HomeMy WebLinkAboutBuilding Permit #669-2017 - 50 JETWOOD STREET 12/23/2016�`��� Aj44 -6 LP BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#:- 0 1? Date Received ..
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
El New Building
VOne family
0 Addition
[I Two or more family
0 Industrial
C�Iteration
No. of units:
0 Commercial
0 Repair, replacement
EJ Assessory Bldg
0 Others:
0 Demolition
0 Other
Septic. wb•
0 181H M Weird
U. F1' * bdo.
atfthi�d ol§ r1c.
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d
r*ir_QfP113T1r)M np wnRK TO RE PERFORMED:
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Identification - Please Type or Print Clearly Phone:
OWNER: Name: W r -/ o V 9K i
Address: 50 L)x7'woo77 0/!K
one
Contractor arne,
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Superviser-is- Construction License
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Date {tifr
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Address:
Phone:
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: $ 00() FEE: $
Check No.: Receipt No,:
NOTE: Persons cT"ra g unregistered contractors do not have: access to the guarantyfund
SknatUre'bf confrb��.tof,'�
n -Arip.n'
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
r
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
VOTE: 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 o CContract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
DOTE: 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
1
-imension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, roast or service drop.requires approval of
Electrical Inspector lies No
DANCER ZONE LITERATURE: Yes
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
No
Doc.Building Penni Revised 2014
VA
Plans Submitted ❑ Plans Waived Certified Plot Plan ❑ Stamped Plans ❑
DISPOSAL
FTYPFWERAGE
❑
Tanning/MassageBody Art ❑
Swimming Pools ❑
❑
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
COMMENTS
Signature
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 Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT' -.Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Location .5 0 j E -T w 0 0 ':-;-/ -
No. (9 C/ - -
Do 1 7
Check
�7
Date go 1 (0
TOWN OF NORTH ANDOVER
Certificate of Occupancy
Building/Frame Permit Fee
Foundation Permit Fee $
Other Permit Fee $-
TOTAL $
b6ildin'g Inspector
Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
8,000.00
m
$ -
$
216.00
Plumbing Fee
$
27.00
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
27.00
Total fees collected
$
370.00
50 Jetwood
Kitchen Remodel
669-2017 on 12/23/2016
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Donald Belanger
Inspector of Buildings
Please print
TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
120 Main Street
North Andover, Massachusetts 01845
HOMEOWNER LICENSE EXEMPTION
Building Permit Application
Telephone (978) 688-9545
Fax (978) 688-9542
DATE: /Z, - Z► - Y, --
JOB LOCATION: h F.
woyrp
Number Street Address Map/Lot
HOMEOWNER ANDD) r�r � (�
Name Home Phone Work Phone
PRESENT MAILING ADDRESS &L % 60ooL)
.&fm( AbyzYmC9 5 -
City Town State Zip Code
The current exemption for "homeowners" was extended to include owner occupied dwellings of one or two family
dwellings and to allow such homeowners to engage an individual for hire who does not possess a license, provided
that the owner acts as supervisor.
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 dwelling, attached or detached structures accessory to such use and/or farm structures. A
person who constructs more than one home in a two-year period shall not be considered a homeowner. (780 CMR
Section 110.R5.1.2)
The undersigned "homeowner" assumes responsibility for compliance with 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. n
HOMEOWNERS SIGNATURE'_�
APPROVAL OF BUILDING OFFICIAL
Revised 9/16
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
ne Commonwealth of Massachusetts
_ Department oflndustrialAccidents
n 1 Congress Sheet, S5 ite 100
Boston, MA 021.74-2017
^F www mass.gov/dia
Workers, Compensaiionlnsurance Affidavit: Builders/Conixactors/Electricians/Pluna ers.
TO BEETLED WITH TEE PERMM'TI.NCr' AUTHORITY. v7o�aa iPr;nt 1
A 'ilicaniWormaw.ou -
t �KD
52
Name, (Business/Orgaroization/Iudividud):
5
Address:
�'1-Ti(- 9 2,1
Phone #:
City/State/Zip:
project (required)
Type of :
Axe on an em ToyCheck the appropriate box:
er.
y p?
7. ElNew c6n&6dii0n
em 10 ees full and/or parttime).
1,❑ I am a employer with P Y
for me in
$.em0 debug
2. ❑I am a sole proprietor or partnership and have no employees working
insurance required.]
9, ❑ Demolition.
any capacity. LNoworkers' comp.
3.0 I am a homeowner doing all work myself PTO workers' comp. insurance required.]
10 [] Building addition
homeowner and will be hiring contractors to conduct all work on my property. I will
11.❑Electrical rppa*s or. additions
4.�am a
ensurethat all contractors either' have workers' compensation insurance or are sole
byn re airs or additions
12,[ Plum, g P
proprietors with no employees.
5. ❑I am a general contractor and I have hired the sub-confractors listed onthe attached sheet
incrmance
13• goof repairs
These sub -contractors have employees and have workers' comp.
14 El Other
6•FIWe are a corporatioliand its, officers have exercised their right of'exemption Per MGL G.
I fx, and vae have no employees. [No workers' comp. insurance required ]
*Any applicant that check box #1 must also fill out the section below showing their workers' compensation policy information:
Homeowners who this affidavit
t indicating
ched n additional ontractors
are sheegshowing thean name of the sobenhire a contractors and stat? wheaermust submit a �or nOthoseentiiiesnhave
Contractors thatcheck
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
X am an employer that isprovidingworker�s' compensation insurancefor my employees. Below is tlzepoliey aradjo�i site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #:
Expiration Date:
City/State/Zip:
Job Site Address:
couipensationpolicy declaration Page (showing the policy number and expuatzon date).
Attach a cope o£ihevvoxkers' to
Failure to secure coverage as require ivil enaltiesderMGL c. 2in the form of as S�TOPal xWORK ORDER and a fine oolation punishable by a ab £uP to $200.00 a
and/or one-year imprisonment, as w P
be forwarded to the Office o£Invesiigations of the DIA for vssurance
day against the violator. A copy of this statement may
coverage verification.
X do Iiereby certify under tlaepa?a andpenaltzes�°fperjzt�' that the inforrrcation provided ah�ve is true (correct
Do not write in this area, to be completed by city or town official.
Of use only.
Permit/License #
City or Town:
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Towu Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Phone #:
Contact Person:
Information and Instrnetions
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 b6 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 intp 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), addresses) and phone number(s) along with their eertiflcate(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. ff 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
IudustrialAccidents. 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
PIease 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 Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston, MA. 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia