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Home My WebLink AboutBuilding Permit #771 - 363 WOOD LANE 6/24/2008BUILDING PERMIT o �tLeo 6gti TOWN OF NORTH ANDOVER o� APPLICATION FOR PLAN EXAMINATION 4( Permit NO: Date Received ° / �q l,�CM g1TE0 Date Issued - !2�r IMPORTANT: Applicant must compl s on this page LOCATION PROPERTY OWNER -tom P *, Pnnf MAP NO: PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes 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 Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: I entifica io Pl a e..Type or Print Clearly) OWNER: Name:t- �°� Phone 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: $ odd G FEE: $ J Check No.: (�2 � Receipt No.: 2 NOTE: Persons contracting pith unregistered contractors do not have access to the guaranty fund 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/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 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. Pennanent 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 HEALTH Reviewed on Signature COMMENTS R t Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comm Conservation Decision: Comments Water & Sewer Connection/Signature & Date Drivewav 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.$10o-$1000 fine 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 ❑ 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) Li 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 Lj 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 BUILDING PERMIT o�,ED ,bgti 0 TOWN OF NORTH ANDOVER - A APPLICATION FOR PLAN EXAMINATION x Permit NO: Date Received Date Issuedf/l'"nCY- O LOCATI IMPORTANT: Applicant must complb�=s on this vase MAP NO: PARCEL:I(O.- ZONING DISTRICT: Historic District yes Machine Shop Village yes 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 Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: f w 6:,% 11 or Print Clearly) OWNER: Name: Address: CONTRACTOR Name: Phone: Address: Supervisor's Construction License: Home Improvement License: ARCHITECT/ENGINEER ;Exp. Date:. Phone: Address: Reg. No. -6 FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ �d Q FEE: $ y Check No.: b2 y Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Si nature,of A ent/Owner .. g_ g Signature of contractor Location �� dU' A,— No. , Date MORTM TOWN OF NORTH ANDOVER f 1 0 9 i Certificate of Occupancy $ ;�b',^° •'tom Building/Frame Permit Fee $ Ss•iCH Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # a vi�i 2 12 / 6 Building Inspector 0 * OOO v o o w " a v cn a ow C'5 Gq C b ' o w x nao o c4 :� U G w a GG "a CL x o c� Ta x a O • ' W °°° c� co � i w OO d 7 o4 ca w' w w �r W m z cn v v o cn C 0 CD O O C H O_ C vV CL m O cp oCD IK WCD V Q C W m l�,l 4V k d W m Jz 0 y Flu ¢ E c r Q 3 ',Mai .0 m * -- cm VJ � c �o �y y 3 Of C � CO CD y �O 'L y :CLv` m • C pQ p,CL Ica, C cc j Z .: L = ohm 3 f- .0.. tOo 'D W C :52L W=:s C CyMD •y W .E C3-0 cmV V O p� C y 0' m�p� = W W O (- s 4- a i m a 0 O L O Z CCD W CL CD D o. O y C C CO CO) Q O H m m C3 _W O a 2L O7 Q1 CO) CLU Orte••• cc COD C Z CD 0 CL V v) O C C C A LLI LU O CO) W /W/ li W U) The Commonwealth of Massachusetts Department of Industrial Accidents 4 ~y IL Office of Investigations ' 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):_ Address: 3(A W�X(A_ utt e City/State/Zip: kb AAosy Phone #:`Z � 'g ~�" 0 7a Are you an employer? Check the appropriate box: 1. ❑ 1 am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ 1 am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance yequired.] ' 3. (' I am a homeowner doing all work myself. [No workers' comp. insurance required.] t have hired the sub -contractors listed, on the attached sheet. $ These sub -contractors have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions I l.❑ Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other *Any 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. 