HomeMy WebLinkAboutBuilding Permit #978-2016 - 43 BRIGHTWOOD AVENUE 3/17/2016V� "o BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
C1 -7 -7
Permit No#: I Date Received
Date Issued: all items on this page
LOCATION 4 f!��b
Print
PROPERTY OWNER VAA
Print 100 Year Structure
MAP bQ-(P—PARCEL: L4 ZONINQ DISTRICT: Historic District yes
Machine Shop Village yes
0
of
no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
El One family
El Addition
11 Two or more family
11 Industrial
El Alteration
No. of units:
El Commercial
;W Repair, replacem 3nt
0 ssessory Bldg
El Others:
[I Demolition
11 Other
D Septic 0 Well
El Floodplain 0 Wetlands
El Watershed District,
El Water/Sewer
MOCt-DIDTIMI nl= WORK TO RE PERFORMED:
/zoo 0=
/V,6 0
Identification - Please Type or Print Clearly Phone: 7 93 - 7 7
OWNER: Name: I)AVI-6 * EA�1111 —L**
Address:
Contractor Name: Phone:
Email:
Address:
Exp. Date -
Supervisor's Construction License:-1--� ---
Home Improvement License: ....................... Exp. Date:
ARCH ITECT/ENGI NEER E L Phone:
J
Address: Reg. No. — tt�,
FEE SCHEDULE: BULDING PERMIT. $12.00 PER $1000-00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: eq d> FEE: $
Check No.: Receipt No.:
NOTE: Persons contractikg with unregistered contractors do not have access to the guarantyfund
'L��i g -of Aqent/Owner
_nature ot Ag_
Location
No. Date
Check #
I
Zj
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $, -3t)
Foundation Permit Fee $
Other Permit Fee $
TOTAL $—)-
Building Inspector
Plans Submitted,9 Plans Waived [I Certified Plot Plan El Stamped Plans 0
TYPE OF SEWERAGE DISPOSTAL
Public Sewer El
Tanning/Massage/Body Art El
Swimming Pool' El
well El
TobMacco Sales
Food Packaging/Sales El
Private (septic tank, etc. El
Permanent Dumpster on Site El
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
Reviewed On
Signature_
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
P ,
�,Conservation Decision:
Comments
Comme
"Water & Sewer Con nection/shgnature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
rr 1 K 19 JJ 9- VA" K.�, I I M M f -1�o
_�siteg y
01
h0pate : jqt 12 --oin 5
Firp: Qe
pa r, ent .9i'
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 21 A —F and G min.$100-$l 000 fine
Doc.Building Permit Revised 2014
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
L3 Building Permit Application
L3 Certified Surveyed Plot Plan
L3 Workers Comp Affidavit
u Photo Copy of H.I.C. And C.S.L. Licenses
c3 Copy Of Contract
E3 Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (if Applicable)
L3 Mass check Energy Compliance Report (If Applicable)
u 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)
o 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
Doe: Building Permit Revised 2014
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Gerald A. Brown
Inspector of Buildings
Please prin
TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
1600 Osgood Street, Building 20, Suite 2035
North Andover, Massachusetts 0 1845
HOMEOWNER LICENSE EXEMPTION
BUIDING PERMIT APPLICATION
DATE: 3 — / -7 — I C.
JOB LOCATION: 43
R A—A / 6- "-T 1--, & & 1� --A LIFE
Telephone (978) 688-9545
Fax (978) 688-9542
Number Street Address Map/Lot
HOMEOWNER Z4L-11D A%jA4v- 912 9 7 7 1 -1 01 -7 01
Name Home Phone Work Phone
PRESENT MAILING ADDRESS— 4 3 a P-/ 6_47- 4.,& o_h A- L/E
A10, A-AIZ)06,1�F MA 8 4,5—
A_ -
City Town State Zip Code
The current exemption for "homeowners" was extended to include owner occupied dwellings of one or two family
dwellings and to allow such homeowners to engage an individual for hire who does not possess a license, provide
that the owner acts as sLipervisor.
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 dwelling, attached or detached structures accessory to such use and/or farm structures. A
person who constructs more than one home in a two-year period shall not be considered a homeowner. (780 CMR
Section I I O.R5.1.2)
The undersigned "homeowner" assumes responsibility for compliance with 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 '42� ??��
APPROVAL OF BUILDING OFFICIAL
Revised 8.2015
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
The Commonwealth of Massa. chusetts
Department of IndustrialAceidents
I Congress Street, Suite 100
Boston, K4 02114-2017
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERIVHTTING AUTHORITY.
Applicant Information Please Print Leeib
Name (Business/Organization/ludividual):
Address: 1 -3 14 (.11E
City/State/Zip: 4/0, 4IVd 0&0 M_ Phone #: V )8 -2 2 / -7
Are you an employer? Check tlie appropriate box:
1. F-1 I am a employer with , _ : employees (fall and/or part-time).*
2.n 1 am a sole proprietor or partnership and have no employees working for me in
any capacity, [No workers' comp. insurance required.]
3.;4 1 am a homeowner doing all work myself [No workers' compAnsurance required.] t
4. n I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
S. n I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These s�b-contractors h6� employees and have workers' con�p. insuranceJ
6.FJ We are a corporation and its officers , have exercised their right of lexemption per MGL c.
152, § 1(4), and we have no emplo,yegs. [No workers' comp. insurance required.]
Type of project (Tequired):
7. New construction
8. Remodeling
9. El Demolition
10 E] Building addition
11. Elect rical repairs or additions
12. F1 Plumbing repairs or additions
13. E] Roof repairs
14. n Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
I Homeowners who subniif Us affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must -attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
0
employees. if the sub-c'ntractorshave' 'employees, ffie� must provide their workers'comp. policy number.
I am an employer that is providing workers' compensation insurancefor my employees.' Below is thepolicy andjob site
information.
Insurance Company
Policy # or Self -ins. Lie.
Job Site
Expiration Date:
City/State/Zip:,
Attach acopy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do h ereby certify u n der th e p ains an d pen alties ofperju ry th at th e informatio n pro vided abo ve is tru e an d correct.
Signature: Date: -3 -7
Phone#: .7 7 -7 Z -2 9, '? 9,
Official use only. Do not write in this area, to be completed by city or town official..
City or Town: PermitlLicense
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 bf hire,
expres's 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 ajoint enterprise, and including the legal representatives of a deceased employer, or the
receiver or truAde 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-contractoi(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 fb� 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'
compensatioii'policy, please call the Department at the number listed below. Self-ftisurtd companies should'enter their
self-insuran*ce 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 "fob 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 Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia