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Home My WebLink AboutBuilding Permit #389-14 - 39 DAVIS STREET 10/24/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: t Date Received Date Issued: (� !,- I ORTANT:Applicant must complete all items on this page LOCATION -D&A S., E-( Print PROPERTY OWNER IC90LAS Print 100 Year Old Structure yes no MAP NO: PARCEL 'ZONING DISTRICT: Historic Districtye no Machine Shop Village ye 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 0 Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: u� Identification Please Ty a or Print Clearly) OWNER: Name: Phone: Address: CONTRACTOR Name: Phone: Address: 4 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: $ d FEE: $ 1`, ( J Check No.: we b Receipt No.: ��q.y NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund Signature of Agent/Owner �ignature of contractor i Plans Submitted Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Location(.( V 1-<-,. Y Date • • TOWN OF NORTH ANDOVER Certificate of Occupancy $ , Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check Building Inspector Plans Submitted ❑ Plans Waived ❑ C-ertified Plot Plan ❑ Stamped Plans ❑ -TYPE-'OF--SEWERAGE DiSPOSAL Public Sewer ❑ Tanning/MassageBodyArt ❑. . 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 DATEAPPROVED PLANNING & DEVELOPMENT- ❑ ❑ COMMENTS -CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Y Decision/receipt submitted es Planning Board Decision: Comments d Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Todw2 Engineer: Signature: Located 384 Osgood Street ='FIRE DEPARTMENT - Temp Dumpster on site yes no Located'at 124 Mair, Street - -Fire Departme►it signature/date-` ; a 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 El Notified for pickup - Date 3 C Doc.Building Permit Revised 2010 Building Department The fol owing is-a list of the required.forms to be filled out for-the appropriate.permit to.be obtained. Roofivg, Siding, Interior Rehabilitation Permits o ` Building Permit Application ❑ Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract o Floor Plan Or Proposed Interior Work Li 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 o Certified Surveyed Plot Plan i o Workers Comp Affidavit I a Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o 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 o Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) a Copy of Contract o Mass check Energy Compliance Report o 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 apt)%-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.tted with the building application Doc: Doc.Buhding permit Revised 2012 NORTH own of t EAndover o _ .,: 10 No. 3 — - ,� oh , ver, Mass, a I coc Nlc"t WICK �1• �d ADRATED j1'Pp,`'�� S U BOARD OF HEALTH Food/Kitchen PERMIT T LD y� Septic System THIS CERTIFIES THAT � i:.�L��-4,��?.......... .. L.:.. .L. . ....-........................... BUILDING INSPECTOR ....... .. .......... .. ....... has permission to erect buildings on ..3� �i(. �1 C - Foundation .......................... .. ..... . .�S........... .. Rough C � 4 .....T;uto be occupied as . :Gs.......... U ..G? ........... Chimneyy tion Finalprovided that the person accepting this permit shall in every respect conform to the terms othe app Ica 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final pp . PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI START 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. SEE REVERSE SIDE .' hasty TOMW OF NORTH ANDOVER ° 6>`-:-, , °� OFFICE OF BUILDING DEPARTMENT ' 00p`y P° 1600 Osgood Street$wilding 20, Suite 2-36 "qs q�uu5��5 •North Andover,Massachusetts 01845 Gerald A.Brown Inspector ofBuildings Telephone(978)688-9545 . HOMEOWNER-LICENSE BXENIpTION Fax (978)688-9542 BIIIDING PERMIT APPLICATION Please print DATE: 1 C7 _4- 1 :J0B LOCATION: Number Street Address Map/Lot .HOMEOWNL�R I�I. S .. Name. Home Phone Work phone PRESENT MAILING.A-DDRESS !e— j To,,m. State. Zip Code The current exemption for`o en age a- was extended to hnclude owner-occupied dwellings to two units or less and to allow su;h homeo�;�ners to engage an i icivSdual.for hire who does not possess a license,provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) r DEFINITION OFHOMEOWNER Person(s)who awns a parcel of land on which he/she resides or intends to reside,on which there is,oris intended to be,a one or two family structuresAerso . person who constructs more that Ane home in a two-year period shall not e considered a homeowner. The undersigned"homeowner"assumes responsibility for compliances with the State Build' Applicable codes,by-laws,rules and regulations, mg Code and other The undersigned"homeownez"certifies That he/she understands the Town of North Andover Building Department eqMinimumrem inspection procedures and requirements and that he/she will com ly with,said procedures and requirements, HOMBOWNLRS SIGNATURE APPROVAL OF BUILDING OFFICIAI, Revised 7.2009 YOTM Homeowners Exemption "BOARD OF APPEALS 688-9541 CONTSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 i The Commonwealth of Massachusetts - Department of IndustriglAccidents Office ofInvestigations 600 Washington Street Boston,MA.02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractor8/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual):, _G—� Address: S59 T -p 1jl c� - City/State/Zip: �� Phone#: -7 S VzL Are you an employer?Check the appropriate box: Typo of project(required): 1.❑ I am a employer with 4• ❑ I am a general contractor and I 6. ❑New construction employees(fall and/or part-time).* have hired the sub-contractors 2111 am a sole proprietor or partner- listed on the attached sheet.+ �• [L�Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g• FJ Building addition WO workers'comp.insurance 5. El We are a corporation and its 10.OElectrical repairs or additions equired.] officers have exercised their 3. 1 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.QRoofrepairs insurance .re uiredemployees.[No workers' required.] 13.❑other ,I comp.insurance required.] 'Any applicant that checks box#1 must also fill outthe 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 anew 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. I am an employer that is pr oviding workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name Policy#or Self-ins.Lie.#: 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 requiredunder Section 25A of MGL o. 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA.for insurance coverage verification. - I do hereby cero under the pains andvena 's perjury that the information provided above is true and correct. - Si afore• ate: 0--� Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/t,icense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - Phnna d$ v I I 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 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 ofits 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 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 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 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 retumed 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"Many 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 orpermit 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: Tho Cowx oac�veattla of 1\4 sarl?vsPtts - Depaxt oat offadwbial Accidents Q face oflavestiptious 600 Washuugtou8txeet BOAQRNA02111 TQJ,#Q7-727-4900QXt406 -1 Revised 5-26-05 Fay,#617-727-7749