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Home My WebLink AboutBuilding Permit #Exception - 50 BRADSTREET ROAD 5/1/2018 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: IMPORTANT: Applicant must complete all items on this age - - - PROPERTY OWNER , . i t.l �1_0 ' 1. - -- PTint 100`Year old Structure yes no: MAP NO: PARCEL:_ ZONING DISTRLCT: Historic District yes no _ Machine�Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family i ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg - - ❑ Demolition ❑ Other - 4O'Septie ❑Well t 7 '' ,. loodplain V11etl; "`t.L ater/Sewer,w DESCRIPTION OF WORK TO B Identi ation Pse Tye P 11 Ia OWNER: Name: Z (.e _ Address: .;" p , "CONT _ACTE)R� Name tiMIffAMMA 1 Address: 11D 5111": z,Supervisor'sConstruction license. = h s' Home ImprovementRLicense: 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: $ FEE: $ '— Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of.Agent/Owrf r . Sig ature of contractor - Plans Submitted 0 Plairg Waved Certified Plot Plan ❑ Stamped Plans ❑ TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION i Permit N0: Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page C (�' _ _ - ' LOCATION_ -�D-f _ C�lr PROPERTY OWNER Print 100 Year Old structure F yes no MAP NO: PARCEL— .___ ZONING DISTRICT____._ ..:Historic District yes -no - Machine Shop Village yes i no ,i TYPE OF IMPROVEMENT PROPOSED USE y Residential Non- Residential ❑ New Building 0 One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic ❑Well' ❑ Floodplain 1fl Wetlands 0 Watershed District El Water/Sewer, DESCRIPTION OF WORK TO BE PERFORMED: � --Identi ation 7zmom int Clearly) OWNER: Name: Phone: 7F12 ajo?S Address: C >J I CONTRACTOR-Name:, Phone:. _ Address Supervisor's Construction License _ Exp: Date:, Home-lmprove.me-nt`License: Exp Date: 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: $ FEE: 1Z� 1 Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature ofAgent/Qwn 6 SI na#ure of-conf_ractor; . Plans Submitted ❑ PIA Waved 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 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 Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW'tbvv : Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENt =Temp Dumpster on site yes.. no Located at 124 Mair, Street Fire Departrnerit 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 l� ® Notified for pickup - Date Doc.Building Permit Revised 2010 if Building Department � The fohowing is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofivg, Siding, Interior Rehabilitation Permits Li Building Permit Application o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses Li Copy of Contract Li Floor Plan Or Proposed Interior Work u Engineering Affidavits for Engineered products NOTE: All dumpster.permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks I i o Building Permit Application u Certified Surveyed Plot Plan u Workers Comp Affidavit o Photo Copy of H.I.C. And•C.S.L. Licenses u Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o 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) u Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (if Applicable) o Copy of Contract o 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 apv,al 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: Doc.Bui ding Permit Revised 2012 Building Department The foRowing is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofiv,g, Siding, Interior Rehabilitation Permits ❑ Building Permit Application Li Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract ❑ Floor Plan Or Proposed Interior Work o 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 o Workers Comp Affidavit o 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) o Mass check Energy Compliance Report (If Applicable) o 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) o Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract o 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 apw-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submAted with the building application Doc: Doc.Buh-ding permit Revised 2012 t,sr. 3 4� r , y j A 04 kO or bey TOWN OF NORTH ANDOVER 0 — `°�° OFFICE OF or, BUILDING DEPARTMENT ' Osgood Street Building 20,-Suite 2-36 I-S North Andover,Massachusetts 01845 SA�+IU Gerald A.Brown Telephone(970)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER-LICENSE EXEMPTION BUIDING PERMIT APPLICATION Pleasevrint. • , DATE: /LQ :JOB LOCATION: /C Number Street Address MaplLot I�OMEOWNER Name Home Phone WorkPhone PRESENT MAILING ADDRESS C=ty To,,,n StM+w. Z'-P code The current exemption for`$omeowners"was extended to include owner-occupied dwellings to two units-or less a to allow such homPot;ners to engage an iridividual•for hire vinnd o does not possess a-1 cense,provided that the owner acts as supervisor). State Building (Code Section 108.3.5.7) DEFINITION OF HOMEOWNER Persons)who 9was a parcel of land on which he/she resides or intends to reside on be a owhich(here is oris intended ne or two farnuly structures. A person who constructs more thatone home in a two-yearperiod shall no he to 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 Forth Andover Building Department minimum inspection procedures and requirements and that he/she will comply with,said procedures and requirements, HOMEOWNERS SIGNATURE APPROVAL OF BUIIAWG OFFICIAL Revised 7.2009 F'Onn Homeowners Exemption OA Rb OF APPEALS 688-9541 CONSERVATION 686-9530 HEALTH 688-9540 PLANNING 688-9535 The Commonwealth of Massachusetts ~ Department oflndustriglAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legib NaT110(Business/Organization/Individual): Address: City/State/Zip: � /' /� yV Phone#: G Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.x 7. ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp,insurance. 9. E]Building addition [No workers'comp,insurance 5. ❑ We are a corporation and its requ' officers have exercised their 10.[1 Electrical repairs or additions 3. m a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roofrepairs insurance required. t employees.[No workers' comp,insurance required.) 13. Other Ql *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 aie doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy anti job site information. Insurance Company Name;: - - Policy#or Self-ins.Lic.4: 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 requiredunder Section 25A ofMGL c.152 can lead to the imposition of criminal penalties of a fine u to$1 500.00 and/or one-year P imprisonment,as well as civil penalties in the form rm of a TOP WORK Y p p S W 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 DIA for insurance coverage verification. X do hereby c der the pains andpenalties ofperjury Aat the information provided above is true an correct. - Signature: Date: Phone F cial use only. Do notwrite in this area,to be completed by city or town officlal.or Town: Permit/Acense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CitylTown Clerk 4.EIectrical Inspector 5.Plumbing Inspector 6.Other - - _ Contact Person• Phone#: Information and ffastruction8 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 ofthe 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 employeT." 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 maybe 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#hat-the affidavit is-complete-and rinted legilY: Th6DeP– b7iit fias-provid6d a sa–e o— fthobofom 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 permithicense 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. ` The Department's address,telephone and fax number: Tho Comm.onwalthof assaclivsetts Department ofJ dustdal AA.ccideats Office of Inyestigations 6QG Washington Street Boston,MA 02111 Tel,#617-727,4900 0A.406 ox 1-87WASSAAFB Revised 5-26-05 Bax#61.7-727-7749 www mass.gav/dia