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Home My WebLink AboutBuilding Permit #615 - 48 WENTWORTH AVENUE 3/21/2012TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial XRepair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other R =- ❑ ptic :❑ Welk s 0 Floodplain ❑Wetland's,, ❑ Watersh6d t'rictx� �< ❑Water/£Sewer, � � � , . -- - _ . � � _ _ ESCRIPTION OF WORK TO BE PERFORMED: or Print Clearly) OWNER: Name: C�MOW.a ARCHITECT/ENGINEE 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. Total Project Cost: $ FEE: $ Check No.: -3 �— 1 �[ Receipt No.: �oq NOTE: Persons contracting yv th unregistered contractors do not have access to the guaranty fund Signature of Agent/Qwner t r i -. :, Signature of contractor _. ._ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ 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 COMMENTS HEALTH COMMENTS Reviewed on Siqnature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes _ Planning Board Decision: Comments Conservation Decision: Comments Water & Sewed' Connection/Signature & Date Driveway Permit DPW Towi ]Engineer: Signature: FIRE 10EPARTMEI Located at '124.Main°S Fire Dep4Hment: COMMENTS Located 384 Osgood Street IT - Temp Dumpster on site yes no -eet ignature/date 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 DANCER 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 2010 ~ , 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 MOTE: 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 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 subm;tted with the building application Doc: Doc.Bui?ding Permit Revised 2012 Location No. --4; 12 26219 Date ( 5. dl—.I-y TOWN OF NORTH ANDOVER Certificate of Occupancy $- Building/ rame Permit Fee Foundation Permit Fee Other Permit Fee $ TOTAL RBuildin- Inspector 0 H rl 0 b LU z am Q cc O v w+ .Q L Q w W Q Q � •; E Q. L N w = - w Q Q v N d 3 Q Q N J ZAP 4, m � c L C 0 N m O O N — 0 O cvQN s o O.cn•� N O O ,Mait c N 3 is o0 L Q Q. di Q CJ Q L L Cc •a d H O N v m N �.+ Cc = W = 'C — O O 4) N C N c m M.2 W d L C) O d co Q. d •� C N O t 0 o C) li� �i L"- ,4L,- v/ U) W W 19 W O oc z U v w "' O a LU z i H Z Z W LL Z a Q Z D Z Z (% W 0 m �. ° 25 o G mC J LJ. E m J ta0+ C d LU +-+' ?.2 Y O Z (l L u v t c t t u t aj Y 3 E m m 3 `° °�° `° O o Q C C i C_ O C 3 0 LLL cu N LLL d' U LL OC LL d' N LL K LL m N N b LU z am Q cc O v w+ .Q L Q w W Q Q � •; E Q. L N w = - w Q Q v N d 3 Q Q N J ZAP 4, m � c L C 0 N m O O N — 0 O cvQN s o O.cn•� N O O ,Mait c N 3 is o0 L Q Q. di Q CJ Q L L Cc •a d H O N v m N �.+ Cc = W = 'C — O O 4) N C N c m M.2 W d L C) O d co Q. d •� C N O t 0 o C) li� �i L"- ,4L,- v/ U) W W 19 W 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): V` J� Vr- Address: City/State/Zip: ��oyti� A� W Mk—Phone W #: "1 S kre you an employer? Check the appropriate box: ❑ I am a employer with 4. [:11 am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors ❑ I am a sole proprietor or partner- listed on the attached sheet. # ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] i employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.0 Plumbing repairs or additions 12.❑ Roof repairs 13. ER OtherP Yece iy applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. omeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ntractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. rn im employer that is providing workers' compensation insurance for my employees. Below is the policy and job site i7rmation. urance Company Name: .icy # or Self -ins. Lid. #: Site Address: Expiration Date: City/State/Zip: :ach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 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 ip to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of estigations of the DIA for insurance coverage verification. hereby cert�7) er thelpains�Jvw d penalties of perjury that the information providedd�a ove is riuee and correct. nnfiirP• �/l TlatP• % 1' 3 113 L, /.\ A official use only. Do not write in this area, to be completed by city or town official. �ity or Town: - Permit/License # ssuing Authority (circle one): . Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector �. Other Informaflon 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 -contractors) 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 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 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 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. .he Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 021.11 Tel. ## 617-7274900 ext 406 or 1.877-MASSAFE Tl--. J1 c117 nl)n 1717 An µoHTy. TO" OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT ' ;^ '_:1600 Osgood Street Building 20,.Suite 2-36 North .Andover, Massachusetts 01845 SA�14 Gerald A. Brown Telephone (978) 688-9545 to Inspector of Buildings . Fax (978) 688-9542 HOMEOWNER -LICENSE EXEMPTION 13WDING PERMIT APPLICATION lease rint • , ' DATE: JpB LOCATION: A )JJ 0 I;T I A t^) It +1 n H'lfP lvumber {� ^ Street Address Map/Lot IJOMEOWNER 3� Name �� ` Rome,Pho e WorkPhone PRESENT MAILING ADDRESS OAJ OA - City Tow Sfa+� . zip Code • The current exemption for "•homeowners" was extended to include owner -occupied dwellings to Uvo units -or Iess and to allow such homeotiners to engage an i?Zdividual-for hire who does notpossess a -1 cense, provided that the owner acts as supervisor). State Building Code Section 7 ( 108.3.5. _) DEFINITION OF HOMEOWNER Person(s) who awns 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 thatone home in a two-yearperiod 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 re uire en nd that he/she will comply with,said procedures and requirements, HOMEOWNERS SIGNATURE APPRO VAL OF BUILDING OFFICIAi, Revised 7.2009 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 -` n->