HomeMy WebLinkAboutBuilding Permit #592 - 385 RALEIGH TAVERN LANE 5/7/2009 BUILDING PERMITo� NORTH q
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TOWN OF NORTH ANDOVER 0�4'. ''
APPLICATION FOR PLAN EXAMINATION
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Permit NO: '� Date Received
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Date Issued: -o
IMPORTANT:Applicant must complete all items on this page
LOCATION ?�S' /Zatr,1l614 aver l 1.9ki-
Print
PR r`fi
PROPERTY OWNER / �� �.
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MAP N0407 o-- PARCEL: /2-/ ZONING 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 Assessory Bldg Others:
Demolition Other
Septic Well Floodplain Wetlands Watershed District
Water/Sewer
JESCRIPTION OF WORK TO BE PREFORMED:
/b X I (
Identification Please Type or Print Clearly)
OWNER: Name: ft/ S4 Phone:ef7$-4S a ` &,s
Address: 3 5� Q-Btr���S�t ?Ve✓h
CONTRACTOR Name: Phone: _
Address:
Supervisor's Construction License: Exp. Date:.
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Phone:
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: $ ► c,� D FEE: $ 30 �-
Check No.: -55-3 Receipt No.: 0 ,100 (�i
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
ignature of Agent/Owner ( ._ u� Signature of contractor
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- t)-9 Signature
, - J r
r
COMMENTS A�6q Ih ck— �164-1A i C
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HEALTH Reviewed on 49 Si nature
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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
t
❑ Notified for pickup - Date
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—...........__....--....__._._.............._—......................_.............__.............-............_----..................-- --- ......................... ._._..._..............
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 f
❑ 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)
i
❑ 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
NORTH
TO" . of over
0
No. 2***
LAKE over, Mass.,
O COCHICHEWICK
00;?ATED
BOARD OF HEALTH
Food/Kitchen
PERMIT T Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT.......141;4Aj.........4.$..*v4........................ . .......................................................... Foundation
has permission to erect........................................ buildings on ......34V.......1� ..... Rough
to be occupied as../10
Chimney
..X.AP...........WT ....... .....0...............................................................................................
provided that the person 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
30 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTIO ST TS Rough
Service
BUILDING INSPECTM*%%ft.
Occupancy Permit Required to Omtpy 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.
11 SEE REVERSE SIDEJI Smoke Det.
f pORTM TOWN OF NORTH.ANDOVER
°•`"��*'�"° OFFICE OF
BUILDING DEPARTMENT
# ` 1600 Osgood Street Building 20 Suite 2-36
•+rev. North Andover Massachusetts 01845
1sswcwus�t '
Gerald A.Brown Telephone(978)688-9545
Inspector of Buildings Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
Please pmt
DATE: �fi IZ Its
JOB LOCATION: 3f65 �Gt�eI`�I� VW0 JAC
Number Street Address
HOMEOWNER cm(p S� - 61W0
Namb Homb Phone Work Phone
PRESENT MAILING ADDRESS WZ(sln `17AV4VI IM
" H^ MA-
City Town State 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 individual 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 owns a parcel of land on which helshe resides or intends to reside,on which there 1s,or 1s 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 for compliances with the State Building Code and other
Applicable codes,by-laws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requimeents.
HOMEOWNERS SIGNATURE 1 ��
APPROVAL OF BUILDING OFFICIAL
Revised 10.2005
Foam Homeowpets Exemption
�I
ROARDOF \PPE.V.S 6880541 CU.NSERV.1' ON 688-9530 HE_1L11f 698-9540 PLANNING 6R8-9535
The Commonwealth of Massachusetts
ki ! Department of Industrial Accidents
�., Ogee of Investigations
600 Nrashington Street
; a Boston, MA 02111
www mass gov/dia .
Workers' Compensation Insurance Affidavit: Builders/Contractors/Eiectricians/Plumbers
Am.Aicant Information Please Print Legibly
Name(Business/Organizafion/individual):- jj �A �J 0(� (� C�14IT
Ad&ess:
City/state/Zip: 111,k►�l �t/P,r 61 �t 5 Phone
Are you an employer?Check.the appropriate box:
1.13 I am a employer with 4, ❑ 1 am a genera(contractor and I Type of project(required)
employees(full and/or part-time).* have hired the sub-contractors 6• ❑New construction .
2.❑ 1 am a:sole proprietor or partner. listed on the attached sheet,t 7. ❑Remodeling :
ship and have no employees These sub-contractors have 8. Q Demolition -
working for mei' any capacity, workers' comp.insurance.
, insurance 5. 9• Building addition
[No workers'comp. ❑ We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
3 1 am a homeowner doing all work right of exemption per MGL 11.[] Plumbing repairs or additions
yseI£ [No-workers'comp• c. 152, §1(4),and we have no 12.'t ❑ Roof repairs
insurance required.]
.employees..[No workers' 13:0'Other ��`�,�
comp. insurance required-] --fid!
'Any applicant that checks bore lE I must also fill out the section below showing their workers'compensation policy information,
t Homeowners who submit this affidavit indicating They are using all work and then hire outside contractors must submit a new affidavit indicating such.
;Contractors that chest this box must attached an additional sheet showing.tare name of the sub-contractors and their workers'comp.policy information.
I
I an employer that is pr,?tndrng:workers
inffoormation. 'compensation insurance for my employees: Below is the policy and job site
'
Insurance Company Name: '
Policy#or Self-ins.Lie.#: Expiration Date:
Job Site Address:
City/State/Zl
p
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration d>ate�
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
of up to$250.00 a da a 1 p m the farm of a STOP WORK QItD£R and a fine
y against the violator. Be advis J
ed that a copy of this statement may be forwarded
investigations of the DIA for insurance coverage verification, y to the Office of
I do hereby cern ),under the pains and penalties of perjury that the information provided above is true and correct
Si tore: Date: /7
Phone#: S
SS.,
FFof
only. Do not write in this area,to be completed by city or town official
n: Permit/License#
use
(circle one):
ealth 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
son: Phone#:
e
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.r 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 nurnber 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 applicarrL
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 fixture permits or licenses. A new affidavit must be fri3ed out each
year. When 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 fur 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 Investibations
600 Washington Street
Boston, MA 02111
Tel.# 617-7274900 ext 4136 or 1-8.77-MASSAFE
Revised 5-26-05 Fax#617-727-7744
www.mass.gov/dia
JUN 27 2008 11 : 06AM YORKS 603 744 6690 10 , 1
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MORTGAGE INSPECTION PLAN
for mortgage purposes only 4
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*Certification is hereby made to CITY OR TOWN�otzTH �iJDo E� MA
Casa►.► o t= A m E 2 r C A DATE OF INSPECTION: Go/Z 4/o e
that the existing structures shown on this plan are
situated on the lot designated In complianos with the SCALE: 1 Inch = 470 eat
setback requirements of the applicable zoning bylaws
of the municipality when constructed, or are exempt DEED AND PLAN REFERENCE:
from violation enforcement action under M.G.L. Title
VII. Chapter 40A, Section 7. Es-5E>( (Q0V-TH- 0 1ST. ) Registry of Doods
'Certification Is hereby made that the existing dwelling Deed BOOK—Ca 5 Cv4 Page o4
or principal structure shown on this plan Plan Book Plan
1._ ' is not situated within a Special Flood Hazard Area *GENERAL NOTES:
2.__is situated within a Special Flood Hazard area A confirMatory survey is advised when structures
3. information is Insufficient to make determination. are shown to be situated at 1 toot or less from
An elevation survey is advised.
property lines or required setback linea, or when
potential encroachments are noted. No responsibility
as delineated on the FIRM Flood Insurance Rate Map is herein extended to the property owner or occupant.
Community No: Z50(>9 8/oo o e C Certifications and representations are on the basis
Effective Date: of my knowledge, Information and belief.
��>•<„s ALPHA SURVEY CORPORATION
^ •^ 126a Pleasant Valley St. - Suite 7-Methuen, MA 01844
.ray
Location 5�157 �& 6%!lh
No. 590 Date
NORTo, TOWN OF NORTH ANDOVER
3?O•,t`•o ,•,hot
►0- %
' r
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # USS
Building Inspector