HomeMy WebLinkAboutBuilding Permit #485-15 - 5 GREENWOOD EAST LANE 11/18/2014BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: ` Date Received
Date Issued: [L`7
IMPORTANT: Applicant must
LO-CATI ON
- LGrv�v�
PROP `RTY OWNER;.
_.
Print
PARCEL ZONING 018 T:
all items on this
istono
I
NORTFf
O�ttf.EC .6 q�O
OL
°; a
no
TYPE OF IMPROVEMENT
PROPOSED USE
Resp ential
Non- Residential
❑ New Building
One family
❑ gddition
❑ Two or more family
❑ Industrial
Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septic Cl Well,
❑ Floodplain 11Wetlands
❑ Watershed District
r. O Water/Sewer__--
DESCRIPTION OF WORK TO BE PERFORMED:
TnSfalJ C-CGC4nha� %PanAS OA exi
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
PLANNING & DEVELOPMENT Reviewed On Signature
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
``COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
NOTE:servation Decision: Comments
:ter & Sewer Connection/Signature & Date Driveway Permit
In all r
tha+DPW Town Engineer: Signature:
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
IVU 1 tJ ana UA I A - (For department use)
❑ Notified for pickup Call Email
Date Time Contact Name
Doc.Building Permit 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
o Certified Proposed Plot Plan
a 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 submitted with the building application
Doc: Building Permit Revised 2014
Location V
N4f—"
'!�a0T )A
Date
TOWN OF NORTH ANDOVER
e a _ Certificate of Occupancy $
Building/Frame Permit Fee .
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check 4t f
28284 Building Inspector
E
�I
U
M
1
� 3
g �
F4W1233- W3633 , N
_
zo 1336.
. 1. o. —
t t
co co
' t
N
_ m_
-
`�' i m —
-
t' Li
O –
t
to
i O
Js
i
i
a u
O
1 E
A :S}j.�� i.
_ .—..I ._. s--------------_7�v I
:a m.; �_OL s' c LIZ tll- o N uco E
�
—�---
s O �j�Q i6 i�7. G. +O-� .0 •" i . ad-. C '� (G
v'TMC U,tt R?Mi'�)fA fn r- N NMLLLL T N 0 S
I I 1
,
I
COWEN ASSOCIATES
Consulting Structural Engineers
29 Vesta Road
NATICK, MASSACHUSETTS 01760
(508) 655.3976 FAX (508) 655-4284
cowenassoc.com
JOB
j SHEET MO. OF
CALCULATED BY - f �.7 DATE 1C4 -
CHECKED BY.
DATE
COWEN ASSOCIATES
Consulting Structural Engineers
29 Vesta Road
NATICK, MASSACHUSETTS 01760
(508) 655-3976 FAX (508) 655-4284
cowenassoc.com
JOB Wit . , G rz=
s SHEET ND.of r -a
1 CALCULATED BY DATE, C ..
CHECKED BY.
DATE
u
;..._.
TY�.tl s l o s� s
COWEN ASSOCIATES
<, Consulting Structural Engineers
29 Vesta Road
NATICK, MASSACHUSETTS 01760
(508) 655-3976 FAX (508) 655-4284
cowenassoc.com
JOB� �T� iY�S��' e
t
SHEET NO. OF-
CALCULATED
F CALCULATED BY_ DATE be
CHECKED BY
DATE
PRODUCT 2041 (5- °Siu!L.} -} SPall-a
reel,
R7 i
All
116
R7 i
All
116
-�k
S2
L
fir'
1
Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
30,000.00
m
$ -
$
360.00
Plumbing Fee
$
45.00
Gas Fee 100 comm.
$
10G.1,00
Electrical Fee
$
45.00
Total fees collected
$
550.00
5 Greenwood East Lane
485-15 on 12/2/14
Kitchen Remodel
0
ENO
t9 *
Gi
i C
0 �
moi+
2 O
(i c
•C i
C d
ca +r
=a
N�
E cL
CD
et E
N
O
N J L
CD
i m d
e
d =t
U) N
•O O 0 0
.04 �E o o co
ex cn CM
O O
o =
w mn 3 c
\C4, a
Q Q- d
cc 0
Lit O
Q L L O
c
W r- "0 .a .i O O
14—
LU �_ •N °' ';grn C O
Q O
W E 00
V = O
a :a a= N J
N U) -=O 4- O O
1— s 4- CL 0 C) >
0
LUa-
Z
Z
D
m
U)
z
O
CD
mc
v+
LLI
Lia CO
X z
W
H �
U)
Cl)
a z
M
•.v
�7
ti
w
0
0
oc
Z
W
LLI
d
d
O
LLI
W
Z
N
N
z
?
U
LLI
C
a
LL
o
Z
CLQ
z
Z
V
N
W
Q
_
0
m
Q
0
W
p
m
v
W
a:
LL
N
m
C
J
d
W
j�
>.
Lncy6
O
Nz
u
\
U
'p
L C
�
t
t u
m
L
�
N +�
i
Y
O
O
O.
7
3
0 :E �
D �
i �
�
N
LL
N
LL
U LL
= LL
� In lL
LL
m LO
N
i C
0 �
moi+
2 O
(i c
•C i
C d
ca +r
=a
N�
E cL
CD
et E
N
O
N J L
CD
i m d
e
d =t
U) N
•O O 0 0
.04 �E o o co
ex cn CM
O O
o =
w mn 3 c
\C4, a
Q Q- d
cc 0
Lit O
Q L L O
c
W r- "0 .a .i O O
14—
LU �_ •N °' ';grn C O
Q O
W E 00
V = O
a :a a= N J
N U) -=O 4- O O
1— s 4- CL 0 C) >
0
LUa-
Z
Z
D
m
U)
z
O
CD
mc
v+
LLI
Lia CO
X z
W
H �
U)
Cl)
a z
M
•.v
�7
ti
w
The Commonwealth of Massachusetts -
Department of Inilustrigl Accidents
Office of Invesfigations
600 Washington Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation bsurance Affidavit: Builders/Cont°actors/ElectricianslPlumbers
Name (Business/Orgmi'zationlin.dividual): A,4r - tor,,,
Address: 2A 1 ss SSS'
City/State/Zip: /Vled ('� 62 J� Phone #: iv -7 g 2-3
Are you an employer? Check the appropriate box:
L ❑ I am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have lured the sub -contractors
2111 am a sole proprietor or partner-
listed on the attached sheet. t
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
3. 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.] ►
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.❑ Plumbing repairs or additions
12. ❑ Roof repairs
13.❑ Other
'Any applicant that checks box Of must also fill out the section below showing their workers' compensation policy information.
f -Homeowners who submit this affidavit indicating they a're doing all work! and then hire outside contractors must submit anew affidavit indicating such.
?Contractors that cherAthis box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policy information.
X 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 S elf -ins. Lie. #:.
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 civil penalties in the form of a STOP WORK ORDER and a rine
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.
Ido liereby cert j tc the pri ns an
,6enalties ofperjury that the information provided above is true and correct.
Official use only. Do not write in this area, to be completed by city or'town offrcial.
City or Town:
Permit/License
Issuing Authority (circle one):
1. Board of Healthl. Building Department 3. City/Town Clerk 4. EIectrical Inspector 5. Pliumibing Inspector
6. Other - - -
Contact Pers
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 ofhire,•
express or implied, oral ox written."
An employeiis 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 H"rising 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 theperformance ofpublic work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
r
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, apolicy is required. Be advised that this affidavit maybe submitted to the Department of Industrial
Accidents for con£r ation 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 fature permits ox 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 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 anal fax number:
Tho GQUUAO Wealth ofMasmrhusPtl-
Department of ladwfdal ,Accident
OfRoe ofIawsligationa
6.00 WaddV. an 8fout
BostQnt MA 0211.1.
Tel, # 617-7.27-4900 ext 406 or x-877-MASSAFE
Revised 5-26-05 Fay O 617-727-7749
w[ W-Mas%guhna
}�-,_` om ',�ry'y■y`���{�(`�Q^BFICEOFyy }�py�"��
' •� - -Bv.�.LfJII 1 �.X jX.+..'.au-�v.T-LP./JJ.�. l Jl t
• ' Q e
-.-1600 Dsgo Da Rreet $uiMing 20, •8urt'2,315
«...�. ti.
7�sSRCKu5� �5 NoxihAndover, Massachusetts 01845
Gerald A. Brown 'Ielepl�one(978} 688 9545
InspectorofBuiIdings - F'ax (978) 688-9542
HQMEO)TER-LICENSE EXSMYTIQN
BERM pRWWT "PLZCA.TfoN
Tease �rmf
- DATE:
SOB LOCATfON., sr
Number SireetAddress
Map/Lot
-
' I�o-AM(AArNER Crve
w �jr,G / 7— S 7/ — 9Z 3 �
Name. . Home Phone
WorkPbom
-PRESENT N.CAMWG ADDRESS
�Zj
City nm. Ott
+p Code
The current exemption for "homeown-ars" was extended to chide ownez occupied divelings to i�vo uns.o its ox lass and
unt
�o allow Mbh ho,neo;,ners to engage anhdividual-for hire, wao does
acts as aotpossess ajicense,
suparvisor). 8=iateDOding (Code Seoton lt)8.3.5.1)
provided owner
DEFINETION OFHOMEOWNER.
Persons) who awns aparcel ofjand on whicIl he/she resides or intends to reside, an whichtbeze is, or is znfended to
cansidezed a homeownez.
be, one or iwo iaDily struciures. A person who constructs more thatAne home in. a twoyearperio d shall not be
The undersigned ".izornedwner" assumes responsr'biliiy for compliances with the State $wilding Code and other
A.pp7icable codes, by jaws, rules audzegulations. x
` The undersigned "homeownef' certifies that helshe ' erstands the Town of
„tri;, „um inspection procedures and require enis thathetslze ill e AndoverBnilding Deparfanent
.requirements, wy withtsaid procedures and
HOMEOW )NRS SIGNATURE
APPROVAL OF $UMD)NG OFFICIAL
Revised 7.200.9
Form homeowners Exemgon
'BOAR)) 0FAPPEAIS 688-9541COhSER,'�r r
• A•i�ON 688-9530 HE.gLT,Ei' 688-9546
PLk.NNNN G 688-9535