HomeMy WebLinkAboutBuilding Permit #40 - 4 LACY STREET 7/8/2010 BUILDING PERMIT of NORTh
TOWN OF NORTH ANDOVER o= h
APPLICATION FOR PLAN EXAMINATION '- ~
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Permit NO:
Date 0 Received gDRtrED
Date Issued: `' SACHU-
IMPORTANT Applicant must complete all items on this page
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I-PRQPER�TI(®WNERtr y ?`
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+ _ �, r- ZONING DISTRICT lHr"stone Des rt ictl �' x' a rib
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
' ptic:'h Floodplain ,WetlandsFWatershec! Dlstr.ict
Water/SeWEr' *
n
DESCRIPTION OF WORK TO BE PREFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: k Phone•Ca/� 5�3Q
Address: I ON-
;;C NTLF �4 CTOR
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Adtlress�
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SU ECYISOr'sConsfru
License >> a ;r . = Date a :
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77.
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ARCHITECT/ENGINEER A144— Phone:
Address: Reg. No.
FEE SCHEDULE:BULD/NG PERMIT: 12.00
$ PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
Total Project Cost: $ FEE: �—
Check No.:-.1 1 Receipt No.: 3ok
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty.f and
• `,-;Signature of_contractor_ ._
Plans Submittedans 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 j
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
f
fl
Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes
i
. i
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature&Date Driveway Permit I
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIREFDEPARTMENT ��Temp Dumpster on
i �' T ....i •`�::fa-.»..k 'k� .1�,,..
* FireDepartments�gnature/date
z
Dimension
Number of Stories: o? 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)
❑ Notified for pickup - Date
Doc.Building Permit Revised 2010
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
p i
❑ 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 ii
-
❑ 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)
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered- products
NOTE: All d re
dumpster permits p p quire 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 l
NOTE: All dumpsterermits require sign off from F'
p q g Ire Department prior to Issuance of Bldg Permit
i
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
I
Doc:Building Permit Revised 2008
4
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Location T
No. v Date —1
� 3
MORT1f , TOWN OF NORTH ANDOVER �+
10. 9
' Certificate of Occupancy $
s'uMUS t�' Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $ r
TOTAL $
Check # 0
23UU1
Building Inspector
F ORTly
: _ Andover
® of _
No. 0 4o -
!216
_=- L K E o dover, Mass.,
A_ COCMICMEWICK ��
ADRATED CO
SS BOARD OF HEALTH
Food/Kitchen
Septic System
R M 1;..T
P E.
BUILDING INSPECTOR
THIS CERTIFIES THAT......... ........ .................................................... ...... Foundation
.................. Rough
has permission to erect.... .... ............................ builk on ...... ...��dG.. g
to be occupied as...... .................. .................® .... ......................................................................................
Chimney
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
PERMIT EXPIRES IN 6 MONTHS
ELECTRICAL INSPECTOR
UNLESS CONS TRU N TARTS Rough
........... ..................................................................................................
Service
BUILDING INSPECTOR Final
Occupancy Permit Required t0 Occupy Building GAS INSPECTOR a
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
The C'ommOnwe¢lth of Massachusetts
Department o f Industrial_Accidents
Office of.£nvestigations
600 Washingon Street
Boston, M4 02111
Workers' CompensationInsurance A ffiavit; g dna
An licant Informaf3on ders/Contractors/Electricians/Plumbers
PIease Print Legibly
Name (Business/Organization/individual):
Address:
City/State/Zip:_�f/' ,Pr�� ! - O/d"��F-Phone#: �7
Are you an employer?Check the appropriate box:
1.❑ I am a employer with 4. ❑ I am a g Type of p7eq7ed : .=eneral contractor and Iirs
employees(full and/orpart-time).* have hired the sub-contractors ❑Nem2.❑ I am a sole proprietor or partner- listed on the attached sheet t 7. ❑Remship and have no employees These sul�-contractors haveworking for me in any capacity. workers coin . ' 8. ❑Dem[No workers' comp. insurance5, P insurance.❑ We area corporation and its 9. ❑Builrequired] officers have exercised their 10❑Aecam a homeowner doing all work riQ t of epairs ddttrons
myselfcomp. � exemption P�MGL 11.❑Plumb repairs�
Y " [No workers' g eP additions
c. 152,§I(4);and we have no
insurance required.] t employees. [No workers' 12'7 Roof repairs
y a^p?icaat+hat b� ! yi comp.insurmce required.] 13 ❑ Other
t �box r..: mus__so sui cu!'Ene aecaa_ceior., boy W.�
I.3omeownees who submirthis affidavit indicating the a*✓deg^aL vcric and r wcr�as'comp--sem^c
s ' tnedhire outside contractor •; . ..-ecu
*Contractors that check this box m s attached an additional sheet showing sbmtt a new affidavit indi ating such.
