HomeMy WebLinkAboutBuilding Permit #160-15 - 43 JETWOOD STREET 8/13/2014 OFtTH ANO
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BUILDING PERMIT 0 No Dr b�ti
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: 6D Date Received 0 a "
gAre
SSAC HUS��
Date Issued:
I PORTANT: Applicant must complete all items on this page
�
LOCATION r��-� ��!�� P C�,.,�` S
PROPERTY OWNER lI C ,P,n.t�i
Print 100 Year Structure yes no
�
MAP 00 PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building X 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:
` ' I
Identification- Please Type or Print Clearly l
OWNER: Name: C ) dd. 14 u G. 14 Phone: F7 �r�d j.
Address: / C tr M L eg a rt 0 ve
Contractor Name: Phone:
Address:
Supervisor's Construction License: 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.
�d
Total Project Cost: $ tq FEE: $
Check No.: I 1 Receipt No.: 2.71Z
NOTE: Persons contracting wunregistered contractors do not have access to the guaranty fund
Signature of Agent/ ature 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 pp Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Cross Section/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
o 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:Building Permit Revised 2014
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 Call Email
Date Time Contact Name
Doc.Building Permit Revised 2014
t
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. ❑ Pennanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
�NSERVATION Reviewed on Signature
oMENTS
L
NOTE: A,.
I, :ALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
j- -Planning Board Decision: Comments
y
Conservation Decision: 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
Location
No. Date
. - TOWN OF NORTH ANDt
Certificate of Occupancy $
Building/Frame Permit Fee $�`L
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check#
�' U Building Inspector
Enter construction cost for fee cal - North Andover Fee Calculation
Construction Cost
12,000.00 m
$ - $ 144.00
Plumbing Fee $ 18.00
Gas Fee 100 comm. $ 100.00
Electrical Fee $ 18.00
Total fees collected $ 280.00
43 JETWOOD Drive
160-15 on 8/13/14
Ktchen Remodel
.The Commonwealth of Massaehasetts
Depa�E�ien�o,�'.7itc�acs�rcclAcczc�en�s
• . Offace ofln-Pestigafeons -
604 Washington Street
Poston,AM 02111
-www.mass.govIdla
Wgrkexs'Comp engation bsuxance davit:BuiZderolContracfor�)FIectricianqI*bM
Applicant Info-rxna#on PXca98 'I�intLe 'bz
NaTbe pus d%vidrzal}: ff -
A.ddress:
City/State/Zi Phone At:
Are yoix an.employer?Check the appropriate box: Type of project(reclufred):
1.Q I am a employer with 4. ❑I am a general contractor and I 6. EJ New cbnsfruction F
employees(fan and/or part time)* haveliiredthe sub-contractors
2.[l I am.a sole proprietor or partner
listed on the attached sheet� 7• 0 Remodeling
Bhip and`haveno.em to ees These sub-contractors have 8. []Demolition
working for me in.any capacity. workers'comp.insurance. 9. L]Building addition
rNo workers'comp.insurance 5. ❑We area corporation and its 101]Electrical repairs or additions
xecpzixed.� officers right
exercised.their
3. Z am a homeowner doing all work right of exemption perMGL II.[]Plumbingrepairs or additions
c.152,§1(4),andwOhaveno 12,Q Raofrepaixs
myself:[Vo workers'comp.
insuxancerecluired.]? employees.[No workers' ME] Othex •
comp.insurance required.]
Any applicantthat checks box#i must also 0 out the section below showingtacir workers'compensationpolicy information.
?'Homeownerswho submit tWg aTidavit indicating tfiey go d9ing au woriv and then wro outside contraGtors must submit a now affidavit indicaffig sucht.
TContractors that cheokthis bob must attached an additional sheet showkg the name of the subro&actors and their workers'comp.policy information.
I aira are emproyer that is providing workers'compensation insurance for my ernprayees Berow is the po.Ticy andjoh life
infarmadon.
Insurance Companyblame:.
Policy#or SOIz ins.YIG.#: ExpiratioaDate:
Sob Site Address; City/State/Zip:
Attach a copy oftlteworkers'cmnpensation-rolieydeclaration page(showing•the Poll cynumber and expirations crate).
Ii`aiturO to secure coverage as xequixedunder Section 25A ofMGL o.152 can lead to the imposition of criminalpenalties of a
.flue up to$1,500.00 and/or' -y'ea'r�nprisgmant,as well.as civil penalties in the form of a STOP WORTS ORDER.and a tine
of-up to$250.00 a day against the violator. Be advised that a copy of this statement maybe foxwarded to the Office of
Investigations ofthe DTA.for insurance coverage verification.
X do lima ce u der flee mins an enaZtie f perjury treat the ire,formadon provid'ed above is tree and eorrreet,
Date:
S' a .
Phone#:
offi-eial use laWy. vo not write in this area,to be compreted by city or torus official
City or Town: JPermi-Mceuse#
Zssning.A nthority(circle one):
1.Board o£E(ealth 2.BuffdingDepartment 3.Cityl-Town Clerk 4.Electrical Inspector 5.Rlumbingf spector
6.Other- - -
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for theft employees.
PArsuaa to this statute,an employee is deflued as`1.•everyy p exson ire the service of another uudex any contract o�l�e,
express orimplied,oral ox wxitten."
