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Home My WebLink AboutBuilding Permit #561-15 - 340 JOHNSON STREET 12/16/2014 BUILDING PERMITSr1QRTFr w- O� t I.ED /6 q-rO •r yF.;. •A'• 6 O TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION71 h Permit No#:6�z'l1 Date Received4 reo y ISSA11 CHUS� Date IssU1d AZI40�RTA�NT: pplicant must complete all items on this page LOCATION Prin _ PROPERTY OWNER, � � CCC �0 Year Structure es no Print Y MAP PARCEL:_'' l�ZONING DISTRICT: Historic District yes no Machine Shop Village yes no I TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 'A One family ❑Addition [I Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ,4 Repair, replacement ❑Assessory Bldg ❑ Others: x Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/S_ ewer DESCRIPTION OF WORK TO BE PERFORMED: �6-Alohe2 Ir'T�itE�J� Identification- Please Type or Print Clearly OWNER: Name: nllofu ee Phone: 7f- 6 -We)0 Cu� Address: 3 U JOHNfUti 7 /V� ✓f'�? rJ��'SSS Contractor Name: Phone: - - Address: Supervisor's Construction Licenser Exp. Date: Home Improvement License: _ Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF TH TAL ESTIMATED COST/BASED ON$125.00 PER S.F. Total Project Cost: $ EE: $ Check No.: J Z— Receipt No.: NOTE: Persons contracting wt n ntract rs o n t h v a c s to he guaranty fund Signature of Agent/Owne Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TyPF'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 IPlanning 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 Call Email Date Time Contact Name Doc.Building Pen-nit 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 ❑ 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 Revised 2014 Location ?VD ()� ,,��P, No. �1 ^ Date/ �6 A4 r . - TOWN OF NORTH ANDOVER Certificate of Occupancy $ izrBuilding/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ i Check# 7P_2 Building Inspector r 1 ,� �yORTtIy _ . W1 . idover No. 14 le ' Z tilm�_ Le A ver, Mass, N' _7biq C O[HIc"awtCM y1. 'x,95 R�reo ?QP��S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ............. . .. ........ ... �. .�. .................. ....... BUILDING INSPECTOR has permission to erect ......... buildings onFoundation .... ... ... . .. .. .. ............. . 5...... . .. . t.. .T.N . .�. Rough tobe occupied as .................. .. ... .. ...................................................... Chimney provided that the person accepting this permit shall in every respect conform 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MO HS ELECTRICAL INSPECTOR UNLESS CONSTRUC RTS Rough (( Coo 000W Service ............ .............. ....................................... Final BUILDING INSPECTOR 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. The Commonwealth ofMassachusetts - -• Department of Xndrxst i ZAccidents . _ Offlee ofInvestigations 600 Washington Street Boston,.MA 02111 www massgov/iia • orkers' Compensation bsurance Affidavit:Builders/Contrcactorsl-let icxaan IPIn�mbex' A liean�Xnforma�.on Please Print Ire bl Name(Businesslorganizationft&'vidud): /) Address-,3LD �D Nf d�� ,q7`• City/StatelZip: Phone — Are you an employer?Check the appropriate box: Type of project(required): ed): 1.[I I am a exnployex with 4. ❑ I am a general contractor and I 6. Q New construction _______ have hired the sub-contractors employees(fall and/orpart time). �. Remodeling 2.KI am a sole proprietor OrPartner' listed on the attached sheet,r ship and have,no employees These sub-contractors have 8. [(Demolition workers'comp.insurance. 9. 0 Building addition working forma in any capacity. [No workers' comp.zCe 5, Q we are a corporation audits 10.p Eleciricalxepairs or additions xecluix'ed.] officers have exexcisedtheir all work right of exemption por MGL Il.[]plmbingrepairs or additions 3111 am a homeowner doing c.152,§1(4),and we haven 12,[]Roof repairs mysekf.[Nb workers comp. employees.Wo workers' insurancerevired.]i l3.[]Other comp.insurance required.] XAny applicant that checks box#1 must also fill outthe section below showing their wbrkers'compensationpolicy information. i Homeowners who submit this affidavit indicatingthey�doing allworlc and then hire outside contractors must submit a new affidavit indicating such, Tcontractors that cheAthis boas must attached an additional sheet showing the name of the sub-contractors and their workers'comp.Dolicy information. jam an employer that is.providing workers'compensation insurance for my employees: Below is therolicy anti jail site information. Insurance CompanyName:. Expiration Date.' Policy#or S elf-ns.Lic.