HomeMy WebLinkAboutBuilding Permit #528 - 393 MAIN STREET 4/8/2009Permit NO:
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Date Issued: O
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
/ IMPORTANT: Applicant must complete all items on this page
LOCATION 3 ?3 In ��✓ %lt'i � ®,::??
Print
'PROPERTY OWNER
Print
MAP NO_PARCEL: ZONING DISTRICT: Historic Distract 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
DESCRIPTION OF WORK TO BE PREFORMED:
uT- Ltv4
C k"g
Identification Please Type or Print Clearly)
OWNER: Name:A Lff,za ice,,, Phone: 79y J45cT
Address: jyAy y -
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: $ -SC% Z) FEE: $ O
Check No.: Receipt No.: s
NOTE: Persons contracying N,1ith unregistered contractors do not have access to the guaranty fund
of
6
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 Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
Comments
Water $ Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
'FIRE DEPARTMENT Temp Dumpster onsite yes no
Located at 1.24 Main Street
Fire Department signatureldlate
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
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
NOTES and DATA — (For department use
❑ Notified for pickup - Date
Doc.Building Permit Revised 2008
MC
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)
a-
❑ 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 DEPARTMENTMFORM07
Revised 2.2008
Location 313 X41 K s
No.a Date J
TOWN OF NORTH ANDOVER
. L
NO MIFF -
A
Certificate of Occupancy $
cMH tom Building/Frame /Frame Permit Fee $
s�ust 9
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # /--�o
2,94
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Building Inspector
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AORTM
TOWN OF NORTH ANDOVER
'`"'e '` ��
OFFICE OF
p
BUILDING DEPARTMENT
1600 Osgood Street Building 20, Suite 2-36
North Andover, Massachusetts 01845
Gerald A Brown
Inspector of Buildings
HOMEOWNER LICENSE EXEMPTION
Plempriat
DATE: �� o
Telephone (978) 688-9545
Fax (978) 688-9542
JOB LOCATION: ,3 % � zt�aiy ST
Number Street Address Map/Lot
HOMEOWNER
Name Home Phone Work Phone
PRESENT MAMING ADDRESS 3 9 � 07,01",, 57 -
Town
State
Code 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 he/she resides or 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 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 pmcedums and
requirenlents.
HOMEOWNERS
APPROVAL OF BUILDING OFFICIAL,
1zaviwd 10.2005
Form Homwwnms Exemptim
BOARD OF \PPF. V.S6RR-7541 CU.NSERV.1' ON 688-9530 ITE.UAll688-95-10 PLNINING688-9535
sN The Commonwealth of MassachusetV
Department o
De art
�(W� P ,f 1'ndustrial Accidents .
Office of investigations
600 Washington Street
i Boston, MA 02111
r -� wwx�_mass.gov/din
Workers' Compensation Insurance .A davit: Builders/Contractors/Electridians/Plumbers
Appficant Information
Please Print Lesibly
Name (Business/Organization/Individual):
Address:
City/Siete/Zip:__ ��,, v� hzLt ®�d�yS•�hone #:�j/�`—%1�'S''—�'��o
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with 4. ❑ I am a ---neral contractor and I
employees (full and/or part-time).* have hired the sub -contractors
2. ❑ 1 am a sole proprietor or partner- listed CM the attached sheet I
ship and have no employees These sub -contractors have
working for me in any capacity. workers' comp. insurance.
[No workers'. comp. insurance 5- ❑ We are a corporation and its
I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
ofiicen 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 ad.ditii.on
.1 0-0 Electrical repairs or additions
I1.❑ Plumbing repairs 'oradditions
1117 Roof repairs
13.❑ Other
*Any applic ant.that checks box # 1 .must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit Alis aiidevtt iniiicarin� iiiei+ erg eir
uiit� ' c r rl atyd Lhcn hi - outsiat wntraciurs rnusi su'omii a now amuavii irdixting such.
'Connaciors.lhal ehecl: this box must attached an additionsl sheet showing the name of the sub-conn�actors and their workers' comp. Plic}l inionnation.
I am ann employer that is proviiiirze workers' compensation insurance for ng' employees. Below is the policy information p cy and Job site
Insurance Company Name:
Policy # or Self -.ins. Lic. #:
Expiration Date:
Job Site Address: City/StatclZip:
Attach a copy of the workers' compensation policy deciaration page (showing the policy Dumber 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 51,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 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 up4r I*e pai
insy4d prr ec of perjury' that the information provided above is true and correcL
O
Official use onlp. Do not write in this area, to be completed by city or town. of,,-iciaL
City or Town: Permit/License #
Issuing Authority (circie one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
Contact Person: Phone P
Information and Instructions
Massachusetts General Laws chapter 152 requires all empioyers 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 includirr.g the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, associati on or other legal entity, employing employees. However the
owner of a dwelling house.having not more than .three ap—vtme'nts 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 cer local licensing agency shall withhold tine issuance or
renewal of a license or permit to operate a basiness 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 contra ting authority.".
Applicants
Please fill out the workers' compensation affidavit compj-etely, 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 certincate(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 affici`a.vit may submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the. affidavit The,affidavit shouid
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 regi ridingthe I-�., or if p re
you a„ required to obtain a workers'
compensation policy, please call the Department . the nQ•icnberiisted below. Self insured companies shouid 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/iicense number which will be used as a reference number. In addition, an applicant
that must submit multiple permitAicense 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
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to they or
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 ticens;_ 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 ofl-idusirial Accidents.
Office of Lavestiagations
600 RzastLington Street
BQSWn; MA 0 111
Tel. # 617-727-4900 e)zt 406 or 1-877-MASS.4FE
Revised 5-2645 Fax 4 617 -?2.7-.7749
W%M'-M3SS.bov%Glia
