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Home My WebLink AboutBuilding Permit #033-14 - 400 DALE STREET 7/10/2013 TOWN OF NORTH ANDOVER PPLICATION FOR PLAN EXAMINATION Permit NO: 0 Date Received Date Issued: PORTANT: Applicant must complete all items on this page LOCATION` "GSD � I� �6 PROPERTY OWNER olvc Pn 1. V Print�A+, 100 Year Old:structure yes no MAP NO vW _PARCEL-: 4ZONING DISTRICT: Historic:DistriQt yes Machine. Shop Village yes n TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family '"ddition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic! ❑Welt ❑:Floodplain p Wetlands ❑ Watershed District: . 11 Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: / )bI � kl1 Identification PLease Type or Print Clearly) OWNER: Name: �gvl fer , �. Phone: �7� 6 M-�� Address: CONTRACTOR Name: _ Phone: -' Address: Supervisor's Construction Licenser 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: $ s6 a FEE: $ 1dt(.0 Check No.: Receipt No.: 941 ,' 0.93 NOTE: Persons contracting with uhregistere4 Contractors do not have access to the guaranty fund $ i natu�e'of•A ent/Owner Giiure of contractor . .g,,. -.�. . .r.g.._ -_.._ ._r Plans Submitted ❑ Plans Waived 0 Certified Plot Plan ❑ Stamped Plans ❑ Location VaO No. Date . - TOWN OF NORTH ANDOVER . Certificate of Occuncy $ T Building/Frame Permit Fee $W(",� v Foundation Permit Fee $ CG Other Permit Fee $ ` -IT n� `4 TOTAL $ Check# 26603 Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE-OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBodyArt ❑. . Swimming Pools ❑ j Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ I THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM I / DATE REJECTED DATE APPRO ED �( PLANNING & DEVELOPMENT ❑ /o? P7 COMMENTS 11 �j' l.yC[ I✓� I x CONSERVATION Reviewed on /a- 13 Signature COMMENTS HEALTHReviewed on Signature COMMEN 77Zoning 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 I DPW Tovvo Engineer: Signature: Located 384 Osgood Street FIRE DEPARTME=NT - Temp Dumpster on site yes no Located at'124 Main Street Fire Departineit signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Deter location, mast or service chop 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 /VO G'N �Gt/ �G( 6 q� '7h B Notified for pickup - Date Doc.Building Permit Revised 2010 Building Department The folE`pwing is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofivg, 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 j ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit I 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 apnaal 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.Bufiiing Permit Revised 2012 North Andover MIMAP June 3, 2013 t 0 e� a a� �l , ,. . w. ek ir Y '�'' VAN M. �" �" � � »�("` 'F fi*'s♦�?,�'�'- y � �s r= ."+� � ,�"�" S ��.. � x �sE� � ,� � �a• +`� hyo �'�C`��':' ^�` �s. M A � _ r� e »w •. ""r�'. � k« "»� i�� ' 7 t Vi m a 1. - `� '�'� �," i � � *�,� •�` �,,� ., ,•(�e' Interstates Interstate Horizontal Datum:MA Staleplane Coordinate System,Datum NAD83, Major Roads Meters Data Sources:The data for this map was produced by Merrimack Roads NORTH Valley Planning Commission(MVPC)using data provided by the Town of t.r Easements Cb 4�Lt o , �O North Andover.Additional data provided by the Executive Office of Environmental Affairs/MassGIS.The information depicted on this map is Q MVPC Boundary 3� • O� for planning purposes only.It may not be adequate for legal boundary rl Parcels O .—• A definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER �- A MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING ♦ THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY * t n y OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF �e THIS INFORMATION �,SSAGHuS�S ; 1"=30 ft ^�` �AORTH Town of E : Andover No. I� ® t - 33- _ .AK• h i ver, Mass, ( (� • 3 COCHIC01WICK AOJ 'ATED S t) BOARD OF HEALTH Food/Kitchen T LD Septic System 11-- THIS CERTIFIES THAT .........(QPERM !�T ..1!l�.t<.. ............ ....... BUILDING INSPECTOR ....... .. ........ ........... . has permission to erect buildings on qW Foundation Rough to be occupiedas ....� �....� ...1G......P1:.:iK..xr.............................................======V .......................