HomeMy WebLinkAboutBuilding Permit #20 - 41 PATRIOT STREET 7/7/2009 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued: _
IMPORTANT:Applicant must complete all items on this page
LOCATION, � .� r
P'nt
PROPERTY OWNER � -
Print
MAP NO: PARCEL:66ZONI'NG DISTRICT: Historic District yes n
Machine Shop Village yes no
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 PREFORMED:
Q 1
Oy�.� i�`J L � (�r1 G.... �iS 4�� yt,-' Gu L 6 e- d
NO
Identification Please Type or Print Clearly)
OWNER: Name: Phone: (4
Address: LA l P�t'`01 of t
CONTRACTOR Name: ' or
Phone: 9.1
Address: 45 PF\xJ-10t � 1� �h2 l�Imo" tL414 01
Supervisor's Construction License: Expo 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: $ 2���— FEE: $
Check No.: L Receipt No.:
NOTE: Persons contracti with re istered contractors do not have access to the guaranty fund
signature of Agent/Owner _ Signature of contractor
Plans Submitted P iv d Certified Plot Plan Stamped Plans
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
o Building Permit Application
. And/Or C.S.L. Licenses
❑ 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
Li Building Permit Application
Li Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
Li Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ P P
I Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o 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
o Workers Comp Affidavit
o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Copy of Contract
Li 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
TYPE OF SEWERAGE DISPOSAL
Public Sewer Tanning/Massage/Body Art Swimming Pools
Well Tobacco Sales Food Packaging/$ales
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
i
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
CQMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Siignature& Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT Temp,Dumpster on site yes T no -
Located at 924 Main Street
Fire Department signature/date
COMMENTS
i
i
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.s100-s10o0 fine
NOTES and DATA— For department use
❑ Notified for pickup - Date
Doc:.Building Permit Revised 2008
Location !4 4P
No. Date —�
0f40RTN TOWN OF NORTH ANDOVER
9
u ; Certificate of Occupancy $ '
s
1SSACNUSEt�' Building/Frame Permit Fee $ a
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
22*1 o9
Building Inspector
x40RTH
® Of 4Andover .
0
No. 2,0
�,o A K E = dover, Mass.; •
COCHICHEwICK y�.
7d AORATED
.S E BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
BUILDING INSPECTOR
THISCERTIFIES THAT.............'.. ............ ..... ....................... ........ ................................................. Foundation
Rough
has permission to erect........................................ buildin s on .............. . :........ ..... ..........�4�T....... .0.....a g
to be occupied as l�. .o.. .. ►. !yGr...A�! -.........,w.r ... .......... 'C�►.� .#.....- ...... .... ''1'�tlf= C imn y
h' e
provided that the person ccepting this permit shall in every respect conform to the terms of the application on filein 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 CONSTRU T Rough
.... ....................... ............................... . Service
BUILDING R
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.
03/29/2009 15:50 FAX 781 279 0725 DAVID FLEMING & ASSOC. 9 001
DAVID FLEMING. & ASSOCIATES MORTGAGE INSPECTION PLAN
Z. Im store►rm 7his plan Nos not dana wfth an kat ment surwry
38 POND STREET FAX and fs to be and for marigage Pw9mmes Wy-
mi) STONEIUM, MASS.(rat)273-am DATE: 3-2B-ay SCALE 1 l-win'
I certify Vmt this dwelling ea lamted oddly as shown and conformed to 71
the zoning b�taws of the oNof A A.vdar. AOW-
when constructed and is not hooted in a flood hom tom a
je-�S�X County Reg. of Deeds CerTl6i�yd: S�de�e/�t/Bad
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DEED BOOK la.,CO PAGE-W N/F Qeec �f Q o
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' GERARD D
CROWS
No.417b
t.
t °RTN TOWNOF NORTH ANDOVER
OFFICE OF
~ BUILDING DEPARTMENT
4�•''� 1600 Osgood Strut Building 20, Suite 2-36
�, a+►�st�� North Andover, Massachusetts 01845
Gerald A Brawn Telephone(978)688-9545
Lnspectpr of Buildings Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
Please pri
DATE:
JOB LOCATION: L41
Number Street Address MRA&
xolv�owNER Lc� Nkm CIA- q -4&S5
Name Home Phone work Phone
4 t P i'R.i(,i tri
PRESENT MAILING ADDRESS
J . b our, 1�1� Ol ScU
City Town . State zip Code
The current exemption for"homeowners"was extended to incl- Ow- -ow~c-upied dw--.11 h gs to two.ngs or lens
and to allow such homeowners to engage an individual for hire who floes not possess a license,prmded 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 conducts more that one home in a two-year period shall not
be considered a homeowner.
The undersigned:"homeowner"assumes responsrbiility for compliancies with the State Building Code and other
Applicable codes,by-laws,rules and regulations.
