HomeMy WebLinkAboutBuilding Permit #865-14 - 4 TYLER ROAD 6/2/2014TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: "l J Date Received
Date Issued: Z
IMPORTANT: Applicant must complete all items on this page
LOCATION.
PROPERTY OWNER,/
LLN-V
V-1 kNm t
Residential
MAP NO: 032- PARCEL:
Print100 Year Old Structure
ZONING DISTRICT: District
yes
yes
�
❑ Addition
Machine Shop Village
yes
e5
TYPE OF IMPROVEMENT,
PROPOSED USE
Residential
Non- Residential
❑ New Building
None family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
Repair, replacement
❑ Assessory Bldg
❑ Others:
0 Demolition
❑ Other
0 Septic 0 Well
❑ Floodplain ❑ Wetlands
❑ Watershed District
0 Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
0
or Print Clearly)
OWNER: Name:
AcirirPss:
e
— 91 331 '
CONTRACTOR Name: Q� �— �-� Phone:
n
Address: 1,30 A34 40,6&W
J
Supervisor's Construction License: G��� I � �% Exp. Date:
Home Improvement License: C Exp. Date:
ARCH ITECT/ENGINEE
Phone:
Address: Reg. No.
FEE SCHEDULE: SULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ FEE: $ <�t-L+ (0
Check No.: Receipt No.:
NOTE: Persons contracting ith u eg' tered contractors do not have access to the guaranty fund
nature of Agent/Owne _ Sigilature of contractor
Plans Submitted L J Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans
-: Plans Submitted- ❑ Plans Waived ❑ .:: ..-._.Certified Plot Plan ❑ Stamped Plans ❑
TYPE OY SEWERAGEDISPOSAL"
Public Sewer ❑
Tanning/Massage/Body Art ❑
Swimming Pools ❑
Well ❑
..Tobacco Sales ❑ .:
Food Packaging/Sales ❑
Private,(septic tank, etc._ ❑ - _.,.
-Permanent Dempster on* Site ❑
THE -FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE. REJECTED - DATE:APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMEN
-CONSERVATION Reviewed on Signature
COMMENTS
HEALTH
COMMENTS
Reviewed on - Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes .
A
Planning Board Decision: Comments
Conservation Decision: :Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW To` 2 Engineer: Signature:
Located 384
-'FIRE DEPARTMh—."NT : Ternp Dumpster on site yes_ no
Located -at 124,Mair, Street
Fire Depal tme►it.signatureldate '
COMMENTS Y
)sgood Street
-.-Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions._
-Total land area; sq. ft.:
ELECTRICAL: Movement of. Meter locaffon, trust -or service drop requires approval of
...:Electrical Inspector Yes No
DANGER -ZONE LITERATURE: Yes No
MGL-.Ch'aPter166.Section 21A: -F and G min.$100=$1000.fine
SIU I t5 and UA I A — (t -or department use
1
El Notified for pickup - Date
Doc.Building Permit Revised 2010
Building Department
_ •The fol; -awing isa list of the retiuired.forms to be -filled out for:the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
a Building Permit Application
❑ Workers Comp Affidavit
o 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)
o 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
❑ Certified Proposed Plot Plan
a 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 cans if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the apn•-�al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submAted with the building application
Doc: Doc.Building Permit Revised 2012
Location 4
No. S16-- Date
Check #49�l
TOWN OF NORTH ANDOVER
Certificate of Occupancy $-
Building/Frame Permit Fee $
Foundation Permit Fee
Other Permit Fee
TOTAL $
Building Inspector
Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
20,000.00
m
$ -
$
240.00
Plumbing Fee
$
30.00
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
30.00
Total fees collected
$
400.00
4 Tyler Road
865-14 on 6/2/2014
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The Commonwealth ofMassachasetts -
Departmint offnd ustrigl Accic%nts
Office offnvestigations
600 Washington Street
Boston, HA 02111
vww.mass:govIdla
Workers' Compensation Insurance Affidavit: Budder°!Cont°actors/Elecir ,clans/, eli*bers
Applicant information Please Prit Le0bly
Name (Businessiorganizaiionffndz`vidual):
Address: �'
7-1 /P it-/- - .94:2,—
City/State,/Zp: e k- Phone #: S -O
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 f
employees (full. and/or pari time).*
2. ❑ I am a sole proprietor or partner
have liked the sub -contractors
listed on the attached sheet.
I. ❑ Remodeling
ship and'haveno.employees
These sub -contractors have
S. [ Demolition
worldng forme in any capacity,
workers' comp, insurance.
9. D Building addition
[No workers' comp. insurance
5. ❑ We are a corpora] on and its
10.0 Electrical repairs or additions
required.]
3 X am a homeowner doing allwork
officers have exercised.their
right of exemption per MGL
11.[( Plumbing repairs or additions
yself [No workers' comp.
c. 152, §1(4), andwehaveno
12.❑ Roofrepairs
insurancere ed.
employees. [No workers'
13.❑ Other
comp. insurance required.]