An enTloyq is defined as"an individual,partnership,association,corporation or other legal entity,or anytwo ormoxe
Of ft toxegoiug engaged in a joint enterprise,and includingthe legalrepresentatives of wdeceased employex,.or tTre
receiver oxtrusfea of"an individual,partnership,association ox other legal entity,employing employees. fi6vex the
owner of a dwelling house having n otmoxe than three apartments and who xesides therein,,or the occupant ofee,
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or onthe grounds or building appurtenant thereto shallnot because of such employment be deemedto be an employer"
MQL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuancee or
renewal of a license or permit to operate a business or to construct buildings lu 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 fbr the performance ofpublic workuntilacceptable evidence of compliance with,the insurance
requirements of this chapterhavebeenpresentedtothecontractiagauthority."
Applicants
Please fill out the workers'compensallon affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),addresses)and phonenumber(s)along with their certifrcate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are notrequiredto carry workers,compensation insurance. Hem lJ-1C orLLP does have
em ployees,apolicyisrequired. Be advised thattbisafCxdavitmaybesubmitted tothe Department of In.dustrial
Accidents for confirmation ofinsurance coverage. Also be sure to sign and date the affidavit. The affidavit should
b e retum.ed to the city or town that the application for thepermit or license is being requested,mot the Do�raxtm ent of
Industrial Accidents. Shouldyou have any questions regarding the law or if you are xequired to obtain a*orkexs'
comp eusationpolicy,please call the Department at the number listed below: Self insured compauies should enter their
self-insurance,Incense number on the appropriate line.
City or Towu Officials
Please be sure thatthe affidavit is complete andprinted legibly. The Department has provided a space at the bottom
ofthe afdavitforyouto fill out in the avant the Office ofluvestigatlons has to contactyouregarding the applicant.
Please be-sure to fll inthe pamaitllncense number whichwill be used as a reference number, fn addition,an applicant
thatmust submitmultiple permit/Uceme applications in any givenyear,need only submit one afffdavit indicating current
PORGY information(ifnecessmy)and under"Ab Site Address"the applicant shouldwxite"all locations an (city or
town)°'A copy o£the afCdavitthat has been officially stamped or marked byth.e city or town may be provided to the
applicant as pro ofthat a valid affidavit.is
"On fWox faturepermits or licenses. Anew affidavitmust be filled out each
year.Where ahome owner or citizen is obtaining a license oxbermit not related to anybusiness or commercial venture
(i.e.a dog license orpermit to burn leaves eta.)saidperson is NOTxequired to complete this affidavit.
The Office bf Investigations would like to thank you iu advance for your cooperation and should yqu have any questions,
please do not hesitate to give us a call.
The Depanm.ent's address,telephone abd fax number;
TlaQ Ca onawCath oryas�a.v*uott,-q -
D�pai.extl
Moe offAmtkAttona
OG wa an 8�:e-t
ROAQ4,: ,02111
T01 61M-2,Z490 e 406 Rl x-S77- _
Revised 5 26-05 FaX#617"727"7749
NORTH
Town of
ndover
so h ver, Mass, YA1,15
coc Klc Kl WlcK �'�•
ll BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
THIS CERTIFIES THAT ................. /'.. -V eY4 ......�� �� ��.1. ...................................................... BUILDING INSPECTOR
......... ....... .
cA e C3 , ll ......................... Foundation
has permission to erect .......................... buildings on ... : .................�....� . ...........
x.'z'.:&
Rough
tobeoccupied as ................... .................................................................................... 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 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION, STARTS Rough
1��y,������� Service
DING INSPECTOR Final
BUIL
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.
OFFICE OB
BUMI]ING DSART ENT `
• ��R��,,�.� ,:'760Q Osgood atreet Building 20,•quite?-36
7�s�ACHu5�s5 NolthAndovar,Massachusetts 01845 ,
Gerald A.Brown Telephone(978)688-9545
Inspectorof.Buildings - Fax (978)688-9542
HOMEOWNER•LICENSE EXEMPTION
PPLICATION
pleasep ran t -
,
DATE:_
SOB L0Mf0N:' j
Number SirMtAddress Map/Z•ot
OMMONER ( G-
Name. Home.'hone
Welk-Phone
'RESENT M G•DDRESS �°,.Q L 'a Rk OF
o D o Vim..
C.ty rotm
dip Cod;
'.'he current exemption for"hoxueownere,was extended to iapinde owner occupied divelIings to t�vo units o� ;ess and
to
allow such homeo:Tens to englge an?idividual•forhire who does aotpossess a 7 cealse,provided that the owner
acts as supervisor). StatoBuilding (Code Section 108.3.5.1)
DEFINITION OFH02VMOWNER
Person(s)who awns a parcel ofland on which he/she resides or intends to reside,on which there is,or is intended to
be, one or two family structures. A person who
conss idered ahomeownez. cthat-one onstructs more that-ohome in a tura yearperiod shall not be
,
The undersigned"homedwner"assumes responsibilifyfor cbmpliances with the State Building Code and other
Applicable codes,by laws,rules andxegulations.
The undersigned"homeOwner"certiIasthat he/sheimderstands the
Town ofNorth AndoverBuildingDe artment
minimum inspection procedures and requirements and that he/she will comply with,said procedures and
requirements,
ROMEOWNP-RS SIGNAT
A7'P.ROVAL OF J3DMD.NG OFFICIAL,
Revised 7.2009
Form Xiomeowners Bxempfion
'BOARD OFAPPEAM 688-9541CO7�SEIZ•4r r
• ti,TlgN 688-9534 HEALTH688-9540
PLANNING 689-9535