The undersigned"homeowner"certifies that she Town of North Andover Building Department
minimum inspection procedures and and comply with saidand
P
HOMEOWNERS SIGNATURE
n
APPROVAL OF BUILDING OFFICIAL
Revised 10.2005
Fam Homeowners Fimmption
BOARD OF PPE:11_S 688-9511 C0 SERN'.Vrj0N 539-953 diE.0 1'1i 698-9540 PLANNING r;gg_9535
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7
The Commarzppea&h of Massachusetts
k -
De
1
Pa��of Industrial Accidents
•r. Offcce of Investigation.
ii 600 Nrasking ton Street
ti\a Boston, MA 02111
c 7
Workers' Compensation www mwssgou/die . .
Insitrance.Affiidavit: Builders/Contractors/Eiectricians/piumbers
A• ficant Information
• Please Print Le�libi
Nanle(Business/prgsniratiorAndividual):
Addmss: -
(�l
City/State/zip: 11. �4,,dv�vsY1
Phone#. . _ (4 9'�
F
re you an employer?Check.the appropriate box:
[❑ i am a employer with 4. ❑ t am a general contractor and IF
prole °1 '
employees(fun and/or part-time).* have hired the sub-contractorsew construction .
.Q I am.a.sole proprietor or partner- listed on the attached sheet? modeling
ship and have no employees These stL&contractom have
working for me in any opacity. workers' comp.insurance. molition
(No workers'comp,insurance S. ❑ We are a corporation and its ilding addition
required] officers have exercised their ctrical repairs or additions
3. I airt a h;.=kirs'eer doing all work right of eatcinption per MGL mbing repairs or additions
myself comp. :G 152, §I(4),and we have no
insurance required.].t .employees.[No workers' of repairs
comp. insurancx required_] cr
`Any applicant that checks}�#7 must and fill out the section below showing their workers'cortrpeesation poiicy infmmation.
t 4Mft n;rig who sebmit this affidavit indicting they are doing an work and them hire outside connectors must submit e.new affidavit indicating
�Cantractors that check this box m„srattecb_4 an additional skier,showing.►rig•khe name of the suh-cootraotois and their workers'care lie;in
!a .an er�rgyer tint is prow wz:workers'co errsadOn ' " Fc fmi°ion.
infomzadon mP uisuranee for rrry errtploy�; Belmw is the pofiry and job site .
Insurance Company Name: '
Policy#or Self-ins.Lic.#:
Expiration Bate:
Job Site Address:
city/Staterzip.
Failure to secure coverage as
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). .
required under Section 25A of MGL c. 152 can lead to the imposition of criminal
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 against the vio Be advised that a copy of this statement may be forwarded to the Office of
Investigations of e DIA for ins uran a co ge verification,
I do hereby cerfi un e a
pen
°lPerl�that the informatior:�rntna(ed abo h•trr�e and correct
Date.
Phone
rofficial
of,}`icial use Only. Do not write to this area,to he completr_d by city or town officid
City or Town: Permit/License#
Issuing Aufhorify(circle one):
1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical inspector 5. Plumbing Inspector
6.Othe'r
Contact Pemoa• Phone#:
Information a nd I11tstructions S.
Massachusetts General Laws chapter 152 requires all emp 3oyers 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 includir-ig the legal representatives of a deceased employer,or the
receiver ortrmtee•of an individual,partnership,associatiom or other legal entity,employing employees.'However the
owner•of a dwelling house having not more than three apastrnents 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 sball withhold the issuance or
renewal of a license or permit to operate a business or *o construct buildings is the commonwealth for any
applicant who has not produced acceptable evidenceAr compliance with the insurance coverage required."
Additionally, MOIL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performnsnce 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, supplysub-contractors)name(s),address(es):Emnd 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 or partners,are not requiredito carry workers'ccvrnpensation 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 it workers'
compensation policy,please call the Department at the nwm. ber listed below. Self.-insured companies should enter their
self-insurance license number on the'appropfiate 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 thel event the.Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which a-ill be used as a reference number. In addition,an applicant
that must submit multiple Minit/iicense 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 cagy ofthe affidavit that has been officiaily stamped or marked by the cityor town may be provided to the
applicant as proof that a valid affidavit is on file for firtmen
r permits or licenses. A now affidavitmust be filled out each
year.When 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
Tho 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 as a call.
The Department's address,telephone and fax number..
The Commonwcmlth of Massachusetts
Department ofL-ndrastTiai Accidents
Office of Inveatlitrstiana
600 Wadhington Street
Boston, 1viA 02111
TeL#617-7274900 ext 406 or 1-977-MASSAFE
Revised 5-24-05
Fax#617-727-774
www.mem.gov/dia y,