HomeMy WebLinkAboutBuilding Permit #646-2017 - 35 OLD FARM ROAD 12/16/2016Al�
,�A_oAd.1 _N �,BUILDING PERMIT
O ' TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#:Date Received 1
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
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septic 1Nell�
D Floodplain n V1/etlards
:-
0 Watershed District .
V1/ater/Sewers. ..�4`�
-
DESCKIP] 1UN Ut- VVUKM 1 U br- rtKrUKivlCv:
OWNER: Name: J� u
Pleare Type or print Clearly' q - L'
a %,L'i 9 ro� Phone: T W� 4
Arlrlracc• 3foW /fi dct�
Contractor Name:.. _._ _ _
Phone_
Address: ....,. - - .._'S;.�•Y:. �.. --
SupenJiso�'s Construction;License: _ Exp:?Date
Home.lmprovemerit License: Exp: xDate:
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.
1_,__ Total Project Cost: $ 14, '0°' 0 FEE: $
Check No.: � � Receipt No., /3
NOTE: Rersons c9ntracting with unregistered contractors do not have: access to the guaranty fund
5_igr atu� _of AgentT weer Signature of contractor''
A 4
Plans Submitted ❑ Plans Waived Ell Certified Plot Plan ❑ Stamped Plans ❑
SEWERAGE DISPOSAL
[TYPEbF
Public Sewer ❑
Tanning/MassageMody 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
COMMENTS
Signature.
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No:
Planning Board Decision:
Conservation Decision:
Com
Comments
ing Decision/receipt submitted yes
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
FIRE DEPARTMENT'- Temp Dumpster on site yes
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Locatea su,+ usgooa btreet
no
-)imension
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.requirea approval of
Electrical Inspector Yes No
®ANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A —F and G min.$10041000 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.
r
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 o CCof Contract
❑ Mass check Energy Compliance Report
❑ 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
Doe: Building Permit Revised 2014
Location 3
No. (v
0 'L C) r 6 A rxi R b .
Date I )' - /& - �-01 (--
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ Aor-
Foundation Permit Fee $-
Other Permit Fee $
TOTAL $-
Check # La F- zY
/Building Inspector
Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
14,000.00
m
$
168.00
Plumbing Fee
$
21.00
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
21.00
Total fees collected
$
310.00
35 Old Farm Road
646-2017 on 12/16/2016
small bathroom and closet into larger bathroom
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Donald Belanger
Inspector of Buildings
Please print
TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
120 Main Street
North Andover, Massachusetts 01845
HOMEOWNER LICENSE EXEMPTION
Building Permit Application
DATE: 1) " (� r (�
JOB LOCATION: 3 S- U� d
Number Street Address
Telephone (978) 688-9545
Fax (978) 688-9542
Map/Lot
HOMEOWNER "16, w\\( Cyj 04(/fd 6ro.,Vv j 7�-- 7 f Lf-_ 'Doc)
Name Home Phone Work Phone
PRESENT MAILING ADDRESS 3 l �'►^ 12�
/Vo 0/, ,A'ovr-k
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, provided
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. /J /j
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING Ol
Revised 9/16
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
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The Commonwealth of Massachusetts
Department of IndustrialAccidents
1 congress Street, S5 ite 100
- d
Boston, MA 02114-2017
_
www mass.gov/dia
-Parkers' Compensationjusurauce Affidavit: Builders/Contractors/Elee-tricians/Pllunbers.
TO BE FIIsED WUH TEE RERMiTTiNG AUI[ORT) Y-
• IDI...,-, Print '
Name, (Business/Oiganizaiionftdividual):.
Address:
City/State/zip:
Axe you an employer?
(2)�j
the appropriate box:
1^, (d a
i,v •A O` S4 Phane #:.
1. ❑ I am a employer with employees (fuII and/or pari tune).
2.[] I am a s ole proprietor or partnership and hate no employees Working forme in
any capacity. INoworkers' comp. insurance required.]
3.E1 I am a homeowner doing all work myself. INo workers' comp. insurance required.] t
4:I am a homeowner and wh] be hiring contractors to conduct all work on my properly. Twill
ensure that all cont.,tb3s either have workers' compensation insurance or are sole
proprietors with no employees.
5. Q I am a general contractor and Ihave hiredthe sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp.
insurance.?
6.L7 -We are a corporation and ifs, officers have exercised their right of •exemption per MGL G.
4 and vre have no employees. [No workers' comp. insurance rem,i+ed ]
Type ofproject (xecluizred)_
7. ❑ Netiv'd6n&ddiion
8. p5Remodel3iig
9. ❑ Demolitiort
10 [] Building addziion
11.[] Electrical repairs or additions
12. ]-Plumbing repairs or additions
11 EI Rb6frepairs
14.0 Other
152, SIM. �-
*Any applicant thatch6oksIbOt4n ustalsofitlouttheseciionbelowshowingtheuvorkers'compensationpofimusontractorstsinformation.'
bmit aew affidavit
TI Homeowners who shmti•th s m t eta hed ha additional hin,316a�ingthpy are eet,a vag th name of the subiro b coontractors and e-whthe eo� 1ea have m
tContractors that checkthis b
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
dingworkers' compensation insurance for my employees. Below is t/ie policy and -
I am an employer iliat is proviob site
information.
Insurance Company
Policy # or Self -ins. Lic. #;
ExpirationData,
City/State/Zip:
lob Site Address:
compensation Policy declaration page (Showing the policy number and expiration date).
Attach a copy of -the workers' to
Failure to secure coverage as requited under M n 152, §S in he f is criminal
OP WORK pDElana �e oo by a ab fup to $250.00 a
and/or one -yea> imprisonment, as well as p
day against the violator. A copy ofthis statement may be forwarded to the Office oflnvesiigations of the D7A fox insurance
coverage verification.
I do hereby certi under theJ/7y/7T�'T ns andpenalties ofperjury t7iat the informationprovide �a ;alae jtr/r�_e �^��orrec
Phone #:
Official use only.
Do not write in this area, to be corrrrpleted by city or town official
Permit/License #
City or'Town-
Issuing Authority (circle one):4. Electrical inspector, 5Inspector
1. Board o£ffealth 2. Building Department 3. City/Town Clerk . Plumbing
6. Other
Phone #:
contactperson*.
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 do ied 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 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
applicafttwho 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=contractor(s)name(s), address(es) andphonenumber(s) along with theircerfiilcate(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. B e advised that this affidavit may be 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'
comperisatimipolicy, pleaso call theDepartmont at the number listed below. Self-insuredconipanies should enter their
self- insurance license number on the appropriate line.
City or Town Offa—rials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
ofthe affidavit for you to fill out in the event the Office ofluvestigations has to contact you regarding the applicant.
Please be sure to fill in the permitllicense 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 maybe provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be fined 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