HomeMy WebLinkAboutBuilding Permit #616 - 428 PLEASANT STREET 5/13/2009BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: k_(_0Date Received
Date Issued:
IMPORTANT: Applicant must complete all items on this page
.LOCATIONPnt IN,'
PROPERTY OWNER N(#J._ 6j'160"W nyf
Print
MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no
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
it re
Assessory Bldg
Others:
Demolition
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
DESCR I.PTIOOF WORK TO BE PREF XWED:
C/1 Mc W Fqv�_X6 f-ovF T
Identification Please Type or Print Clearly) T-
OWNER: Name: au►A 6J(V-g1,rJ0 Phone: t lsls
Address:
CONTRACTOR Name: ou�Phone:
Address;
Supervisor's Construction Licenser Exp. Date:
Home Improvement License: Exp. -Dater
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: $' ®G FEE: $
Check No.: �� Receipt No.:
NOTE: Persons contractingft unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner Siqnature of contractor
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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2008
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 Signature
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department 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 Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes
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
No
Locatio42f S -r- le -
No. (446
Date 5 / j,
401ITh TOWN OF NORTH ANDOVER
4,
Certificate of Occupancy $
24 Ust Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TAL $
Check itaok
22U61'21 Q Building Inspector
The Commonwealth of Massachusetts
k- ? Department of Industrial Accidents
j
• Office of Investigations
z• p,� 600 Tf ashington Street
U �� •
\U 11 i Boston, MA 02111
www nZassgov/dia .
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A m licant Information Please Print LeQibl
Naffie (Business/organization/Individual): V II Ile rftr
Address: q
City/Sta&Zip.—_ jLLq( &I'-- K__ ✓V1Phone
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with 4 Type of project (required):
❑ 1 am a general contractor and I
employees (full and/or part-time).* have lured the sub -contractors
b. ❑ New construction .
2. ❑ I am .a:sole proprietor or partner- listed on the attached sheet. ? 7. ❑. Remodeling
ship and have no employees These suli-contractors have 8. ❑ Demolition
working for me .in any capacity, workers' comp. insurance.
o workers' comp. insurance 5. ❑ We are a corporation and its 9 Building addition
3 7uired.] officers have exercised their 10.❑ Electrical repairs or additions
1am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing
m sell: p § () g repairs or additions
y [No•workers' com , c, 152, 14 , and we have no 12-C] Roof repairs
insurance required.] t employees. [No workers'
camp. insurance required.] 13.❑.Other
'Any applicarn that checks b001 1 must also fill out the section beiow showing their workers' compensation policy in
t homeowners who submit this affidavit indicating they are doing an worts and then hire outside contractors must submit a new affidavit indicating such.
;Contractors that check this box mustattaehed an additional sheet showir'g. the name of the sub -co ntrsetnra and f it workers' camp. pc?icJ irrnm�ation.
I am an employer that is prprOing:workers' compensation insurance for nty. employeex Below is the o '
information. p lacy and job site
Insurance Company Name:
Policy # or Self --ins. Lic. #:
Expiration Date:
Job Site Address: City/statelzip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration datej. .
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 of the DIA for insurance coverage verification.
1 ao Hereby cert under the p penalties of perjury that the information provided above is�true
and correct
Si Lure: Date: ilia Y' %may
77 6,FQV?g7
t7fj`icial use only. Do not write at this area, to be completed by city or town official
City or Toww Permit/License #
Issuing Authority (circle one):
L Board of Health 2 Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person: Phone #•
'1
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, assodiation, 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
owneT•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 our 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, MOL chapter 152, §25C(7) states "Neither tine commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public woric 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 -contractors) name(s), address(es):arud 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 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, notthe 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 cornraanies 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 hes 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 vvilI be used as a reference number. In addition, an applicant
that must submit multiple pennit/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 fi&= permits or licenses. A new affidavit must 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 flog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit
The Office of Investigptions 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.
'Che Department's address, telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
TeL # 617-7274900 Ext 406 or 1-8.77-MASSAFE
Revised 5-26-05 Fax # 617-727-7744
www.mass.gov/dia
MORTM TOWN OF NORTH ANDOVER
�•`'�• `�"° OFFICE OF
BUILDING DEPARTMENT
�o* �Ys, :� * 1600 Osgood Street Building 20, Suite 2-36
Two • t� North Andover, Massachusetts 01845
Gerald A Brown Telephone (978) 688-9545
Inspector of Buildings Fax (978) 688-9542
HOMEOWNER LICENSE EXEMPTION
DATE:
JOB LOCATION: o- � Pky�'gm �-'
Number Street Address M*4A
HOMEOWNER �gUl'1�6J [,P- "((q ti
Name Home Phone Work Phone
PRESENT MAILING ADDRESS q_�7- Oeq�q'n�
/144441z -
City Town
State
6/W
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 helshe resides or intends to reside, on which there is, or is intended
to be, a one or two family structures. A person who constrncts 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
minimum inspection procedures and requirements s
requrre�nts.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Reviwd 10.2005
Form Homwwom Emotion
ands the Town of North Andover Building Department
helshe will comply with said procedures and
110ARDOF \PPE:\I.S (M-9541 CQNSER\".VRONN F.,88-9530 HEAUJIi 688-9540 PLAN-NI\G 6R8-9535
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