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Home My WebLink AboutBuilding Permit #577 - 36 LINDEN AVENUE 1/31/2012 I TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION � L,6n8 Print PROPERTY OWNER !'� r Unit# Pr' MAP NO: PARCEL: ZONING DISTRICT: Historic District yqno Machine Shop Village y100 year-old structure y TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition 0 Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assesso ryBldg 11 Others: ❑ Demolition ❑ Other E� Septic ®W,ell "77 � �®Flo�odpl� E We-Hands �® Wat.,,,�ershed Dstriet� .` - - Ow ater,,Sewer_ .. ti - DESCRIPTION OF WORK TO BE PERFORMED: (Identification Please Type or Print Clearly) OWNER: Name:::TZ— .A-N 4Q ISAJ �T "Yy'I t Phon : � r Address: L on U .. —h a U 7z M A CONTRACTOR Name: �1L�` L f' Phone(- ML-� � e Address: Ln1 ,4J /- fo() � Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERM $92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. d C/ Total Project Cost: $ � FEE: $ 2- I t Check No. Receipt No.:. � C� NOTE: Persons contracting wit unregist ed contractors do not have access to the guaranty fund Signafure,�ofAgent/O.wne .- Signature3ofcontractor� _; _ � �I 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 HEAUTH Reviewed on Siqnature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Siqnature& 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 1.� -rr®M- _ - . ...- -- -- _ i 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 2011 June/mi I I 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 I ❑ Building Permit Application o 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 o 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) o 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 thea appeal period is over.v r. Thea applicant must then et this recorded a P pp g t the Registry of Deeds. One copy androof of recording must be submitted with the building application P Doc: Doc.Building Permit Revised 2008mi Location,3/,:z 4 Wo., No. Date NORT�y TOWN OF NORTH ANDOVER 10 R 41 40 ^o Certificate of Occupancy $ F 'SSACHU `� Building/Frame Permit Fee $ Foundation Permit Fee $ ++'' Other Permit Fee f/w/- $ TOTAL $ Check # 24990 Buii ing Inspector NORTH Town of _ Andover ., � o , lover, Mass., • 3� • � a•• LAKI '. HICHEWICK �. d ADRATED PP�t�� 7 S U ` BOARD OF HEALTH Food/Kitchen Septic System PERMIT . T D BUILDING INSPECTOR .......6..e.�.. .64..�.1.............................................................. THIS CERTIFIES THAT..........� .�t.�r..... . .. Foundation has permission to erect........................................ buildings on ........ ........Lt-wd(40.0 ..•••0 •O•......•••• Rough to be occupied as ....... .................................................. Chimney .... .. n ......... ......... M�.. e provided that the person accepting this permit shall in every respect conform tot 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 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR V 1 V LESS CONSTR V CO T S Rough .......................... . ................ I ........................................... 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 (Mall To BeDone FIRE-DEPARTMENT Until Inspected and Approved .by the Budding Inspector. 'Burner Street No. SEE REVERSE SIDE smoke Det. µoRTH TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT . 1600 Osgood Street Building 20,-Suite 2-36 CHus North Andover,Massachusetts 01845 SgcH Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978) 688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERNHT APPLICATION Please Print DATE:• . JOB LOCATION: _3 Number Street Address Map/Lot IJOMEOWNERFf Name Home Phone -Ack Work Phone PRESENT MAILING ADDRESS City Town Mate. Zip Code The current exemption for"homeowners"was extended to include owner-occupied dwellings to two units or less and to allow such homeowners to engage an ilidividual for hire who does not possess a license,provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) DEFINITION OF HOMEOWNER • Person(s)who Awns 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-year period shall not be considered.a homeowner. The undersigned"homeowner"assumes responsibility forcompliances with the State Building Co Applicable codes,by-laws,rules and regulations. de and other The undersigned"homeowner"certifies that e understands t Town of North Andover Building Department minimum inspection procedures and requir ents d that he/sh will compI with said procedures and requirements. HOMEOWNERS SIGNATURE - s APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 ._,• HEALTH 688-9540 PLANNING 688-9535 � The Commonwealth ofMassachusetts Department of Industrial Accidents Office oflnvestigations' 600 Washington Street Boston,MA.02111 www.massgov/d'aa Workers' Compensation Insurance Affidavit:guilders/ContractorsfFIectricians/Plumbers APP licant Information please Print Le ibl Name(Business/Organization/fndiyidual):�� Address: 1—c ti City/State/Zip:1 Phone [3. 1 an employer?Check the appropriate box: a em 10 er with 4. Type of project(required):p Y ❑I am a general contractor and Iloyees(full and/or part-time).* have hired the sub-contractors6 ❑New construction a sole proprietor or partner listed on the attached sh.et.t 7• ❑Remodelinand have no employees These sub-contractors hve s. ❑ ging for me in any capacity. workers'comp.insurance. Demolitionworkers com .insurance 5. 9• ❑Building additionp ❑ We aie a corporation and itsred.] .officers have exercised their 10.❑Electrical repairs or additionsa homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additionslf.[No workers'comp. c. 152, §1(4),and we have noance required.]t employees. 12•[]Roofrepairs [No workers' comp,insurance required.] 13.[]Other 7Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers,comp,policy information. lam an employer that isproviding workers'compensation insurancefor my employees Below is thepolicy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.M Expiration Date: rob Site Address: , 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 required under 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 violat r. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the for insuranc coverage verification. Ido hereby certif under th pains dpenalties of rjury that the iMfornzation provided above is true and correct. Signature- 3 Date: Official use only. Do not write fn this area,to be completed by city or town offcial City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person• ' Phone#: 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 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 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'wxthhold 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 ofpublic work until acceptable evidence of comp-fiance with the ins uranc erequixemenis of this s chapter have been 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)andphone number(s)along with their certificates)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 confi mation 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 and printed legibly. The Department has provided a space at the bottom 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 pennit/license applications in any given year,need only submit one affidavit indicating current Policy information(ifnecessaty)and under"Job Site Address"the applicant should write"all locations in town)"A copy of the affidavit that has beenofficially p or marred by the city or provided to the stamped town may be (city or 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 rmit not related tor any business or co (i.e.a dog license or permit to burn leaves etc)said person is NOTrequired to complete this affiddvitmmercial venture I The Office of Investigations would like to thank you in advance for your cooperation and should you have please do not hesitate to give us a call. any questions, The Department's address,telephone and fax number: The co.-mmoRWea to of M�assac�asetts Department pa nt of ZndusWa- 1 Accidents Of to of Investigations - 600 Washi i&n 8trQet Boston;.M1 A,0211 X - TW.#6X7-727-4900 ext 4406 ox l.•-877-MASSAFE Revised 5-26-05 Fax#1617-727-7749 i 'wWW mass.jZav"a