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HomeMy WebLinkAboutBuilding Permit #850-14 - 369 GREAT POND ROAD 5/1/2018 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: � Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION � �1 u Print: PROPERTY OWNER Print 100 Year Old Structure yes no MAP NO: 57 PARCEL: / ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT, PROPOSED USE Residential Non- Residential ❑ New Building ROne family f ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial R Repair, replacement ❑Assessory Bldg ❑ Others: ' ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer _ DESCRIPTION OF WORK TO BE PERFORMED: �� ��o/a u s,-�s�,1 G-•`nom/ �1' l'��� e� �rot� � �'��v -� e�..�' �a-v r r-L�'��['�/ 7�©t� r���'''�-f~�,t� �rT2.+l o',G�r n�n.9 lrJ!Ll• � -o Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: E TRACTOR Name: , Phone:ss:rvisor's Construction License: ' - Exp. Date: e Improvement License: _ Exp. Date: _- ARCHITECT/ENGINEER Phone: �r 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: $ FEE: $ 12-2 6tspl Check No.: / Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner ��]/Z,4,S� iglnature of contractor Plans Submitted Pans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Plans Submitted ❑ - Plans Waived ❑ -: 7.Certified Plot Plan ❑ Stamped Plans ❑ TYP,EM—=SEWERAGEDiSPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑... ..Swimming Pools ❑ i Well ❑ ..Tobacco Sales ❑ Food Packaging/Sales ❑ Private,(septic tank,etc Permanent Ditmpster on:Site 'THE-FOLLOWING SECTIONS FOR OFFICE USE ONLY ' _ INTERDEPARTMENTAL SIGN OFF - U FORM DATE. REJECTEQ.. DATE,APPROVED j `PLANNING& DEVELOPMENT` ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature I j COMMENTS HEALTH Reviewed on Signature COMMENTS i 1 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'Tuvvo Engineer: Signature: Located 384 Osgood Street FIRE-DEPARTfl :t:NT ;= Temp Dum st8r on site p e Located at-124 Mair Street-.- yes no Fire Depa'rtmeit signature/date-'' COMMENTS r ' I . I Dim-eFis i oti Number of Stories: Total square feet of floor area, based on Exterior dimensions _ Total land area, sq..ft. ELECTRICAL:-Movement of.Meter l:ocaton,'niast-or service drop requires approval of -Electrical Inspector .Yes No DANSER.ZONE LITERATURE: -Yes MGL-Chapter 166.section 21A.-,F and G min.$100=$1000.fine No 1 NOTES and DATA— (For department use ® Notified for pickup - Date Doc-Building Permit Revised 2010 - r Building Department artment j fhe following i94-list.of the required.forms to be filled out-for:the appropriate.permit to.be obtained. Roofivg, Siding, Interior Rehabilitation Permits L B.i ildin9 Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H'.1.C. And/Or�G.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 1 ❑ 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 i 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 cans if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the api).�al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must bp subm.tted with the building application Doc: Doc.Building Permit Revised 2012 Location (�/` ( ��F4 Iz No. �S�Q —��/ Date 9 7 /y • - TOWN OF NORTH ANDOVER Ix, :. Certificate of Occupancy $ Building/Frame Permit Fee $4�w Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# 7 wilding Inspector � NORTf� I Town of ndover t No. soh ver, Mass, cocHIcHewIc« 1' 7� 00 ATED PP S U BOARD OF HEALTH Food/Kitchen PERMIT T LD I Septic System THIS CERTIFIES THAT ... .U.���°: /r.......... ��� BUILDING INSPECTOR //I� Foundation has permission to erect buildings on , r �J.�`��r..f °`y� .......................... ..... . ............... ......... . ................... Rough to be occupied as ...... ...... 1�: .4:^, .....:... �� ��:�r .. 7r:,d .................. Chimney provided that the person accepting this permit shall in every respect conform 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 UNLESS CONSTRUCTION TARTS 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. Smoke Det. The Commonwealth of Massachusetts - Deparhnent ofIndusfr!g1 Accid&ts Office Of Investigations 600 Washington.Sheet Roston,MA 02111 www.massgov1d1a Workers'Compensation Insurance davit:)3tulders/Cont°actors/ElectricianslPliim.ber,,q Apo :cant Information Please Print LegibXy 'Name(Busyness/Orgmization/Individual):s�O.fC,�4 ��- Address: 34e le6,ftd - City/State/Zip: Phone#: .5 b d'-to G 2- 25 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 I 6. []New construction f employees(full and/or pax(-time)* have hiredthe sub-contractors 2.[l I ant a sola proprietor or partner- listed on the attached sheet.I 7. [)Remodeling ship and'hava no.employees These sub-contractors have 8. []Demolition working forme in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers' comp.insurance S. ❑ We area corpora] on and its equixed.] officers have exercised.their 10.0 Electrical repairs or additions 3.Q I am a homeowner doing all work right of exemption per MGL 11. Plumbing repairs or additions myself.EEO workers'comp. c.152,NO),andwehaveno 12.❑Roofrepairs insurancerequired.]? employees.[No workers, 13.