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Home My WebLink AboutBuilding Permit #18 - 36 AUTRAN AVENUE 7/7/2009 BUILDING PERMIT "ORT"qti TOWN OF NORTH ANDOVER c - APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received �SSACHUS�� Date Issued: VW O DqLAppficant m complete all items on this page LOCATION A/A� F . PROPERTY OWNER Ar.". Print MAP NO: PARCEL: Z` 'ING DISTRICT: Historic District yes no Machine Shop Village yes no 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 Assess_ory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: l�J (Ja entificati ase T or riot Clearly) OWNER: Name: Phone: c�JA Q Address: / CONTRACTOR Name: _ Phone: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 06 FEE: $ :�),La �— Check No.: Receipt No.: L*0 �— NOTE: Persons co ra ti with un istered contractors do not have access to the guaranty fund Signature of Agent%O er ature of contractor �/ I Location No. Date v NORT1y TOWN OF NORTH ANDOVER ' f 9 Certificate of Occupancy $ as tt Building/Frame Permit Fee $ AC Mus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check x(U t 2 21 u '7 Building Inspector Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature .r 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 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 I ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 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 o 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 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 The Commcsnweaft of Massachusetts j I Department of Industriad Accidents Office of.[nvel;w MS iii, 600 Nlashington Street tia"a %• Boston, MA 02111 wKm=mnss.gov/dia . Workers' Compensation 1MbL ance Affidavit: Builders/Contractors/Eiectriciaas/Piambers Applicant Information. Please Print LeQibi Name(Business/Drgeniationnndividuel): ` C Address: City/,State/Zip: roc�.L� Phone TAmyouemployer?Check.the appropriatebox: employer with 4. ❑ I am a F7. of project(required): ganarai contractorand Iees(foil and/or part-time).* have bii ed the sub-earrtracors haw construction sole proprietor or partner. listed on the attached sheet ? Remodeling ship and have no employees' These stili•-contractors have working for me in any capacity, workers' comp.insurance, 8. Q Demolition o workers'comp. insurance . 5. ❑ We are a corporation and its 9• El Building addition urmd.] officers have exercised their 10•0 Electrical repairs or additions 3. 1 am s homeowner doing all work right of exemption per MGL 1 I.❑ Plumbing repairs or additions myself [No•workera'comp. c IS2, §i(4),and we have no insurance.required.]t .employees. [No workers' 12❑Roof repairs eorrip. insurance require&] 13.11 Other°Any eppiicmta that checks bob#l must also fill out the section below Showing their workers''nom t Homeowners who Submit this affidavit indicating they are Hain all work 1�m10°policy in nrmation ;Contractors that check this box must g end��hrts outside contractors must Submit a new affidavit indiaetiag such athu*ed an additionni sheat show• tttractors and their work=,cern pal:.•• tug•the name of the sub-co r pal a nfonrL on. I stet an employer tftat is Provfdulg:workers'compensation insurance or information, mJ' Payees: Below fs thePofdcy andjoh site . Insmranee Company Name: Policy#or Self-ins.Lie.4: Expiration Date: Job Site Address: . City/state/zip- Attach a copy of the worlcets'compensation policy deciaration page(showing the policy number and expiration date cure coverage as requited.under Section 25A of MCiL C. 152 can lead to fine to$1 00 the im osition of .' lip ,5 ,0 and/or o . . P criminal one-year imprisonment,as well as truth pen in the form of a S'Il7P W• pies of a Of up to$250.00 a against the viol opK ORDER and slot. Be advised that a fine lnvestigatio o e DIA for insurance co ge verification.copy of this statement may be forwarded to the Dffice of Ido /c Jy under th en . P alties of per*7 that the informadon Provided ore ' true and eorrUt Si Date: Phone Official use only. Do not write in this area,to be convicted mp elect by rxty or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Ins 6.Other g parlor Contact Person: Phone#: Information a nd Instructions Massachusetts General Laws chapter 152 requires all emp 3 oyers 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 defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the'foregoing engaged in a joint enterprise,and includirig the legal representatives of a deceased employer,or the receiver ortuvstoc of an individual,partnership,associatio in or other legal entity,employing employees.'However the owner of a dwelling house having not more