Loading...
HomeMy WebLinkAboutBuilding Permit #57 - 470 MAIN STREET 7/21/2009 i I BUILDING PERMIT "°RT"gtio TOWN OF NORTH ANDOVER c� °`: "`A *° APPLICATION FOR PLAN EXAMINATION QA tetwK iwrKw`V7' Permit NO: Date Received Ss Date Issued: ��' O ACHus IMPORTANT:Applicant must complete all items on this page LOCATION �`� xr�1 Print PROPERTY OWNER t, 1 Print a MAP°NO:£PARCEL: ZONING DISTRICT: Historic District yes InMachine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial eration No. of units: Commercial Repai replacement Assessory Bldg Others: i Demolition Other Sep ic' a Floodplain Wetlands Watershed''District Water/Sewer DESCRIP ION OF WTR TO BE PREFORMED: ,� 1 Identificatio'"lease Type or Print Clearly) OWNER: Name: AXn229L © Phone: ` 1A q (p Address: ��O b) CONTRACTOR Name: Phone: Address: Supervisor's Construction License: _ Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ SOD FEE: $ � �— Check No.: Receipt No.: a NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund ignature O A�ent/Owner gnatureof 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 9 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 2008 Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL 4 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 Reviewed on Signature `COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Y Decision/receipt submitted es Planning Board Decision: Comments 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 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 - Date Doc.Building Permit Revised 2009 Location No. Date �aRTh TOWN OF NORTH ANDOVER Certificate of Occupancy $ 7; Also Building/Frame Permit Fee $MU ` Foundation Permit Fee $ Other Permit Fee $ r TOTAL $ Check # ;7� 22261 Building Inspector V40RTfq Town of Andover . No. it dower, Mass., a2* 0 LAKE COCHICO...... OA?ATED P'? C7 BOARD OF HEALTH Food/Kitchen PERMIT T D Sep.tic System BUILDING INSPECTOR THIS CERTIFIES THAT.....5�......... ......... ....... ...In I .. ............................................................................. Foundation has pertnission to erecl............. ....... .. ............. buildings ........... I. .........r. ............................ Rough Chimney to be occupied as... ..... ...h.x....... . ........ ......... .......... provided ed that the pe on 9- this`*P4 sha�6�-every respect the e***terms'"' ...of the application on file in Final 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 PERMIT EXPIRES IN 6 MONTHS Final ELECTRICAL INSPECTOR UNLESS CONSTRUC STARTS t conform o STTS Rough .................................... Service CTOR Final Occupancy Permit Required to Ocmpy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No U.- thing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. The Commanwealt h ofMassachusetts Department of Industrial Accidenft f Offlce of Invem ig ations 600 Washington Street Boston, MA 02111 www n:ass gou/dia , Workers' Compensation Insurance Affidavit~ Builders/Contractors/Eiectricians/piambers A P Iicant information Please Print Leeibl Name (Business/Orgenization/Individual); Address: n Citystate/ • ; �F_ Fl Phone Are you an employer?Cheek.the appropriate box: I.❑ I am a employer with 4. ❑ 1 am a general contractor and I ors Type of Project(requirep: PIoY (foil and/or part-tuns).* have hired the s .c 6. ❑Naw construction . 2.Q I am.a-sole proprietor or partner. listed on the attached sheet 3 7. ❑Remodeling ship and have no employees'. These su&contractotS have working far me in any capacity. workers' comp.insurance. g' Q Demolition [No workers'comp, uasurance 5. ❑ We are a corporation and its 9• Q Building addition officers have exereused their I O.Q Electrical repairs oraddi#ions 3 meowner doing an work right of exemption per MGL I I_ Pl mysei£ [No workers, co umbing repairs or additions camp. t �2, §I(4),and-we have no 12.❑Roof repairs insurance required.]t .employees.[No workers' '�+nynppGcamthitt �P• insurance required.] 13•❑.Other dmeks bot#I must also fill t out the section below showing their workett;'oompeuntion policy information t Homeowners who submit this affidavit intiitatittg they are lain an ;Coanactors that g M'o arnd than hue outside con ick . this box inose an addict ��must submit a nein affidavit anal shear showing the name of the sub- mdteatios such contractats and their workers'ce I��erpioyer thaf[s m , »•p•}clic;irfnmiation p ung workers compensation insurance or anfarmafion• f my avloye Below.ir the policy andyob site . Insurance Company Name: Policy#or Self-ins.Lie.