HomeMy WebLinkAboutBuilding Permit #385-15 - 385 APPLETON STREET 10/23/2014 i
NORTH d
BUILDING PERMIT 0.4.11 D 16'' 0
Q2 y' •,' '. 6 O(A
TOWN OF NORTH ANDOVER
AP LICATION FOR PLAN EXAMINATION
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Permit No#: Date Received 7 �AATEO'07 Pp
�SSACHUS��(
Date Issued: b !i
I P RTANT Applicant must complete all items on this page
-
LOCATION - '` S - 5��va,.� �-r�3 �v�2 poi-e_, .4,*4-.
+Print - -
RROPERTY 01IVNF2, 464ow
-
Armt 100 Year Structure yes no.
MAP'_—PARCEL ..?y _- ZONING DIS, ,RlCT �Z 1 _ Historic ®isfinct yes no
-__ - — -
Machine Sfop Uilfage q yes ono
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
I-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 p Wetla_nd`s Watershed Distnct� ,
x ,.❑'Water/Sewer w .
DESCRIPTION OF WORK TO BE PERFORMED:
12 I-e I (77� -30AO61:�o 15'
ts .
Identification- Please Type or Print Clearly
OWNER: Name: /y114n/C Foy /Jeri,4 Fa /? _V Phone: r'i 73,.9! 7-�I-Sd 7
Address: ��
- - - _
Contractor'Name. SJ> O. Rhone-_ Tv j ��C S�7? -' /tet dna
Addre- �7/it e i ,c7r>2X13 l ea L tW 4-' 1c9' S
Address: _ _ �-� -
r ,
ti
Supervisor's Constrfuctron License - +Exp Date; -:
Home lfirnp vement License ,__ iExp Date: . v. _m;
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BA ED ON$125.00 PER S.F.
Total Project Cost: $ l`0� FEE: $
Check No.: � Receipt No.:
NOTE: Persons contracting with unregisterW contractors do not have access to the guaranty fund
Signature of.Agent/Ovne - _ __ _ Signature of contractor _
Location � P
No. i Date V
1
. - TOWN OF NORTH ANDOVER
o Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check28.1 71# �
�- -- 61ding 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
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Si nature
/1,4 Lk
'i
COMMENTS
.I
HEALTH Reviewed on Signature
COMMENTS
I
i
t
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
- _-,.
AFIRE DEPARTMENT Temp iDumpsterxonrsite yes _ no
(Located-gat 1241 aintStreet
FFire Department signature/d:ate
e
tC`OMMENTS '-
i
Dimension
Number of Stories: j Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast Qr service drop requires approval of
Electrical Inspector Yes - >lJ No
DANGER ZONE LITERATURE: Yes /L,,'4 No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
I'
NOTES and DATA— (For department use)
❑ Notified for pickup Call Email
Date Time Contact Name
Doc.Building Pen-nit Revised 2014
Building Department
The followingi
s a list of the required forms to be filled out for theappropriate r '
q pe mlt 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
o 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 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:Building Permit Revised 2014
i
I
i
r 1 NORTH .
_ : w : ver
0
No.
n0 h ver, Mass, t)
COC
.41Nl WICK ��•
004reo 01PP,��(5
S lJ
BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
THIS CERTIFIES THAT ...............mwft-tv...... ............................................................ BUILDING INSPECTOR
.. ... ......
.. .... Foundation
has permission to erect .......................... buildings on ..z� ...... .. . . . . t.....TT=
..
Rough
to be occupied as ...................a.xc q.......... .l............................................................ 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 MONTH ELECTRICAL INSPECTOR
UNLESS CONSTRUCTIA ST IS 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.
• ��°£� °r a�a TOWN OFi�MTffANDOVER .
OFFICE OF
BUMDING DEPARTMENT
• ' Q ,,� = 600 D--kODdStrOOtBuRding20,•Surte2-36
North Andover,Massachusetts 01845
Beaus
Gerald A.Frown
Tell-
Phone(978)6889545
Tuspeetorof$uitdings - Fax (978)689-9542
IIQNCEOWMR-LICENSE tX F,MPTION
BbIID►Zi l PEZ3.lWT"PLIC.AT. ON
pleaseurint .
