-\
Address.__35
n �y� M A Phone #: `
City/State/ZiP:_,q l4
Axe mChkthe appropriate box:youane
1. Q I am a employer with employees (full and/or part-time),*
2•❑ I am asole proprietor or partnership andhaveno employees Working forme in
capacity. [Noworkers' comp. insurance required.]
'
3. I am a homeowner doing all work myself [No workers' comp. insurance required.]
4.❑I am a homeowner and will be hiring contractors to conduct all work onmy property. I will
ensureher have workers' compensation insurance or are sole
that all contractors eit
proprietors with no employees.
comp. fiO
S.❑ I am a general coniiactor and I have hired the sub -contractors listed onthe attached sheet.
These sub -contractors have employees and have workers' raaco-�
6. Q We are a corporation and its. oft i0drs•have exercisedtheir right of exemption per MGL c.
1 4 and ive have no empldyees. [No workers' comp. insurance required-]
g Za g �g i 3
Type of project (xecluirecd.);
7. ❑ Nevi'd'onsfruciion
8. 0 Remodeling
9. ❑ Demolition
10 Building addition
11.❑ Electrical repairs or additions
12. UPlu—mbing repairs or additions
134] Rbof repairs
14.M Other
*tiny applicant that chgcks boxV1 must also fill o heare s doing aIl work pd then hire outsidecontra oors molicy ust subfmit a new affidavit indicating such.
T Homeowners who submit•this affidavit indicating Y
TContractors that checkthis box the n
h�attachedcn �'II3 s provide thea workers' comp policamo of the y naunber.�d e whether ornotfhose entifies have
employees. Ifthe sub-contractorsemployees,
Xam an employer tliatisprovidingworkers' compensation insurancefor my employees. $elow is tliepolicy aridJah site
information.
Insurance Company
Policy # or Self -ins. LiG. #:
BxTirationDate__
City/State/Zip:
Job Site Address:
Attach a copy of the workers' compensation policy, declaration page (showing the policy number and expiration date)*
as re uired under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00
Failure to secure coverageq
and/or one-year imprisonment; as well as civilpenalties
be forwarded to the Office O � ORDER a of the DIA for i asuran 0 a
day against the violator. A copy of Ibis statementY
coverage veri.uc
.ado hereby
thepains andpenalties ofperjury that tine information provided above is true ant curl
07_1�
official zcse only. Do not write in this area, to he completed by city or town offzciaL
• Permii/Eicense #
City or Town-
sgAuthariiy (crcle one): ector
[s1. Board u health iBuilding Department 3. CitylZ�own Clerk 4. Electrical Inspector 5. Plumbing xnsp
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 defuied as "an individual; partnership, association, corporation or other Iegal 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 ofths
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 b6 deemed to be an employer."
MGI, 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 buildiugs in the commonwealth for any
applicafttwho Inas not produced -acceptable evidence of compliance with the insurance coverage req'ui'red:'
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 mb'contractor(s) name(s), address(es) andphone 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 does have
employees, a policy is required. be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation ofinsurance 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 wrorkers'
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 EU 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 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 notrelated to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT requited 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-I5 wwwmass.gov/dia