# Expiration Date: Job Site Aridrass: C�l9tate/�rp• Attsch a copy of the workers' eompensabon policy declaration page(showing the policy number and expiration Failure to secure coverage as required.under Section 25A of MGL c. 152 can lead to the imposition of � � fine up to$UDO,00 and/or one-year im sonm criminal penalties of a of up to$250.D0 a i Y well as civil penalties in the form of a STOP WORK ORDER anal a fine day age nst 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 cerfi•fy under the pants and enaides o dzuy p IPe that the information provided above is true and coned 5i tt�e: nn Date: r ct Phone#: vl 3 Fa onfy, do not write is this area,to be cOnVicted by city or town official rt: Permit'/License# hority(circle one): Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plnm6ing Inspector son• Phone#: Information a nd Instructions fi Massachusetts General Laws chapter 152 requires all emp 3 overs 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 mcludireg the legal representatives of a deceased employer,or the receiver orbmtee-of an individual,partnership,associatio=n 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 maintmmce,construction or repair work m such dweiling house or on the grounds or building appurtenant thereto shall not because of such employment be de„-mid to be an employer," MGL chapter 152,§25C(6)also states that"every state ua-local Ceensing agency shall witbhold the issuance or renewal of a license or permit to operate a business or *o construct buildings is the commonwealth for any applicant who has not produced acceptable evidenceziF 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 compiertely,by checking the boxes that apply to your situation and,if necessary, supply sub-contractors)name(s),address(es)Eund 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'ccvrnpensation insurance. If an LLC or UP does have empioyees,a policy is required. Be advised that this affid.-x-*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' oompensation policy,please-call the Department at the nwmberlisted below, Self-insured companies should enter their self insurance"license number on the*appropriate.Sine. 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 afficlavit for you to fill out in the event the Office of Investigations has tD 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/iicense 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 starnped 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. When a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a clog license or permit to bum leaves etc.)said parson 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 CommonwCa-Llth of Massachusetts Department of Industrial Accidents Office of Iwvestieatiions 600 Washington Strict Bosfon, MA 02111 TeL #617-7274900 ext 406 or 1-8.77-MASSAF£ Revised 5-26-45 Fax#617-727-7744 wwwanass.gov/dia i o+ No�TM TOWN OF NORTH ANDOVER •`-' ' ' `•°� OFFICE OF BUILDING DEPARTMENT •, ,,,, 1600 Osgood Street Building 20, Suite 2-36 ��ss;►stt� North Andover, Massachusetts 01845 Gerald Brown inspectpr of Buil .ngs Telephone(978)688-9545 Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION Pleasc mint _ DATE: C JOB LOCATION: Number Strep Address Mapes _Z HOMEOWNER tZ2�� Name Home Phone work Phone PRESENT MAILING ADDRESS gip,� City Town State Zip Code The calrtent exempbwn mr"nam®owneit"was odmided to include 0"WAT-a—""nPied dwellings to two units or leas and to allow swk homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as mgxn isor). State Building.P&Section. 108.3.5.1) DEFlI\RTION 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 faulty structures. A person who constructs more that one home in a two-year,period shall not be considered a homeowner. AThec' ed'K�,m��P°� 'fOr co-PH-11 s with the State Bmidmg Code and other -Tncable[ by-laws,nfles and regulation. The undersigned"homeowner"certifies that Wshe understands the Town of North Andover Building Department. minimum inspection procedures and requite and that he/she will comply with said pmcedmm and • HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 10.1005 Fam Homwwtm Emw i(m BOARD OF \.PPEAI.S 688-9511 C0..SERVXr10V 638-9530 ITEALTH 6xR-9c,40 PLANNING rt33-9535