XAny applicant that checks box#I must also fill dut the section bel6w showingtheir workers' compensationpolicy information.
f'Homeowners who submit ihis affidavit indicatingthey kdoing allworK and then hire outside contractors must submit a new affidavit indicating such.
tContractors that cheokthis box must attached as additional sheet showingthe name of the sub -contractors andtheir workers' comp, policy information.
I am an employer that zs providing workers' compensation insurance for my employees Below is the policy andjoh site
information.
Insurance Company
Policy I# or Sel£ ins. LIG.
ExpirationDate:
lob Site Address: City/State/Zip:
Attach a copy of the workers' compensatlon'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 $1,50 0.00 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.
Mo hereby cert jjmpairzstridvenalties ofperjury that the information, provided above is true and eo rect.
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. CitylTowwn Clerk 4. Electrical Inspector 5. Plumbing inspector
6. Other -
Coatact Person: Phone
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statate, an ernployee is defined as "...every person iii the service of another under any coi Tact ofhixe,-
express orimplied, oral orwxitten."
An ewfoyei is defined as "an individual, partnership, association, corporation or other legal entity, or any two ormore
Of the £oregging engaged in a joint enterprise, and including the legal representatives of a•deceased em to ex or the
xeceiver ox trustee of an individual, partnership, association or other legal entity, employing employee However the
owner of a dwelling house having notmore 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."
UGL 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 ofpublic work until acceptable evidence of compliance with the insurance
requirements of this chapter have bcon presented ta the contracting authority."
Applicants
Please fffl out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub -contractors) name(s), addresses) 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 orpartners, axenotregaixedto carryyworkers' compensation insurance. If an LLC orLLP doeshave
employees, apolicy is required. Be advised thatthis affidavit maybe submitted to the Department of Industrial
Accidents for confirmation ofiusurance 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 pemlit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law ox if you are required to obtain a *orkers'
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 andprinted 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 whichwill be used as a reference number. In addition, an applicant
thatmust submitmultiple permit/11conse applications in any givenyear, 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
tow:')." .A: copy ofthe affidavit that has b een 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 fature p ermits or licenses. Anew affidavit trust be filled out each
year. Where a home owner or citizen is obtaining a license ox permit not related to any business or commercial ventuxe
(i.e. a dog license orpermit to burn leaves eto.) 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 numb or:
Tho Gaxrojjw0atL olas z..c?vsPil
D�paex�� o£XuCTZI'�a1.A.aC�(iexlis •
( face onwoi ggoo.na
6Q0 WasW-a&n Gx�
TO.9 617-7-2,7-49 0 at 406 Qx I-877-WASM . 9
Revised 5-26-05 FaY, 0 617-727-7749
• �vv.�a�s,gQv�ctia
P4 � � ev7iy TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEM
• ' �r K °ry y :'7600 Osgood StreetBt�.ilding20�, -Snzfie �36 `
y�S�Rc+�us �5 ' NOAAndover, Massachusetts Q1845 -
Gerald A. Brown - Telephone (978) 688-945
7nspecforofBuildings Fax (978) 689-9542
HOMEOWNER. -LICENSE EXEMPTION
WDJNG PHRMT PLICATTON
Mase print
DATE: j
JOB LOCATION: L
umber SfreetAddress lVlap/Lot
' I�OMEO�NER �' — � ..
Name. . Horne Phone
LRaZ2
WorkPhone
PRESENT MAILING .ADDRESS i
Ci �i Tut=m
`t`{w lip Cods
The current exemption for "-homeowners" was extended to iuclude owner-oc.,tipied
to allow such hon7P0 :-r - r dwenk-'s to two -units -Or less and
�ue.�s to engage an i1dividual•forhire who does notpossess a license, provided that the, owner
acts as supersrisor}. Siafe3uilding (Code Section I08.3.S.I)
DBFMITION OFHOMEOVMP
Persons) who Awns a pazcel ofland on which hQ/she resides or intends to reside, on which -there zs, or is intended to
rjo s one or two feown structures. A person who constructs more that -One home in a t o yearperiod shall not be
considered a homeowner,
The undersigned "homedwner" assumes responsibility for compliances with the State Building Code and other
Applicable codes, by-laws, rules andregulations,
The undersigned "homeowner" certifies that he/she vnderstauds th wu of l�%rth AndoverBuilding Department
minimum inspection procedures and requirements and that h e comply withtsaid procedures and
requirements
HOMEOWNERS SIGNATURE
APPROVAL OF BUMD.MG OFFICIAL
Revised 7.2009
Form Homeowners Exemption
'EOARb OFAPP.EAYS 688-954-CO7�SEr �
R'4AMN688-9530 HEALTH 688-954o PLANNING 688-9535