HomeMy WebLinkAboutBuilding Permit #724 - 475 MASSACHUSETTS AVENUE 5/18/2010Permit NO: / J
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
TYPE OF IMPROVEMENT
PROPOSED USE
v
Residential
Non- Residential
New Building
ne family
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
Others:
epair, replacemen
Assessory Bldg
Demolition
Other
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OWNER: Name:
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Phone:
ARCHITECT/ENGINEER Phone:
Address:
Reg. No
FEE SCHEDULE: BOLDING PER�MIIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COSTBASgp ON $125.00 PER S.F.
Total Project Cost: $ FEE: $ �'-
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
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
o 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
Li 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
o 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
o 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 2008
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.
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
s
i
HEALTH
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comments
Conservation Decision: Comments
Water & Sewer Connection/signature & Date Driveway Permit
DPW Town Engineer: Signature:
t_ocatea 384
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=COMMENTS
Street
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-$1000 fine
NOTES and DATA — (For department use
❑ Notified for pickup - Date
. . .... . .. . ... . ..... . . ..... . ....... . ................... .
Doc.Building Permit Revised 2010
Location 7>
No. Date
"ORT" TOWN OF NORTH ANDOVER
Ot.•o ,• ,NO
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Certificate of Occupancy $
��s',•• E<�' Building/Frame Permit Fee $
s�CHus
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # d &--�
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The Commonweizlth of Alassacitusetts
Department o f Industrial Accidents
Office Offnvestibations
600 N%ashingtnn Street
Boston, M<4 02111
Workers' Compensation Insurance Affida•,i Builders/
�plicant Information Contractors/Electricians/Plumbers
Name (Business/Organization/indivi dual):
Address: 7 Met -.S . +e- .
City/State/Zip:r-
Phone #: q 7(�-- k
Are you an employer? Check the appropriate boa:
1. ❑ I am a employer with
4. ❑ I am a general contractor
2.0 employees (full and/or part-time).*
I am a sole
and I
have hired the sub -contractors
proprietor or partner-
ship and have no employees
listed on the attached sheet #
working for me in any
These sub—contractors have
capacity.
[No workers' comp. insurance
workers' comp, insurance.
5. ❑ We are a corporation
3. VIequired.]
and its
officers have exercised their
am a homeowner doing all work
right of exemption per MGL
Myself [No workers' comp.
c. 152; § 1(4), and we have
in required.] t
no
P Ya ,
em to--�S_ (No workers
Pomp. insuz-an
Type of project (required):
6• ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12.❑ Roof repairs
.. ce recurred.] 13Other
Wy that checks box �1 Must also iuI Qe:
the 3P LJ^ belQY.• E- V'—i-^o c?r Q^ C
Iioineowuers who submit this affidavit indicating 1tse., are doing aL' work and' P-,-' = `° y„-ti°i
Contractors that check this box must attached an additional sheet showine the �� outside C°u�°tO� n" q S°b-it a new affidavit indicating such.
name of the sub-contmcton and their worker'
r-
_ -" ; npeoyer neat IS providing workers' compensation insurance or m employ -1--
in
....,a..,,,.,
information f y employee,, Below, is the policy and job site
Insurance Company Name:
Policy # or Self -ins. Lic. #:
Expiration Date:
Sob 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 )
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
P criminal penalties of a
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification
I do hereby cerci er the airs d penalties of perjury thurr the information provided above is true and correct
Official use only. Do not write in this area, to be completed bJr cnj, or town official
City or Town:
Pernut/License #
issuing Authority (circle one):
1. Board of Healtb 2. Building Department
6. Other
City/Town Clerk 4. Electrical Inspector 5. Plumbing irrsnector
Contact Person:
Phone #:
Information an_ ci Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including tibe legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association o$ other legal entity, employing employees. However the
owner of a dwelling house having not more than three aparta ents and who resides therein, or the occupant of the
dwelling house of another who employs persons to do mainte3nance, 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 tical licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to C-- onstrvct 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 Im it 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-contractor(s) name(s), address(es) and phone number(s) along with their cerdficate(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' comp enation incm,-ance. 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 011 or town `hat the au✓iication for the ^ cense i be' requested, {We
l rout or li ... , s mg . ques*.ed, not of
Industrial Accidents. Should you have any questions regardiri g the law or if you arere.,/ , . ed 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 Investigation 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 `.`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 pert 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 than you in advance for your cooperation and should you have any question,
please do not hesitate to give us a call-
The
allThe Department's address, telephone .and flax. number: .
The Commonwealth of Massachusetts
Delaartment of Industrial Accidents
Office of lurestigaifons
600 Washington Street
Boston, IVIA 0.2111
Tel. # 617-72.7-4900 ext 40,6 or 1-977-MASSAFE
Revised 5-36-05
Fw. - 617-72.7-7749
vrvrw .mass.. gov/dia
NORTH TOWN OF NORTH ANDOVER
ob ,ztso �"°oma OFFICE OF
BUILDING DEPARTMENT
�o a .1600 Osgood Street Building 20, Suite 2-36
North Andover, Massachusetts 01845
Gerald A: Brown Telephone (978) 688-9545
Inspector of Buildings Fax (978) 688-9542
HOMEOWNER LICENSE EXEMPTION
GUIDING PERMIT APPLICATION
Please print
DATE: l
JOB LOCATION: q 7 S . / v(h 5-5.- 14dZ
Number Street Address Map/Lot
HOMEOWNER
Name
97�--&�j& -3S�o
Home Phone
PRESENT MAILING ADDRESS �75 /�aSS . �✓e .
. /149,-Y�A 406v�,f�_
City Town
Work Phone
ON -VI
Zip Code
The current exemption for "homeowners" was extended to include owner -occupied 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/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. 1 1-1
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Revised 7.2009
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535