the name of the sub-contractors and their workers'comp.policy information.
information.
I am¢n employer that is psoviding workers'compensation and
for my employees, Below is the policy and job site
Insurance Company Name:
Policy#or Self-ins.Lic.#:
Expiration Date:
Job Site Address:
Attach a copy of the workers' compensation policy declarationa.e(showing City/Stats/Zip:
Failure to secure coverage as required under Section 25A of MGL c.. "e(sh lead to a policy number.and expiration date).
fine up to$1,500.00 and/or one-year imprisonment,as well as c= the imposition of criminal penalties of a
of up to$250.00 a day against the violator. Be advised that a co Penalties in the form of a STOP WORK ORDER and a one
Investigations of the DIA for insurance coverage verification. FY of statement may be forwarded to the Office of
I do hereby certify under the pains and penalties o er ,
fP %� thrri the information.provided above is true and correct
Siffiature:
..... Date.:._.:. _./-Z-,r-'i0
Phone#: / _
O
fficial only. Do not write in this area, to be completed by city or town official
n:
PermitUcense#
use
(circle one):
Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector S.plumbing
Inspector
son•
Phone#:
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NORT#t 1 TOWN OF NORTH ANDOVER
� OFFICE OF
p BUILDING DEPARTMENT
=o+ A 1600 Osgood Street Building 20, Suite 2-36
`;"e®+u:�r' * North Andover,Massachusetts 01845
..Teo
Gerald A.Brown Telephone(978)688-9545
Inspector of Buildings Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
Please print
DATE: ,7'7��y v
JOB LOCATION:
Numbe�r� Street Address Map/Lot
HOMEOWNER 14`!L!G- �//wGc��.r— ���—�7 �S3�KO)
Name Home Phone Work Phone
PRESENT MAILING ADDRESS Z, q
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 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 procedures and
requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Revised 10.2005
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
Information an_ d Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employers.
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,
as n,co oration or o
n, rp ther legal entity, or any two or more
of the foregoing engaged in a joint en
€ a engaged se.and includin
. � �Pn €tie legal „ resentatives of a d
. - r"P deceased
r employer, or the
receiver or trustee o,
an individual,partnership, association
DW other legal entity,employing employees. However the
owner of a dwelling house having not more than three aPartooL ents 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 c onstruct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of coimpliance 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 uti-tl 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), addresses) and phone numbers)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'comp C-11sa{ion 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 s -we to sign and date the affidavit:. The affidavit should
be mt.arned to the city or to7,rn that the applieattion for the^ nanen 1�0' �e
r it or li,.,,..se'-R Bing. ques cd,not the.Department.of
Industrial Accidents. Should von have any questions re-ardiT,b the haw or if you :.^hired to obtain a workers'
compensation policy,please call the Department at the numbez-listed below. Self-insured companies should enter their
self-insurance license number an 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 BE in the p=nit/license number which will be used as a reference number. In additiom 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 perxiits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a Iicense or permit not related to any business or commercial venture
(i.e.a dog license or permit m burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would Bice to than 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,tel phone and.fax-min ber._. .
The CommonwealtiL of Massachusetts
Department of Industrial Accidents
Office of Investic ai ons
600 Washington Street
Bacton,MA 02111
Tel. - 617-72.7-4900 eaft 406 or 1-9 7/7-V1 4sSAFE
Revised 5-26-05 FD. #617-727-7 749
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