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Home My WebLink AboutBuilding Permit #548 - 435 CHESTNUT STREET 2/13/2007,7— Permit NO: / 0 Date Issued: '/'3 - Q _. TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received 'I " IMPORTANT: Aaalicant must complete all items on this page i �- Print PROPERTY OWNER �� ao n, 2 4 C- Print MAP NO.: 9'�& L PARCEL: '94I ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New BuildingOne ❑ Addition Alteration family ❑ Two or more�family No. of units: ❑ Industrial ❑ Repair, replacement ❑ Demolition 0 Assessory Bldg ❑ Commercial ❑ Moving relocation 0 Other ❑ Others: ❑ Foundation only FRK TO BE PREFORMED Identification Please Type or Print Clearly) OWNER: N Address: CONTRACTOR Name: r Supervisor's Construction License: z f'� Exp. Date: 4� Home Improvement License: l3 (05%q<4 Exp. Date: S:! i t b ARCHITECT/ENGINEER Name: Phone: Address: Reg. No. - FEE SCHEDULE. BULDING PERM/T.. $12.00 PER (1000.00 OF THE TOTAL ESTIMA ED OAST BASED ON $125.00 PER S.F.S.Total Project Cost :$ moo. FEE:$ Check No.: f d Receipt No.:/ vle�e Page lof 4 7 Location No. L Date TOWN OF NORTH ANDOVER a y Certificate of Occupancy $ t' s4CNus Building[Frame Permit Fee $ eyo-,sip Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 19986 t2 �---- Building Inspector TYPE OF SEWERAGE DISPOS L TanningtMassage/Body Art ❑ Swimming Pools ❑ Public Sewer Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dempster on Site ❑ Electric Meter location to project • • v A r.. Ar crwn W"grw:r,ng MIR rmregrsrerea contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ S Pi ❑ 1� THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS i FIRE DEPARTMENT - Temp Dumpster on site yes no / Fire Department signature/date COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Sianature & Date Driveway Permit Building Setback ft. Front Yard Side Yard Rear Yard ed Provided R uired Provides "F—Re wired Provided Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions._ Total land area, sq. I: 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 o Copy of Contract ❑ Floor Plan Or Proposed Interior Work Addition Or Decks ❑ Building Permit Application ❑ 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) �2. 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 o Mass check Energy Compliance Report 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 Dee: INSPECTIONAL SERVICES DEPARTMENTMFORMO! Page 4 of 4 of MORTN TOWN OF NORTH ANDOVER 3: �';°_ • ��'� �� OFFICE OF A BUILDING DEPARTMENT 400 Osgood Street $ACMIlSt North Andover, Massachusetts 01845 Gerald A. Brown Telephone (978) 688-95454 Inspector of Buildings Fax (978) 688-9542 HOMEOWNER LICENSE EXEMPTION Please mint DATE: o JOB LOCATION: 4 �� ti � h U� -_ C L/i9y Number Street Address Map/Lot HOMEOWNER r, �= I a ; t -a- 379 -cg� -- �aq � Name Home Phone Work+hone PRESENT MAILING ADDRESS �-/� L��S�Ay� 5� . City Zip Code The current exemption for "homeowners" was extended to include owner-Occtlpied 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 he/sh/e understands thin g of North Andover Building Department minimum inspection procedures and regi rements'and that he/she comply with said procedures and requirements. HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 10.2005 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNLVG 688-9535 m m m m YI m mm _p, y d C � d 10 O CD az y 06 C) C C? y CD o p CD o CLQ %c d cD CD 0 ca w C CD CCDO) _. n0 co) 40 C 0 Oq z rr, t C 0 e ? 1'09 d y S dyam CLm � om y m•� m oma: � CD� CL d . �` ?a.+d CL a v1 co ..o. y O... ism: O _ m C.,0 7 = m o .__. 3o�rr • M � om y y � O ow oma: � CD� CL d . �` N CLcr cn .__. M O y y � O ow O CM) ; = dW o00 �` w mo: v1 CA Vim: t'1 �o � y C3 0: = c wd: ate: ncl o as rb r p f z 1� t am y 0 9 + 4 ,w CL rw r Q r .__. M .� ro A 1� VI M z 1� t am y 0 9 + 4 ,w CL rw r Q r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address:.�- City/State/Zip: R4 Phone #: 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 employees (full and/or part-time).* have hired the sub -contractors 6. ElNew construction 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. EJ Demolition working for me in any capacity. employees and have workers' 9. E] Build' addition [No workers' comp, insurance comp. insurance.t required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. 1 am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right Of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13•❑ Other comp. insurance required] *Any applicant that checks box #1 must also fill out the section below showing their workers' 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 state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. 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. 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 of the DIA for insurance coverage verification. I do hereby ce�flfy under the pan and penalties of perjury that the information provided above is true and correct ,G -e - q3 q7 use onty. uo not write in this area, to City or Town: or town officiaL Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 6. Other Contact Person: 4. Electrical Inspector 5. Plumbing Inspector 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-contcactor(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 permitgicense 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 02111 Tel. # 617-727-4900 ext.406 or 1-877-MASSAFE - - - - - -- --- Fax # 617=727=7749-- -- --- Revised 11-22-06 www.mass.gov/dia REGULATION ` S p OF of PING SUPER\jISOR :CONS gOAR TION w+.. s®. Licen pgA107 KA Number CS by281'1964 Tr no: X8523 t Blrthdete: . expires: 0212812008 Re1 i. steicte8: 0° ,y A TABOR JR RICwlL SONST MA 01862 cwnlsstone� t NO 811-1-ERICA, � -- �P W U1 n 3 (D D c rn CD v D 90 r v c v :37. v Z� Drn :3 rn a� 0 < rn