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Home My WebLink AboutBuilding Permit #354-14 - 35 OLD FARM ROAD 10/15/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: — Date Received I '� Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION '35 G L P FA&M. go,4P Print PROPERTY OWNER JA r1 i E ll _D$V I D bO` tJ Print 100 Year Old Structure yes MAP NO: PARCEL ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Resiplential Non- Residential ❑ New Building One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial M"Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: 310, 4 ., AL (,--,pluca roup Identification PI ase Type or Print Clearly) OWNER: Name: "DAVID S, b4c wz Phone: 9-4-9 Address: 3 S OLIO F44-2wI ROAD kmTH 6tlPwr-li ISA 6 l Q(05- 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: X00. d)a FEE: $ Check No.: Receipt No.: NOTE: Person cont ct' 'th uQnre i:�7 c tractors do not have access to the aranty fund Signature of Agent/Ow r �+'0 Sig nature of contractor I Plans Submitted L� P Certified Plot Plan ❑ Stamped Plans ❑ Plans Submitted-0 Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYP&0E-;SEWTRACrEDISPOSAL" Public Sewer ❑ Tanning/Massage/BodyArt ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc.. ❑ Permanent Dempster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED: DATE.APPROVED PLANNING & DEVELOPMENT? ❑ ❑ COMMENTS CONSERVATION Reviewed on Siqnature 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 Tow;z Engineer: Signature: Located 384 Osgood Street _ FIRE DEPARTMEIVT - Teriip Dempster on site yes no Located-at 124 Mair Street Fire Departineritsignature/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 2010 Building Department The foliowing is a list of the required forms to be filled out-for the appropriate.permit to be obtained. Roofh,g, 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 ConstructionSin le and Two Family) � 9 Y) ❑ 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 apw-al 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 2012 . Location No. Date • - TOWN OF NORTH ANDOVER • 4 "fLED • Certificate of Occupancy $_�� Building/Frame Permit Fee Foundation Permit Fee $; Other Permit Fee $ TOTAL $ Check# Ui ing Inspector i � NORTIi Town of o . - .:;. No. n0 � .� ver, Mass, .Q Coc"1041WI[K 1' �•9 Q°p�ren �P��,��(5 S l] BOARD OF HEALTH Food/Kitchen PER IT T LD Septic System THIS CERTIFIES THAT ............ I& r.........6rvW.V%. M ,,,,,,,,,,,,,,,,, BUILDING INSPECTOR E has permission to erect .......................... buildings on ... ......6 ...4kroft. ...,,�/ ..... , Foundation Rough to be occupied as ............. ... ............:"r.......:�.�.�i.IR.. .......�............................. Chimney provided that the person accepting is permit shall in every respect con) m 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 I UNLESS CONSTRUCTI ST S Rough Service ............... .. .................... ................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. TgMW OF INTO RT$ANDOVER - �{ OFFICE OF * BUILDING DEPART MENT ` o, R�•°° '1600 Osgood Street Building 20,-Suite,2-36 North Andover, �Act�us�. Massachusetts 01845 Gerald A.Brown Inspector of Buildings Telephone(97g)688-9545 MAMOWNER-LICENSE EXEMPTION Fax (978)688-9542 BIDING PFRMIT APPLICATION Please print DATE: IO 15 ! 2013' ' JOB LOCATION: 255 OLb FARW` {�olkl7 Number Street Address OWNER DA - MapJLot 1J0 ' v-1v S. 6o..Owff ��g-�qY- too Name. Home Phone Work Phone PRESENT MAILING.A_DDRESS 35- AD N p A TA f4kpovex I'✓l ►� Ci �To,r,,, �I $ ��' • • State. zip Code The current exemption for"homeowners"was extended to include owner-occ to allow subb homeo;niers to engage an indivSdual.for hire who doupied dwelings to two units or less and es not possess a license,provided That the owner acts as supervisor). State Building (Code Section 108.3.5.1) DEFINITION OFHOMEovrNER Persons)who gwns aparceI of land on which he/she resides or intends to resid be, one or two fown structures. A person who co structures. e,on which there is,oris intended to conssidered a homeowner. nstmore that one home in a two-yearperiod shall not be The undersigned"homeowner"assumes responsibility for compliances with the State Building Code and Applicable codes,by-laws,rules and regulations• g other The undersigned"homeowner"cert that he/she and minimum inspection proceduresjlacl.rp• ds the Town of North Andover Building Department requirements, and that he/she 'lI comply with,said procedures and HOMEOWN$RS SIGNATURE _ I APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption ''BOARD OF APPEALS 688-9541CO1\SEr TATION RZ 688-9530 HEALTH 688-9540 PLANNING 688-9535 The Commonwealth of Massachusetts - Department of lndustrlgl Accidents Ofj ice of Investigations 600 Washington Street Boston,MA 02111 www.nmssgov/dia Workers' Compensation Insurance Affidavit:Builders/ContractorslEIectritcians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/In dividual : DRV-ZD S 69,OW t� Address: 3 S O L"O City/State/Zip: N��c r� l��D0� (�- R11- Shona#: M- 79 - a0y 1 d Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have Hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.x 7. ❑Remodeling ship and'have no employees These sub-contractors have S. ❑Demolition working for me in any capacity. workers'comp.insurance, g, ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.El Electrical repairs or additions required.] officers have exercised their 3.[ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.%Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] 1 . 1311Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they die doing all work and then hire outside contractors must submit anew affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy andjob site information. Insurance Company Name:. Policy 4 or Self-ins.Lic.#: ExpirationDate: Job Site Address: r City/State/Zip: Attach a.copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c.152 can lead 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 of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby c rti un r p s anrlpe alties ofperjury that the information provided abov is true and'correct, - Signature: Date: 10 1 sr 2013 Phone 4: q S- 77q` a Oo 1 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: Information and ffustructi®n's 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 ofhire, 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 ofthe foregoing engaged in a joint enterprise,and including the legal representatives of a deceased Y emP 10 er 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 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 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 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 does have employees,a policy is required. Be 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 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-andrioted legiblY. TLdDepartrrient Hs'pfo-Vided a sac—e- a— tthebotfom' 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/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 not related to any business or commercial venture (i.e.a dog license orpermit to bum leaves 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: `aha Commonmatth of mfassarhuseutts - Dopartment offadustdal Accidents Offtce ofJAVestigatiol 600 Wasbi. gtoxi 8ttect Boston}M&02111 • �`e�,#6Z7�727-4�Qp e�.t406 ox�-S??:I�AS�.A�`.� Revised 5-26-05 Fay#617-727-7749