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HomeMy WebLinkAboutBuilding Permit #683 - 51 AUTRAN AVENUE 5/7/2010BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: / [S IMPORTANT: Applicant must complete all items on this pane LOCATION ji Au7-12AAU Print PROPERTY OWNER ) L -G A 01 " 601,4 Print MAP 210 PARCEL: ZONING DISTRICT: Historic District yes !Machine Shop Villaae ves 0 p TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building Or Mormore Addition Two family Industrial Alteration No. of units: Commercial CE e air, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: SC N rgfGP ROOF- Identification OO Identification Please Type or Print Clearly) OWNER: Name: UJ,4L //4 m T'GoJ-41v Phone:91­�F_6',F.3-SVd/, � 9 Address:S/ /-4UP /UD27_� AA1Oor1P2 ?"W� ®JF SY,S CONTRACTOR Name: Phone:: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: ARCH ITECT/ENGINEE Address: Date: 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: $ %,�5700 ,,Ob FEE: $ Check No.: Receipt No.: , Q3 1 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor Location 5- 1)vr%�11,0P, No. 4� AS Date NORTH TOWN OF NORTH ANDOVER Of t"D °,ti0 i °• OL . s Certificate of Occupancy $ ',s'••°° Eta' Building/Frame Permit Fee $ JACMUS Foundation Permit Fee $ Other Permit Fee $ TOTAL $ r Check # t d 23'i 28 Building Inspector 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 N 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 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 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) ❑ 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 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/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 submitted with the building application Doc: Building Permit Revised 2008 O z a w VJ w A d � v 1. w° e E Un u cC/)w° v z z a a s co -o to rG° x U alwco w a wow ca o w,� c a°' c w a w v .c c�° ch ii O u a ° w' w a w A w � „ w� z cn a, 4 cn C O N � Ea CF _ - . C o N m = C ' N /a y �a V y O 'o Z 5 C) 5 C1) 9 P !9 co 0 L cm Z CD C. O CO) 0 CD Cm I p 'CC coCA M �y) •� W W CD o M d a- CM Q c CO.) Ccc C�.3 J •0 COD caQ CLC C..) CO) C ev , — C C d CO) 0 LLI Y/ LLI Y♦ W W lz W W c" t— m ym� a = m m 0 +=- W L 2=...25 �,• C L N O A O RI, N •� O � C0.7 ® f7 Q! CD COO d O O m-0CA = t0H E :a Om 5 C) 5 C1) 9 P !9 co 0 L cm Z CD C. O CO) 0 CD Cm I p 'CC coCA M �y) •� W W CD o M d a- CM Q c CO.) Ccc C�.3 J •0 COD caQ CLC C..) CO) C ev , — C C d CO) 0 LLI Y/ LLI Y♦ W W lz W W The Commonwealth of Al assachusetts Department o f rndush uzj Accidents Office of Lnvestigations 600 Washington Street UT . Boston, MA 02.711 Workers' Compensation Insurance Affidavit Build s/Contractors/Electricians alicant Information /Plumbers Name (Business/organizationd dividual): L 1-6 14 t1i Address: .IV I AU P L City/State/Zip:"a T� A p J 0 t Phone #:2'>d -6 -3 Are you an employer? Check the appropriate boa: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 2• ❑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. [No workers' comp, insurance 5. equired.] m a homeowner doing all work myself. [No workers' comp• insurance required.] t workers' comp, insurance. ❑ We are a corporation and its officers have exercised their right of exemption per MGL C. 152, § 1(4), and we have no employees_ [No workers' comp. insulanc Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 1 I. ❑ Plumbing repairs or additions 12• oof repairs _ e recrurred.] I3.❑ Other I3om o � -t that chR:;s box. -1 must also izil c;:t the section be_oV. Wo `^ a• wners Who submit this affidavit indica c a�� ^' a . do ug �l work- and then hire outside cont 9CtoiS t{ Jst, submit a new affidavit indicating such. "Contractors that cher'.: this box must attached an additional sheet showing the same of the sub-contcacton and their wL--, r —r, r ----.Y ... uii Uu. informatwn er is Providing workers' compensaz on insurance for my employees Below is the policy and job site 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 ane (showing Failure to secure coverage as required under Section 25A of MGL cp. 152can tothe �poolicy numbof crer iminal expiration date). fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties of a of up to $250.00 a da against penalties in the form of a STOP WORK ORDER and a fine y amst 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. I do hereby certify under the pains and penalties of perjury thrrr the information provided above is true and correct Signature: --'v Phone #: • ,> s-- Official use only Do not write in this area, to be completed by city or town offlcurl City or Town• Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. 71�tq6. Other Contact Person: Phone r: Information an- d 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 Iegal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association ox- other legal entity, employing employees. However the owner of a dwelling house having not more than three apartmLents and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintemance, 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 c onstruct 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.perfomiance of public work un -til 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' comp enation 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 sore to sign and date the affidavit. The affidavit should be returned to the City or toidn that the ai p -Th -C urJn for the pert nit or license is be1Sn£'eglteSGed not the .Je7aT—ne tt of Industrial Accidents. Should you have any questions reg ardimg the law or if you are required to obtain a workers' compensation policy, please call the Department at the numberr 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 stamne d 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 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 question, please do not hesitate to give us a call- The allThe Department's address, telephone and,f m number... The Commonwt2lth. of Massachusetts Department Of Industrial Accidents Office of Investigations 600 Washing -ton Street Boston, MA 02111 Tel. # 617-72.7-4900 cot 40.6 or 1-877-NL4SSAFE Revised 5-26-05 Fax # 617-72.7-7749 v rvry .mass._ aov/ala NORTH TOWN OF NORTH ANDOVER Ob RSyEo yb allo` OFFICE OF 100 BUILDING DEPARTMENT d� * 1600 Osgood Street Building 20, Suite 2-36 sq„�A„Eo �PPi�h North Andover, Massachusetts 01845 Gerald A. Brown Telephone (978) 688-9545 Inspector of Buildings Fax (978) 688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE:: /Z / /0 JOB LOCATION: S/ P y7r/I /V Number Street Address Map/Lot HOMEOWNER M41V IIl4M 6014 x1 610 — %Z/clo 9 2,, > oylaz, S c� Name Home Phone Work Phone PRESENT MAILING ADDRESS ��j / UTI?j},k,) 17X)oovP2 .ss ©l� City Town State Zip Code The current exemption for "homeowners” was extended to include owner -occupied dwellings to two units or less and to allow such homeowners to engage an individual 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 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 structures. A person who constructs more that one home in a two-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 SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535