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Home My WebLink AboutBuilding Permit #447 - 41 HAWTHORNE PLACE 12/11/2009 TOWN OF NORTH ANDOVER J APPLICATION FOR PLAN EXAMINATION Permit NO: l Date Received Z + v Date Issued: IMPOaTANT! Applicant must complete all items on this page LOCATION c� pp ` PROPERTY OWNER_ 7�it� 6aM6&-' Print MAP NO: _PARCEL�_,�ZONING DISTRICT: Historic District yes o Machine Shop Village yes o 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 PERFORMED: U A-' Y IdentificatiPlease T e o Print Clearly) g,� �7� OWNER: Name: Phone: Address: L r *V/ J CONTRACTOR Name:h4gkgzzS � Lsff 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: $ FEE: $ q z Check No.: l� T C� Receipt No.: 10Z NOTE: Persons contractin regist d actors do not have access to the guaranty fund Signature of AgentlOwner Signature of contractor Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Swimming Pools Tanning/Massage/Body Art x,� 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 C7 Si nature COMMENTSfid! - Lj,`l A V G50 S ' l HEALTH Reviewed on Signature COMMENTS IOD% Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water $ Sewer Connection/Si nature &Date Driveway Permit g v DPW Town Engineer: Signature: f Located 384 Osgood Street FIRE DEPARTMENT Temp Dumpster on site yes no } Located at 124 Main Street Fire Department signatureldate 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 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 2008 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: Doc.Building Permit Revised 2008 Location // � No. Date E TOWN OF NORTH ANDOVER N 2 " Certificate of Occupancy $ Building/Frame Permit Fee $ JACNUS Foundation Permit Fee $ Other Permit Fee $ TOTAL $ i' Check #�T 226y6 Building Inspector The Commonwealth of Massachusetts Department of Industrial Accidents Office of investigations UV 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zip: �/ �� CO�� Phone Are you an employer?Check the appropriate box: Type of roject(required): 1.❑ I am a employer with 4. El am a general contractor and I 6 X�11ew construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet # 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its quired.] officers have exercised their 10.❑Electrical repairs or additions 3. I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.] t employees. [No workers' comp.insurance required.] 13.❑ Other '.=Wv applicant that ch—ticks box i±l must also fill out the section below showing t, wore::ss'compensation policy information. t Homeowners who submit this affidavit indicating they are 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number 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$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 forwarde d to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce u the pat a p r ury that the information provided abovefzs&qe and correct Si ature: 7, Date: v Phone#: /(/ 9 / 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.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 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"...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 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 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 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 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),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 not required 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 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 regarding the law or if you are required to obtain a workers' 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 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/license number which will be used as a reference number. In addition,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 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 or permit to bum 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 of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 021.11 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-72.7-7749 Revised 5-26-05 www.mass..govfdia F µOR7H TOWN OF NORTH ANDOVER o0 OFFICE OF BUILDING DEPARTMENT -50L4 1600 Osgood Street Building 20, Suite 2-36 yq4°q�ttp�pR�1y North Andover,Massachusetts 01845 SSACHUSE Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE: �� D JOB LOCATION: Number Street Address Map/Lot HOMEOWNER (j&<C7i7i7� I Name H/onme Phone Work Phone PRESENT MAILING ADDRESS `1 I� �,N44 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 /she understands the To f o Andover Building Department minimum inspection procedures and requir d th e/s o y aid 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 � �pRT1-r Town of : ove r No. - 09 L dover, Mass., COCMICMEWICK y1. 7� RATED S BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System I BUILDING INSPECTOR THIS CERTIFIES THAT.................................................... .................. .................................................................................. Foundation has permission to erect........................................ buildings on ............... f......... .. . .. . .......................................... Rough to be occupied as Chimney provided that the person acce tin this permit shall in eVe respect conform to the terms of the application on file in Final P P P g P nl 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 7. PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI STA -- — ---� Rough ...............................S............................................................................ Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. SEE REVERSE SIDE Smoke Det. ATA-W-1 - - 169' I EXISTING FOUNDATION TOP OF X FOUNDATRON z o I / LOT 7c-L 0 T . 8A I / 94 DRAINAGE / EASEMENT_ • o / 0 LOT- 2A \ 75' HHTHARY STRUCTURE SHOWN CONFORMS TO LOCATION PLAN TEORIZONTALSETBACKREQUIREMENTS OF THE LOCAL APPLICABLE ZONING BY—LAWS IN EFFECT WHEN CONSTRUCTED. (THIS C£RT7FIC4TION DOES NOT CONSIDER ANY OTHER RESTRICTIONS SUCH AS COVENANTS,WETLANDS,EASEMENTS, CLIENT: COOLIDGE . REALTY TRUST ORDERS OF CONDIT'ONS,ETC-) THIS DRAWING SHALL NOT BE USED BY THE CLIENT FOR ANY THIS CERTIFICATION 75 MADE AND LIMITED PURPOSE OTHER THAN THAT OUTLINED ABOv£EXCEPT WITH THE WRITTEN PERMISSION OF CHRISTIANSEN & SERGI INC, TO THE ABOVE CLIENT. FURTHERMORE THIS DRAWING IS THE COPYRIGHTED PROPERTY OF CHRIS71ANSEN A• SERGI INC. AND ANY UNAUTHORIZED USE IS PROHISITED.CHRISTIANSN & SERGI TAKES NO RESPONSIBILITY FOR THE UNAUTHORIZED USE OF THIS DRAWING OR ANY INFOR— MATION.CONTAINED HEREON. LOCATION: LOT 8A HAWTHORNE PLACE NORTH ANDOVER, MA. „ EAI;H OF • 1 = 40' AT OCTOBER 11 1995 �r9 • SCALE. DATE. o s , s v� 9 w J 'Ta PROFESSIONAL ENGINEERS `u F s: Ci R CHR/STlA NSEN 0,SERGI LAND SURVEYORS `�l 160 SUMMER ST. HAVERHILL•MA. 01830 TEL 508-373-0310 --. '- @1994 BY CHRISTIANSEN & SERGI INC. RA WING No. 94090008 Town of North Andover Page 1 of 1 �r Base Map Zoning 2005 Aerials Watershed Zone Utilities [] Size0E]G Selection Legend Location Markup El Help Scale 1"= 56 ft Select Parcels (show all) FOwner __ Address Lot Size ytX: 1 AM BAILEY FAMILY REALTY TRUST 0 BELFAST STREET 19.08 Lawrence ;' —70 1 ° •.`t 026D-013113 1 selected To Mailing Labels To SpreadSheet *'. Om6DA02t -�OT6D-0016 OS6D•8015 Propertp • .. ,':..: Print A•.i..- , -- t '. 1-1;nethn�•ne d'lnee a 107` Owners BAILEY FAMILY REALTY TRUST Owner2 ROBERT C&THOMAS L BAILEY,TR ., 02S0-00M 026.0-0018 Address 0 BELFAST STREET Map/Lot 026.0-0021-0000.0 Lot Size 19.08 sq.ft. PID Fiscal Year 2007 i Land Use 803 _ + Code t Last Sale 02/12/1991 Get Pictometry Imag Go vs.o.c AppGeo Save Map as Image - http://maps.mvpc.org/NorthAndoverTnimapNiewer.aspx 12/1/2009 The Commonwealth of Massachusetts _ Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: Vz City/State/Zip: Al, � hone#: g�� / 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.�ew construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 7. R I am a sole proprietor or partner- listed on the attached sheet$ ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3. I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions yself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' 13.[:] Other comp.insurance required.] *.k--.y applicant*.hat checks box r'r,1 must also file out the section below showing their workers"compensation policy:nfozmation. t Homeowners who submit this affidavit indicating they are 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. I am an employer that is providing workers'compensation insurance for my employee& Below is the policy and job site information. 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 page(showing the policy number 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$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 ns of the DIA for insurance urance Covera a verification. n. I do herebyerti u er the p 'cs d e s of perjury that the information provided above is �u/e and correct Si ature: 7 Date: Phone#: LTJ d 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.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 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"...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 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 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 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 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),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 not required 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.ret rued to the city or town that the a—yplication Jr 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 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 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 which will be used as a reference number. In addition,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 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 or permit to bum 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 of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 021.11. Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia