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HomeMy WebLinkAboutBuilding Permit #752 - 5 BELMONT STREET 4/19/2012BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION �—Z TYPE OF IMPROVEMENT ❑ New Building ❑ Addition ❑ Alteration ❑ Repair, replacement ❑ Demolition '< ❑ 1N:atet/Sewer �.:� ' ` ��__ `.; � _ DESCRIPTION OF WORK TO BE PREFORMED: Date Received ❑ Two or more family No. of units: ❑ Assessory Bldg _ Nal nIM Identification Please Type or Print Clearly) OWNER: Narne:- P Phone: q —J � I floe ARCHITECT/ENGINEER 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: $ -7/0 FEE: Check No.: (C'B Receipt No.: G� '(; C NOTE: Persons contracting with unrestered contractors do not have access to the guaranty fund T i ey Identification Please Type or Print Clearly) OWNER: Narne:- P Phone: q —J � I floe ARCHITECT/ENGINEER 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: $ -7/0 FEE: Check No.: (C'B Receipt No.: G� '(; C NOTE: Persons contracting with unrestered contractors do not have access to the guaranty fund Location No. S 2- Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ s'` Building/Frame Permit Fee $ r Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 25211 Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ElTanning/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 PLANNING & DEVELOPMENT ❑ COMMENTS DATE APPROVED El DATE REJECTED DATE APPROV D CONSERVATION o El 0— j� I a COMMENTS HEALTH r COMMENTS NK DATE REJECTED DATE APPROVED ❑ Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/Signature & Date Driveway Permit Located at 384 Osgood 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 21A—F and G min.$100-$1000 fine Doc.Building Permit Revised 2007 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 o 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 o Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses a 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 submitted with the building application Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 cd ui z c•a ?W C H : Cn O C �j �..� 3 w C7 cc.. 0 H E-mv; co �.., �co :w c fA E E Cn 0 O ' m ci p o 0 m = :c �O :� n• a _ m 9 -m U 0 0 3 (%� H C c a O :.. go Cf) ymCD CDs C/) 0 cm W CM _c O -C= m • O O � a H -.m c •o = m :0 3 N o, o 0 F- cn � � +r _ o «. c .. •CD ~ •Vl LE C •C o mQ cm H V •p O � . CO3 o. m . = C • H Z gyp, p. r=-. m 9 Ea O CD L C3 o � CD cm Z � Q CIO C .0 co.� y 0 0 CIO m CD CD co CL ~ =-• = 0 A Q � co 0 em o g CL C o _ cc C.3 .5.0 ,& O CD C Z 5 CD CL. V y 0 C 'C C W CLCO2 is ui 0 LLI W W 19 W U) o w° cn �, U) W 00 C w° a�' U w A. n�' w oG W �" w°' u c w Cd w w rA cn o cn ; ui z c•a ?W C H : Cn O C �j �..� 3 w C7 cc.. 0 H E-mv; co �.., �co :w c fA E E Cn 0 O ' m ci p o 0 m = :c �O :� n• a _ m 9 -m U 0 0 3 (%� H C c a O :.. go Cf) ymCD CDs C/) 0 cm W CM _c O -C= m • O O � a H -.m c •o = m :0 3 N o, o 0 F- cn � � +r _ o «. c .. •CD ~ •Vl LE C •C o mQ cm H V •p O � . CO3 o. m . = C • H Z gyp, p. r=-. m 9 Ea O CD L C3 o � CD cm Z � Q CIO C .0 co.� y 0 0 CIO m CD CD co CL ~ =-• = 0 A Q � co 0 em o g CL C o _ cc C.3 .5.0 ,& O CD C Z 5 CD CL. V y 0 C 'C C W CLCO2 is ui 0 LLI W W 19 W U) TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT Osgood Street Building 20, -Suite 2-36 North Andover, Massachusetts 01845 Gerald A. Brown Telephone (978) 688-9545 Inspector ofBuildings - •Fax (978) 688-9542 HOMEOWNER'LICENSE EX.EW- TION BIIIDING PERMIT APPLICATION Please print DATE: 7 f �- JOB LOCATION: W tvumber Street Address Map%Lot HOMEOWNER / . T -67//2..j 57% <P' Name Home Phone Work Phone PRESENT MAILING ADDRESS r City To �*fin U 61fy Zip Code The current exemption for "homeowners" was extended to include owner-occtipied dwellings to ttivo units -or less anr7 to allow such horneotT�ners to engage an ir�dividual-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 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 that one home in a Iwo -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, HOMEOWNERS SIGNATTmF � % , � , ' APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 The Commonwealth of Massachusetts - Department of Industrigl 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): 4 z " /,'(f Fa L' 16 Address: City/State/Zip: Itla Y {� �r� t6lGW � Q Phone M 97 e Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 44. ❑ I am a general contractor and I 6. F1 New construction ' employees (full and/or part-time) * have hired the sub -contractors �• F1 Remodeling 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and, have no employees These sub -contractors have 8. ❑ Demolition workingfor me in an capacity. Y p tY• workers' comp. insurance. ' 9. EJ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10. ❑ Electrical repairs or additions required.] 3K] I am a homeowner .doing all work officers have exercised their right of exemption per MGL 11.❑ Plumbing repairs or additions Sys elf. [No workers' comp, c. 152, § 1(4), and we have no 12.E] Roof repairs insurance required.] employees. [No workers' .1311Other 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 their workers' comp. policy information. 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 requiredunder 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 civilpenalties 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 DTA for insurance coverage verification. Ido hereh�fy under tl gains andpenalties ofperjury that the information provided above is true and correct. S 7 � — J3 %c/ - ,-:,?I© Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical Inspector 5.Plumbing Inspector 6. Other - - - Contact Person: 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 ofpublic 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-contractor(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 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. 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 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: Elie CommonwealthofMassacliusetts Department oflndustdal Accidents Office ofwestigatiou 6.00 Washington Street Boston, MA 02111 Tel, # 617-727,4900 est 406 or 1-877:MASSAEE Revised 5-26-05 Fax # 617-727-7749 ww=w.xnass.gov�dia File number: 120110-16 UNREGISTERED LAND Attorney: TOMLINSON & HATCH, LLC Deed Book 1193 Pae 273 Lender: MERRIMACK VALLEY FCU Plan Book 33 Pae Lots 36 Owner: FARO REGISTERED LAND Reg. Book Sheet Lot(s): Date: 1/11/2012 Certircate of Title Assessor's Ma 210 Blk: 18 Lot 16 Census Tract MORTGAGE INSPECTION PLAN Scale: 5 BELMONT STREET, NORTH ANDOVER, MA LOT 40 pi 50.00' 01 LOT �3 5000 F 0 0 LOT 37 LOT 35 C5 0 0 #5 2 ST. 50' TO HODGES ST. 50.00' BELMONT STREET CERTIFICATION 1 CERTIFY TO THE ABOVE ATTORNEY, BANK,AND THEIR TITLE INSURANCE COMPANY THAT THE MAIN BUILDING, FOUNDATION OR DWELLING WAS IN COMPLIANCE WITH THE LOCAL ZONING BYLAWS IN EFFECT WHEN CONSTRUCTED (WITH RESPECT TO STRUCTURAL SETBACK REQUIREMENTS ONLY) OR IS EXEMPT FROM VIOLATION ENFORCEMENT ACTION UNDER MASS. GENERAL LAW TITLE VII, CHAPTER 40A, SECTION 7. FLOOD DETERMINATION BY SCALE, THE DWELLING SHOWN HERE DOES NOT FALL WITHIN A SPECIAL FLOOD HAZARD ZONE AS DELINEATED ON A MAP OF COMMUNITY # 2500980003C AS ZONE X DATED 6-2-93 BY THE NATIONAL FLOOD INSURANCE PROGRAM. or 4 !-- f Olde Stone Plot Plan Service, LLC' .G. KE P.O. Box 1166 tG.Lw 4 Lakeville, MA 02347 x Rio' 3'51&q r f s g Tel: (800) 993-3302 Fax: (800) 993-3304 PLEASE NOTE: This inspection is not the result of an instrument survey. The structures as shown are approximate only. An instrument survey would be required for an accurate determination of building locations, encroachments, property line dimensions, fences and lot configuration and may reflect different information than shown here. The land as shown is based on client furnished information only or assessor's map & occupation and may be subject to further out -sales, takings, easements and rights of way. No responsibility is extended to the landowner or surveyor, or occupant. This is merely a mortgage inspection and is not be be recorded.