❑Other comp.insurance required.] NAny applicant that checks box#1 must also fill out the section bel6w showing their workers'compensation policy information. Homeowners who submit lbis affidavit indicating they 2're doing allworlg and then hire outside contractors must submit a new affidavit indicating such. TContractors that cheAthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am are employer that ispr oviding worrkers'compensation insurance for my employees Bellow is the pokey and'job site information. Insurance Company Name% Policy#or Self ins.I.ic.#: Expiration Date: lob Site Address- City/State/Zip: Attach a copy olthe workers'compensation-policy declaration page(showing the policy number and expiration date). Failure to secure coverage as recuiredunder Section 25A ofMGL o. 152 can lead to the imposition of criminal penalties of a flue up to$1,50 0.00 and/or one-year imprisonment,as well as civic 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 statementmay be forwarded to the Office of Investigations of the DIA for insurance coverage verification. f do Hereby cert �fizep'alqs. nd pena7tiesofperju that the information provided above is true and correct.Si Date: Phone#: J �' f✓ - S�(v Oficial use onfy. .Do not write in tliis 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 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 of the foregoing engaged in a joint enterprise,and including the legal representatives of a'deceased employer,or Ilse receiver or frdstee 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 ofthe 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 employes." 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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fail out the ' workers com ensa6on affidavit p fir avit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)andphonenumbex(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 LL C or LLP does have employees,a policy is required. Be advised thatthis affidavit may be submitted to the Department of Industrial Accidents fox 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 eimit o p x license use is being re e' p g qu steel,not the Department o£ Industrial Accidents. Should you have any questions regarding the law or if o g g y u axe 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 lice. City or Town Officials Please be sure that the affidavit is complete andpxiated ogibly. The Department has provided a space at the bottom of the affidavit for yen to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be-suxe to fill inthe permit/license number whichwill be used as a reference number. In addition,an applicant thatinust submit multiple permit/license applications in any given year,need only submit one affidavit indicating current PORGY information(ifnecessary)and under"fob Site Ade « Address;the applicant should write all locations in .(city or town):'A copy of the affidavit that has been officially stamped or marked by fibs city or town may be provided to the applicant as pxoo£ that a valid affidavit is on file fox future permits or licenses. Anew aflxdavit must be filled out each ear. e y Wh re a home owner or citizen is obtaining a license ox permit not related to any business or commercial venture (i.e.a dog license orpermit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office 6f 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 a`nd fax number: TN Go>l ox wealth ofAfosSaeA-v is - Department of 1.duMal.A c.c%dej�ta . ��ce o�Ir�yeStiga�o,�S. ' 6O WaA l g- reg Bwton,.:[ice.02111 TO,#617-7.2'ZK4.9QQ est 406 ox 1-877-NA.SSM Revised 5-26-05 Fax 0 617"727'7749 _��v�vzuaSs,gov�dia. T �T OF N0RTff 1.� ANLOVE1'l • o OFFICE OF } BUILDING DEPARTMENT 7 600 0sgood Street Building 20,-Suite 2-36 r g S�seNorth Andover,Massachusetts 01845 Gerald A,Brown Inspector ofBuildings Telephone(978)688-9545 • HOME - Fax (978)688-9542 ' O WNER•L . ICENSE EXEMPTION B17IO G tRRM- T APPLICATION • Pleaseurint DATE: J/2,-7//,L/ J•pB LOCATION: .J� [rye •e Number Street Address I OWNER ; IVIap/I of ame Home Phone WorkRhone PRESENT MAILING ADDRESS ,Z flex X,/� [�'%tsi Int=m ' State-- Zip Code The current exemption for"homeowners"was extended to include owner-occupied dtvelings to t�vo units oL;ess and to allow suite 3,ompo,rners to engage andividual.for hire who does not Possess a-license,provided that the owner acts as supervisor). State Duizding (Code Section 108.3.5.7) DEFINITION OFHONIEOWNER Persons)who Qwns aparcel ofland on which he/she resides or intends to reside,on which there is intended to consOr irate , be, considered a homeowner,one or two fwn structures. A person who constricts more that-one home in a two-yearperiod shall not be The undersigned"homeowner"assumes responsibility for compliances with the State Building Co Applicable codes,by-laws,riles andregulatiom. de and other The undersigned"komocedur"cert fies that he/she requirements, understands the Town of North AadoverBuilding DeparfnQent zninzmum inspection procedures and requirements and that he/she wall comply with said procedures and HOMEOWNERS SIGNAx C ZE AI'P.ROVAL OF BUEDING OFFICAL Revised 7.2009 Eorin.Homeo'Amrs Exemption 13DARD OF APPEALS 688-9541 CONSERVATION 688-4530x HEALTH 688-9540 PLANNWG 688-9531