than th=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 shat not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local Eicensing agency shall withhold the issuance or renewal of a license or permit to operate a business or *o construct buildings in the commonwealth for any applicant who has not produced acceptable midenceat compliance with the insurance'coverage required." Additionally, MOL 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 compliarrcx with the insurmc e requirements of this chapter have been pres:=ftd to the corttrac€ing authority." Applicants Please fill out the workers'compensation•affidavit compke--tely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(cs)mind phone number(s)along with their certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no empioyees other than the members or partners,are not requiredito cant'workers' cc�,rnpwsation insurance. lfan LLC or'LLP does have employees,a policy is required. Be advised that this of idavilt may be submitted to the Department of industrial Accidents for confirmation of insurance covcmge.. Also*lie 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,notthe Dgxu tmant of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' oompensation policy,please-call the Department at the number listed below. Self-insured oompanie:should enter their self-insumn=—license number on dw'appropfiate tine. 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 fire event the Office of Investigations has to contact you regarding the.applicant. Please be sure to fill in the permittlicense number which mviIl be used as a mfcrence number. in addition,an applicant that must submit multiple pmmitflicense applications in any given year,need only submit one affidavit indicating-current policyinformation(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy ofthe affidavit that has been officiaily stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for futum permits or licenses. A new affidavit must be filled out each year.When a home owner or citizen is obtaining a license or parmit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit Tho 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. The Commonweadth of Massachusetts Department of Industrial Aacidmts Office of Lavesttigations 600 Washington Street Boston, MA 02111 TeL#617-7274900 6=406 or 1-8.77-MASSAFE Fax#617-727-7744 Revised 5-26-05www.mass.gov/dia N0RTH Town of 4jAAnndover No. A K E = dower, Mass., coCMI. ....CN y1. 7,p ADRATED C7 `s BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT ..... .........................��I�'y............................................... """"""""""' Foundation • has permission to erect. ..................................... buildings on .. �....... . ...... OA....... .......... Rough to be occupied as. ...�I 1 .�� .. ... .✓..�..� ...v ' �ii►....1r �� .4......... Chimney provided that the p rso accepting this permit shall in every respect conform to the terms of the application on file in Final 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 26 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR. UNLESS CONSTRU SILTS Rough ........................................................................................ Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. MOR*M TOWN OF NORTH ANDOVER c ". '. .• o� OFFICE OF BUILDING DEPARTMENT f •• . 4«« 1600 Osgood Street Building 20, Suite 2-36 ��s�,,,•• "� North Andover, Massachusetts 01845 a•►nais� - Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 E HOMEOWNER LICENSE EXEMPTION c Please Mid DATE: JOB LOCATION: C Number Strut Address HOMEOWNER Name Home Phone work Phone PRESENT MAILING ADDRESS a City Town WC gtaft Z$Cade ne carresd exemption for"homeowner"was mdmxW to include ow.,,f-occiipied dwellings to two anis or less and to allow such homeowners to engage an individual for hire who does not Possess a Iicenge owner acts as State B P that the supervisor). wilding Code Section 108.3.5.1 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 structures, A person who constructs more that one home in a two- be considered a homeowner. Y�period shall not The undersigned'"homeowner"assumes responsbility for compliances with the State Building Code and other Applicable codes,by-laws,rules and regulations. The undersigned"homeowner"certifies she understands the Town of North Andover Building Departm minimum on P and and that he/she w fflij comply with said procedures and HOMEOWNERS SIGNATURE00 APPROVAL OF BUILDING OFFICIAL isevind 10.soo5 Far Homeowners Eme w ion BOARD OF U'PF,ALS 699-9541 CO.\SERN'.Mo N Egg-953q ITE.ILTH 689-95 40 PL.L\5i[VG r;gg-9535