HomeMy WebLinkAboutBuilding Permit #786-12 - 40 MOODY STREET 5/1/2012 (3)BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: �L Date Received
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One family
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
Others:
Repair, replacement
Assessory Bldg
Demolition
Other
DESCRIPTION ,OF WORK TO BE PREFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
Address:
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: $ FEE: $�
Check No.:
Receip t No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty_ fund
i
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 a 1d Si nature /
C0MMEN TS
HEALTH Reviewed on Signature
COMMENTS
n ( h 0 r
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:
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
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
❑ 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)
❑ 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: Building Permit Revised 2008
Location da
No. _1'�! Date l v
NORTH TOWN OF NORTH ANDOVER
O
F 9
* ; ; Certificate of Occupancy $
9
U Building/Frame /Frame Permit Fee $�`-
s,+cMse
Foundation Permit Fee $ "-
Other Permit Fee $
TOTAL $
Check #
2
Building Inspector
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F
µORTH TOWN OF NORTH ANDOVER
O tt.�o n6 �H
bE °� OFFICE OF
BUILDING DEPARTMENT
1600 Osgood Street Building 20, Suite 2-36
4goxw..�a.
North Andover, Massachusetts 01845
Gerald A. Brown Telephone (978) 688-9545
Inspector of Buildings Fax (978) 688-9542
HOMEOWNER LICENSE EXEMPTION
BUIDING PERMIT APPLICATION
Please print
DATE:
JOB LOCATION: 90 Y 0QW S- 0-Axi 6Ve,2 dl q q, -
Number Street Address Map/Lot
HOMEOWNER Y_k'� j l SSO (LP' Q7 �"'� Qg— 1.38 i P 1 % 5Z �l
Name Home hone Work Phone
PRESENT MAILING ADDRESS
City Town
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 7.2009
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540
PLANNING 688-9535
The Commonwealth of Af zssachusetts
Department o f rndustrW Accidents
Office of fnvestigatwns
..600 WashineQton Street
Boston, X4 02111
Workers' Compensation Insurance Aff da assgov/did
An licant Tnformation vit: Builders/Contractors/Electricians/Plumbers
PIease Print LeQibiy
Name (Business/Organization/Individual):
Address: ry,
City/State/Zip:00-0 $ta' Phone--
�--ag--
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with 4. ❑ I am a general contra7�F
f project (required):
2. ❑employees (full and/or part-time).* have hired the sub-coew, construction
1 am a sole proprietor or partner_ listed on the attached emodeling
ship and have no employeesThesesub-contractors haveworking for me in any capacity. workers' c emolition
omp, insurance.[No workers' comp• insurance5. ❑ We are a corporationand itsuilding additionre4tiired ] officers hake exercised their lectrical repairs or additions
3. I am a homeowner doing all work right of eXemption per MGL 11.❑ Plumbing repairs or
myself. [No workers' comp. c. 152, § 1(4), and we have no motions
insurance required.] t em to ees. 12.7 Roof
P Y o [No workers repairs
j ?icrx comp. msuxmce required-] 13•❑ Other
I Omeowneswag summit this affidavit indicating the secs ^ ce?o',• r^oY^^� `^� a or =s'
+Contractors that check thL- box must attached an additional sheet showing thea ® hire outside contuzcttc:s ryc� u�
iii... submit a new affidavit indicating such.
name of the sub-comuactors and to
T,. _._ eirwocker<'�r,,,.,
•� — _U[
"'W"sycr utas is r ---r• r�•••.y manon.
information.
P g workers ' compensaiiorc insurance for my employees. Below is the oft
P cy and job site
Insurance Company Name:
Policy # or Self -ins. Lic•:
Expiration Date:
Job Site Address:
City/State/Zip:
Attach a copy of the workers' compensation policy declaration age (showing
Failure to secure coverage as required under Section 2SA of M p the policy
number and expiration date).
fine up to $1,500.00 and/or one-year imprisonment, as well as Glc. 152 can lead to the imposition of criminal penalties of a
Of up to $250.00 a day against the violator. Be advised that a co penalties m the form of a STOP WORK ORDER and a fine
Investigations of the DIA for insurance coverage verification, py of this statement may be forwarded to the Office of
7,r,. L --L-- -
,.'�y "����.,,��J, `KRuer me pains and penalties of per• jury thQt � � formation provided above is true and correct
ahirP� 1 1' I D I,�ii_A R � 9 � ... _ ., -
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Issuing Authority (circle one):
1. Board of Health 2. Building Department
6. Other
Permit/License #
City/Town Clerk 4. Electrical Inspector.
Contact Person'
Phone Y:
e• Plumbing inspector
Information an_ d Instructions
Massachusetts General Laws chapter 152 requires all employers to provide worktrs' 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 includingthe legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association ox- other legal entity, employing employees. However the
owner of a dwelling house having not more than three aparmz eats and who resides therein, or the occupant of the
dwelling house of another who employs persons to do mainte:mance, construction or repair work on such dwelling house
or on the grounds or building appn,t n=thereto shall not bt:<--ause of such employment be deemed to bean employer."
MGL chapter 152, §25C(6) also states that "every state or local hcensinb a- ncy shall withhold the issuance or
renewal of a license or permit to operate a business or to C-- anstruct 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.perfoffiance of public work IML -til acceptable evidence of compliance with the in ur=C.
requirements of this chapter have been presented to the contracting authority.,,
Applicants
Please HE 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 certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited L'
Iabi-lity partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers, comp ration 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 1 Vt'u acd to the City ar town that the Arca ion for the P-Crrmitor license :8 being r= Sf«".d, not the .Depart^ e1t Of
Industrial Accidents. Should von have any questions regard, -b `ke law, or if you are :;:fired to ocain a workers'
compensation policy, please call the Department at the numbe=r 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 permiVlicense number which will be used as a reference number. In addition, an applicant
that must submit multiple permitllicense 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 permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or pert 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 than you in a&-mr--e for your cooperation and should you have any questions,
please do not hesitate to give us a call
The Department's address, telephone and.fammumber. _..
The Commonwealth of Massachusetts
D pwtment of Industrial Accidents
Office of inNesdaativons
600 Washingbn Street
Boston, M —A 02111
Tel. # 617-72.7-4900 est 40.6 or 1-8 77-1\/! 4SS:AFE
Revised 5-26-05 Fay: # 617-72.7 i 749
vrvrv,.mass._ gYov/dia