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MO SSITHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO AR 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 TO"OF NORTH ANDOVER OFFICE OF BUILDING DEPART MENT �A :'1600 Osgood Street Building 20,-Suite 2-36 y'�s a�usc�5 North Andover,Massachusetts 01845 Gerald A.Brown inspector ofBuildings Telephone(978)688-9545 ROMEOWNER-LICENSE EXE&TION Fax (978)688-9542 LjaING PERM[T.APPLICATION Pleas__enrint DATE: JOB LOCATION: no -- Number Street Address — . MaplLot. .. F50MEOWNER Vv G C� `73� q Name. 6 95 �H/ome Phone Work Phone PRESENT MAILING ADDRESS "G bo City Tn•=m qf- Zip Code The current exemption for thomeowners"was extended to include owner-occupied d�velIings to ttivo units or less and to allow subh l,omPo,rers to engage an:,- hire who does not possess a license,provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) DEFINITION OFHOMEOWNER Persons)who Qwns 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 fan-iIy structures. A person who constructs more that one home in a which there O shall not e considered a homeowner. The undersigned"homeowner"assumes responsibility for Applicable codes, compliances with the State Building Code and other by-laws,rules and regulations. The undersigned"homeowner,,certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requ' ements andthat he/she will comply with,said procedures and requirements, HOMEOWNERS SIGNATURE , APPROVAL OF BUILDING OFFICIAL Revised 7.20o9 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONTSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 The Commonwealth OfMassachusetts - Department o,f IndustriglAccidents Office of Investigations 600 Washington Street Boston,MA.02111 www.mass govIdia Workers, Compensation Insurance Affidavit:Buil.ders/Contractor$/Electricians[Plumbers Applicant Information Please Print I,e ibl Name(Business/Organi'zationftdividual): Address: YQ City/State/Zip: e Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.Q T am a employer with 4. ❑ Tam a general contractor and T 6. ❑New construction employees(full and/or part-time)* have hiredthe,sub-contractors 2.❑ T am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. D Demolition working for me,in any capacity. workers'comp.insurance, g• ';,\Budding addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their right of exemption per MGL 11.1]Plumbing repairs or additions 3M I am a homeowner-doing all work myself.[No workers'comp. c.152,§1(4),and wehave no 12,0 Roofrepairs insurance required.]t employees,[No workers' 13.❑Other comp,insurance required.] "Any applicant that checks box 41 must also fill out the section below showingtheir workers'compensation policy information. I Homeowners who submit this affidavit indicating they ire doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. X am an employer that is providing workers'compensation insurance for my employees. Below is the polfcy and joh site information. Insurance Company Name:. Policy#or Self-ins.Lic.#: ExpirationDate: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation-policy fleclaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c.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. - X do Taereby t r tTie /ns ��pye�nnalties ofperjury that the information provided ahove is true and correct. Si afore: W '" C, Date: / Phone#: Official use only. Do not iVrite in this area,fO he completed by City or town Official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector 6.Other 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"...everyperson in the service of another under any contract ofhire,• express or implied,oral or.wxiiten." 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 df another who employs to p ys persons to do maintenance,construction or repair vrork 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 an of its political subdivisions' i enter into an contract 3' p ivzszons shall y t for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have beenpresented to.the ogntractingauthority." 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 certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are notrequired to carry workers'compensation 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 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 p 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 fila 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 mast submit multiple permit/license applications k 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 maybe provided to the applicant as pro of 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 bum leaves etc.)said person is NOTrequired 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 Goa onwealt�of Massa.,chwo is Departme.at offadustdal.A,ccidonts Qfce of Y �1. uVestsgWQuw 600 Wasbi><apa Stxoet Boston?MA.021 Z Z TO,#617-727«49QQ eYt4O6 ox l-877,: '.ASS.A,F,F, North Andover MIMAP June 12,2013 00 :::_;sl; ..::�:-;5::alit:::::::.::;-• :::.-•-�..aUt�. t .:' r .:: ,.ir..::��ri... ♦ i — 064.0-0010 _:. .__:.' .��`.._:"�=:_.-:::.�:!a4;� ' _:••�� _: ._::.}064:0-0009 .: ::. _..•._,r.:.:._ . slv :__:at i .:::: i1u'_ •. .• ... ::-:_ �1.�:::_::•.:' ��lu.•:::�:-:_:��._.,•:::=_•�v_tr�:::__•' '�'�:::•�_'?��'::�::��a. ....: .;.':�J,�.r:- .•:�ltr.•::i=:;��:!xl!.r._._.. .•`.-'••.. ..u..: •...:- •,y...atlrc : .:.:- -,t,--fir.. `f•.:-�U,:t•.: ,t,� , -- .... .. . .._. _ - _. ._.. t _ ul.,t. "._.. ..atbt<....::'.._.. ...moi..... •��u:.s_<." ..••:.:'aatJ.v•:....;."� .lu ..}I,-- -- a�lu.-_. flu.::__'.. 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