DATE:
JOB LOCATION. --Y
6 2' 10
Number Strea dress Map of
• I�aAMO I.ER 114,4724.- D*A.),v�� Gt' 79 907
S�Tame. Horne Phone work I?hone
-PRESENT MAILk!ADDRF-SS '
i1L �s 'S`
r?-071o4— ot, ' �Lv' S
M,T = Ufa+�. _
zip Code
The current exemption for`$omeowners"was extended to?nclLide owner occtip'sed ctive� rgs to isvo unifs car;ass an_d
fo allow ;h h
suoMso,Tern to engage an.n-dividual.for hire-who does not possess a license,provided that the owner
acts as snpervisor). StateDLilcling (Code soabon.108.3.5.1)
DEFMITION OF110.IVIEOWNER.
PEIS04-9)who 9was aparcel of land on which.he/she resides or intends to reside,on which thew is,or is infended to
+
be,a one or two famffY stm(;tures. A.parson who constructs more thatone home in a e
considered ahomeowner. twa yea'r eisd shall not l
The tuzdersigned"homedwner"assumesresponsibility foTcompliances with the State Building Code and other
Applicable codes
by-laws,zules andzegulations, t
Theundersigned"bomeowne 'cezti,Res that he/sherindersfands the Town ofgorth DMUA.ndover73urtding �arfinent
.,,,ra iram inspection procedures and requirements and that he/she will coma ly with;said procedures au
requizements, .
HOMEOIVVIMI.ERS SIGNATURE
APPROVAL OF 33DED)'G OFFICIAL
Revised 7.2009
Form Homeowners Exemption
'$O.ARI)OFAPPBATS-688-954Ir TAIdON
CO7�SER4688-9530 HEALTH 688-9$40 PI_MNIN0688-953-
M The Commonwealth of MassachusettsIn -
Department oflnrlustrialAccidents
Office of Investigations
600 Washington Street
Boston,MA.02111
www mass gov/cdia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/individual): �
Address: za.�
City/State/Zip: /a-Phone#:
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
employees(full and/or part-time).* have hired the sub-contractors
2.El am a sole proprietor or partner- listed on the attached sheet. 7. F1 Remodeling
ship and'have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9, E]Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
r ed.] officers have exercised their
3. am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance
required.] employees.[No workers'
- 13.90ther 5��
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
-Homeowners who submit this affidavit indicating they a-re 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 is providing workers'compensation insurance for my employees. Below is the policy anti job site
information.
Insurance Company Name:.
Policy#or Self-ins.Lie.#: Expiration Date:
Job Site Address: City/State0p:
Attach a copy of the workers'compensation-policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as requiredunder 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 tine
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.
Y do hereby cert under the ains and p nal' of perjury that the i na on provided above is true and correct.
Simature: ate: l
Phone#:
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.PIumbing Inspector
6.Other - - -
Contact Person: Phone#:
Informati®n and Instructi®ns '
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 employeiis 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-contractors)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 maybe 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 permit/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 bum 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 o£Ia�estigalions •
6.00 Washington Street
Boston,MA.02111
TO,#617-727-4900 ext 406 on 1-877-MASSAFE
Revised 5-26-05 Fax#617-727-7749
www mass,govfdia
i
MORTGAGE INSPECTION PLAN
NORTHERN ASSOCIATES, INC.
401 SOUTH BROADWAY, LAWRENCE MA. 01843-3522 TEL:(978) 837-3335 FAX:(978) 837-3336
MORTGAGOR:MARK 4 DONNA FORD DEED REF: 2737/282
LOCATION:385 APPLETON 5TREET PLAN REF: 20161282
CITY,5TATE:N.ANDOVER, MA SCALE: 1"=G0'
DATE: 10/30/06 JOB,#: 206.05215
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APPLETON STREET R"833 62, 3\2a
CERTIFIED TO:. 1-800 MORTGAGE LLC
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