#: . CitylState/Zip: ' lob Site Address: Attach.a copy of the workers'compensationlpolicy declaration page(showing the policy number and expiration date). imposition of criminal penalties of a Failure to secure coverage as xecluixed under Se ent as5A of weltas�c vil penaltiGL o.152 esinin ethe formad to s f a STOP WORK ORDER.and a fine fine up to$1,500.00 andlox one-year imprisonment, of up to$250.00 a day agains violator. e advised that a copy of this statement maybe forwardedto the Office of Investigations ofthe D ox' vexage verification. X d0 IZereby eel /anclpenaltces of jleYju tr2at tlae infOYmat�On pYOviflecl aloveS tPlle and COYYeCt. Date: Si ature- Phow 71 Official use only. Do not write in Mis area,to be cow pleted by city or town official. Cit or Town: Permif/License# issuing A.uthority(circle one): ent 3.City/Iowa Clerl>? 4.Electrical Inspector 5.PlnmbivagXnspecto 1.Board of Health 2.Building Departmr° 6.Other - • Phone U. 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 orimplied,oral orwritten:' An employer is defined as"an individual,partnership,association,corporation or other legal entity,or anytwo ormore of the foregoing engaged in a joint enterprise,and including the legal representatives of wdeceased 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 or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a tousmess or to construct buildings in the commonwealth for any applicant who has not produced.a.eceptable evidence of compliance with the insurance coverage rewired:' Additionally,MGL chapter 152,§25C(7)states`Walther the commonwealth nor any of its political sub"ions shall entery into any contract#br the performance of public work until acceptable evidence of ccmpranc e with the insurance e requirements of this chapter have been presented 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)and phonenumber(s)along with theircertifxcate(s)of Insurance.' Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other thaft the members or partners,are notrequired to carry workers'compensation.insurance. If an LL C orLLP does have employees,apol ayis required. Do advised that this affidavit may be submitted to the Department of industrial Accidents fo;confi oration of insurance coverage. Also be sure to sign and date the afffdaAt. he affidavit should be retumedto the city or town thatthe application for thepermit 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 andprinted legibly. The Departmenthas provided a space atthe bottom of the affidavit for you to fill out iu the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number whichwill 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(ifnecessary)and under"3ob Site Address"the applicant shouldwrite"all locations in (city or town)."A copy of the afff davit 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. Anew affidavit m ust be filled out each year.viVhere a homeowner or citizen is obtaining a license ox permit not related to any business or commercial venture (i.e.a dog license orpermit to bura leaves etc)said person.is NOTrequixed 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: no CQMIAOUW.ealthofMromachmot.� Departwout o f du al Accldouts (Moe,ofTuVortgaMM& X00 w*gM float TO,#617-7-2,7_4. 00 at 406 or I-877:MASSA Revised 5-26-05 Fax#617-727-7749 '4vw4v.�71�,g4v�t�2 TOS'OFNOR'H ANDOVER OMICE OB • ' Q ,� 16000sgoadStreet Building20,-Suite 236 N•orthAndaver,Massaabnsetts 01845 RCaus . Gerald A.Brown Telephone(978)688-9545 IuspectorofBadings Fax (978)689-9542 HOMEOWNER LIMNSE PXEW TION ' BUIDING PFPMT Aj pLIOAT`ION Pleaseprmt • DATE: ro-B LOCATION, 3 6 • ' Jo � Number 8freetAddress Map/Lot . I�OMEOWNBR All"VlCcYal 17F _ — �� aSZs7F Ff— qV0 Name• Home Phone WorkPhone -' ,SENT MA6NG ADDRP-SSj L10 U. j all ' 7iP The current exempfion for"homeownexs"was extended to i chideowner occupied fp allow 5�ic �ipg7Pp„�- - dtvelli gg to two units•oX legs and acts as s ue�s�o engage aa?�r"d�}Qlsal•forhire Who does no-tpossms a 7icemse,provided that the otter npbzudsor). MoDuilding (Code&Gc on DEFINITION OIi HOMEOWNER. Persons)who awns aparcel of land on which he/she resines or intends to reside,on which there is,or is intended to + be,si one or two Family structures. A person who constmots more that-One home in a twoyearpmi d shall not be considered a honteownez; _ , The undersigned`K()Medwner”assumes responsibiIi forcom ' a tY Olt aces with the 8 teBuildin Code .A.pplicable codes by-laws, g and other ,y ,rules andxegulattons, t • The undersigned:'hO nepwner"certi i-es that he/s d ' minimum inspection procedures and require n North AndoverBuilding Department requirements, °mplY with,said procedures and x�o�ozzs SrGI�TA , APPROVAL OF BIITLD)NG OFFICIAL Revised 7.2009 Form T�omeowners Fixempfion r Y; '13DARD OF APPEALS 688-954I CONSERVATION 688-9530 . IEALTH 688-9540 PLANNING M p;s;