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 is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. 9: Expiration Date: Job 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 violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify ander the pain .andpenalties of perjury that the information provided above is true and correct. Phone 4: ✓ 4q, V ^ 1^0. C1 sl� — 4 l UL 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. 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 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-contractor(s) 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 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 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 pen-nit/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 or permit to burn 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: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-7274900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT 41 4- 1600 Osgood Sbvd Building 20, Suite 2-36 North Andover, Massachusetts 01845 C Gerald ABmwn Telephone (978) 689-9545 . Inspecor of Buildings Fax (978) 698-9542 HOMEOWNER LICENSE EXEMPTION Pie= mild DATE: 1dDto JOB LOCATION:. '36S ubf)g L& Number Sued Address _ Map/Lot I / I �, HOMEOWNER CS k6\ kctt KL (4,\ � W7 Name Home Phone Work Phone PRESENT MAILING ADDRESS- 3(6p-im� ue-yp V - C, %110,k-- 9 ( Ta 11 -/U V �-L4 C—W�U-V-f City Town State Zip Code The current exemption for "homomneit" was extended to include owner-owipied dwellings to two units or I= and to glow sack homeowners to engage an individual for hire who does not possess a license, provided that the owner am as supervisor). State Building (Code Section 108.3.5.1) DEFINITION OF HONWVVNER. Person(s) who owns a parcel of land on which he/she resides of 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 m a two-year period Shall not be considered a homeowner. The undersigned "homeowner" assnines responsibility for compliances with the State Building Code and other Applicable codes, by-laws, rules and regulations. I The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department inspection procedures and requirements that belshe will comply with said procedures and Zf A HOMEOWNERS SIGNATURE. I APPROVAL OF BUILDING 0MCL4,L Revised 10.2005 Form Homoomas ExmWdm BOARD OF \PPF:V-S 689-9541 CONSERN'NrioN' 689-9530 JTE.1LTH 6XF-9540 PLANNING (;FN -9535 :wa V. ,Baked on Texture-Kote finish`on ,all toptails� sand verticals and Protectoloc wall coating"s 11` Y provides long-21asting protection against5" scratching.; corrosion,,and UV rays.r' *,R",Tnn YaI�A SAI"1r 9,,.1 //171 �iorii�nln ri rr:. T -.a vallable a,5 special order only. P L u.j, PLAA� 363 Wood Lane North Andover, Massachusetts Date: November i x)76 } s si`39=3o�E' LOT #/6 z.CIL A ,EA= /DOD r� `J2 o a .W s I� � L.OT #S .? �° mss � N ,LOT /7 I� ( -Sol k/� N rraFRowR�i i. 4 DI 36.0 �5: 0' f /D0.0 WOOD00, WiDE) Z AAE— �/pEFrR T!)' NFARD. WAN;04S6 I hereby certU*Y that the bu l rl i n b on th s property is located as shown on plan and complies with the D=cing and Zoning Laws of the -Town of �� ",• : ;r`,., - North Andover: 7 CHARLES E. CYR CIti7Z IIJGIMER ` ._ LAWRENCE, MASS. .� , I FORM - U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all -necessary approval / permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements,` logo APPLICANTkC r t}LC€.PHONE�� ASSESSORS MAP NUMBER - LOT NUMBER SUBDIVISION LOT NUMBER STRE "1 -- Lc',) '� "�- STREET NUMBER OFFICIAL USE�ONLY....LL............... ,.......................... RECOMMENDATIONS OF TOWN AGENTS (� �L DATE APPROVED 00 C SERVATION ADMINISTRATOR REJECTED P per(DATE COMMENTS 1i� F V✓t� � °" f^ coo/ DATE APPROVED TOWN PLANNER DATE REJECTED COMMENTS DATE APPROVED FOOD INSPECTOR - HEALTH DATE REJECTED DATE APPROVED SEPTIC WSPECTOR - HEALTH DATE REJECTED COMMENTS PUBLIC WORKS - SEWER ! WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIRE DEPARTMENT DATE REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR DATE