HomeMy WebLinkAboutBuilding Permit #620-2017 - 46 RALEIGH TAVERN LANE 12/8/20164�_911Y A-aW �
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: &0 Zell _-7-
Date Received
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
0 Septic 1Nell
❑ Floodplain 0 Wetlands' ` '
0 Watershed District
dYVater/Sewer
`
DESCRIPTION OF WORK TO BE PERFORMED:
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den ification - Please T e or Prig
OWNER: Name: f', e , V3411 -r -c'
n �r-Gr-1
Phone( AD31 ,54a"
Address: ''� (L" k,�4�v G,�v ef- ✓� �,-ac,M-v �vt'I� w c�•� v w lM t� 1 v �i
Contractor Name: - Phone:.
Address:
a-
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Supervisor's Consfruction License _
.Exp `Date _
Home'.lrri rovement License:)
P Exp: 'Date=
v ... - W...� . _ -r - .., _
ARCHITECT/ENGINEER
Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT. $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F.
f
__�.Total Project Cost: $ 1-50 FEE: $
Check No.: Receipt No,-
NOTE: Persons contracting Ath unregistered contractors do not have: access to the guaranty fund
S_igiatu�e_of._Agent/OwnerSignature of contractor;
Plans Submitted ❑
Plans Waived 0. Certified Plot Plan ❑ Stamped Plans ❑
IYPE-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
PLANNING & DEVELOPMENT Reviewed On
COMMENTS
Signature
CONSERVATION Reviewed on Sianature
COMMENTS
HEALTH
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comm
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
FIRE DEPARTMENT - Temp Dumpster on site yes
Located at 124 Main Street
Fire Department signatureldate
COMMENTS
Located M4 Usgood Street
no
-imension
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.Yrequires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A —F and G min.$10041000 fine
Kin -MC . "rl rIATA _ /Fnr r1,nnartmPnf imp)
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❑ Notified for pickup Call Email
ate Time Contact Name
Doc.Building Pennit 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
❑ 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/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
❑ 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
40TE: 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
tliat 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
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Donald Belanger
Inspector of Buildings
Please print
TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
120 Main Street
North Andover, Massachusetts 01845
HOMEOWNER LICENSE EXEMPTION
Building Permit Application
DATE: I -2-L,7 /, 1,4
JOB LOCATION: q 6
Telephone (978) 688-9545
Fax (978) 688-9542
Number Street Adc5ess Map/Lot CAo 31
HOMEOWNER B� CI �c-'` ��—�Z3�d '.�� 0-2111
Name Home Phone Work Phone
PRESENT MAILING ADDRESS L -J' .11
L,..yo(mss ., "4+ o3jTq
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,rop vided
that the owner acts as supervisor.
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 IO.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/shill comply with said procedures and
requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Revised 9/16
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
1'he Commonwealth of Massachusetts
Department of IndustrialAccidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www mass.gov/dia
CompensationTnauce Affidavit: Builders/Contractors/Eleciricians/Plumbers.
swr
TOBEFLEDWIT'HTHE PERAMT'NGAUTfCORITY-
Name (Business/Ozgabizaiion/Individual):
Address:
City/State,/Zip:-
Axe you an employer?
407
l 1dq SPhone #: G �✓?
tbie approprlafe box:
1. ❑ I am a employer with employees (full and/or part-time)-*
2. ❑ I am a sole proprietor or par[uershiP and have no employees Working for me in
any capacity. [NO workers' comP. insurance required]
Ir i am a homeowner doing all work myself [No workers' comp. insurance required.] t
4.Q I am a homeowner and will be biring contractors to conduct all work on my property.
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
Type of project (required);
7. ❑ Nd'pf `d6ns 66iion
8. Itemode&g
9. ❑ Demolition
10 ❑ Building addition
I will
I1.❑ Electrical repairs or additions
Plumbing repairs or additions
5. F1 I am a eneral contractor and I have hired the sub -contractors listed on the attached sheet -
g,
These sub -contractors have employees and have workers' comp. insurance.
6. ❑ We are a corporation and its, officershave exercised their right of'exemption per MGL c.
2 1(4) and we have no employees. [No workers ]
' comp. insurance required.
13•. [] Ro6f repairs
14.�Other �"'r'r`
1-), §
box#1 must also fill out the section below showing their -workers' compensation policy information:
*A� applicantthat checks
i Homeowners who submit•thig af$davit mdreairng they are doing all work and then hire outside contractors must submit a new affidavit indicating such
'Contractors that check finis iioX must attached an additional sheet showing the name of the sub -contractors and state whether or not (hose entities have
P,. nlnvees. If the sub contractors have employees, they must provide their worker' comp. policy number.
I am an employer that is providing workers'
information.
Insurance Company Name:
Policy # or Self -ins. Lie. #:
compensation insurance for my employees. Below is the polzey and job site
Expiration Date;
City/State/Zip:
Job Site Address:
comipensatiou policy declaration page (showing the policy number and expiration date)-
Attach a copy of the workers' to
is a critninal violation I
Failure to secure coverage as required under MGL penalties 152, §
and/or one-year imprisonment, as well P he form of a STOP WORK ORDER and as 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 DTA for insurance
coverage verification.
Ido herehy certify under the andpenalties ofperjary that the information provided above is true and correct.
r—,\ Date:
01 uu-u.i.•.
Phone #: ZIF—
Official use only. Do not write in this area, to he completed by city or town official.
permit/License #
City or Town -
Issuing Authority (circle one): ector
1. Board of Health 2. Building Department 3. city/Town Clerk 4. Electrical Inspector 5. Plumbing xnsp
6. Other
Phone #:
Contact Person'
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 employes is d'efuied as "an individual; partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint eni6rprise, and including the legal representatives of a deceased employer, or the
receivefor, 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 ofthe'
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 comm onvs;ealth for any
applicautwho has not produced -acceptable evidence of compliance with the insurance coverage requilred."
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=contractors) name(s), address(es) and 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, not the Department of
Eadustrial•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 willbe 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 "lob 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. Anew 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 burn 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
1 Congress Street, Suite MO
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-NUSSAPE
Fax # 617-727-7749
Revised 02-23-15 wwwmass.gov/dia