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HomeMy WebLinkAboutBuilding Permit #544 - 51 BUCKLIN ROAD 3/25/2008BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION * ,� Permit N0: Date Received 'ti4 °kArev •�' �y �SSAc►+us�� TYPE OF IMPROVEMENT PROPOSED.USE Residential Non- Residential New Building One family Addition Two or. more family Industrial Alteration I No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other + s Se tic(ell� i,F 5b`'+ and taara��ar�ds7atershedDistnct F� r� a � _. ,� ��- x`. -.T ''".5., ,s 7h� z�.... ''ark �v ¢a,Tc „�j� �� � •'rr�. ��r t 4 :.s, -sc ��" fir. _ r .a+^'� ,f �� � s � g �� ' � �. OWNER: Name: DESCRIPT N OF WOKK T U Lit FKtl-UKMtU: ✓2� / �^ ��GGtJz�irt�1 I I- &14 /-7'l A /A/ 90 tlL- ft ARCHITECT/ENGINEER Phone: Address: Reg. No e lrz'(-5— 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 2 Location No. 7 Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ r TOTAL $ Check `— _ " 8 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 DATE REJECTED DATE APPROVED CONSERVATION COMMENTS DATE REJECTED DATE APPROVED HEALTH COMA ENTS 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 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 o 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) o 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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 � � ® v c y- o UU. z z o Z co y 0 �CD o u . c � or. Cd G v o U X. ato w c y- o Z co y �CD o v J �! c � C C : o = c c O h Q 'D U h E m ca O ® _vV O CD QO c ev m C cn • r.s " �. CD°� ® o cn z CO E Q CD v OL i O 0. � C c< u J is = t = a CO rrV�) CJCc w ' O m Q CD z CD C.) $ L: V y m m a � C e O �H N 1: y cm > 3 0.5 t N .ter C c ._ H O zip to Co H O O ca :Ew CD 0 C CD Z:CLC.3 h m ID JCOQ `S cOavo � CCU3 ' Z o i Q m C y Occ _c �c to CD coo C co c ',On .� LLW Z = '." C +r O �E W ca 'o o ti CM O y O. GO m, 0:5 o0=�o a=m�om PQ o Z co y v J �! C C —, zCA c 0 Q 'D U h E m ca ® O CD c cn • r.s " �. CD°� ® cn z CD v OL i O 0. 0y c< u = t = rrV�) CJCc w ca CD z CD ^W^� Ind V y ® � C e .® C _cc H 1 PA The Commonwealth M of assachusetts Department of Industrkd Accidents Office of Investigations y 600 Washington Street .Boston, MA 02111 r, www.mciss.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricans/1°iumbers DDUCant Infnrmai;nn Name (Business7(3r nizationandividual): Address: . VR /Slate/Zi : U/gam Ci 13' pOfRC�I ��©=_ Phone.#: 652 ,ir Are you an eto , Cit "' m Type of project (required):.` 6. ❑ New construction 7. Remodeling . 8. ❑ Demolition 9. ❑ Building -addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13.0 Other Harneowriers who submit this affidavit indicating they are doing all work and then hire outside carcompensation Policy information. +ContractOrS that check this box must attached an additional sheet showin the n tors must submit a new affidavit indicating such. employees. If the sub-contractors.have to ge of the sub-cantractors and sate whether or not those entities have emp Yees, they must provide their workers, comp; policy number, • information. n coyer rear is ovutIng workers' compensation insurance for my employees. Below is the policy.and job site Insurance Company Name: Policy # or Self -ins. Lic. #:, Job Site Addre attach a copy Expiration Date: ------------ City/State/Zip: workers' compensation policy declaration page (showing the polic}� number and expiration date). Failure. to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of fine up to $1,500.00 and/or one-year � � . criminal penalties -of a y imprisonmen as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarde&to the Office of Investigations of the DIA for insurance coverave verifinarin., Ido hereby certify under the pains •and penalties of perjury that the information provided above is true and correct Silonatar`e: area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Departm 6; Other ent 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector Contact Person: Phone #: p yer. eck the appropriate box: 1. ❑ I am a employer with 4. 0 1 am a general contractor and I employees (fiill and/or part-time). have hired the sub -contractors 2. ❑ I am a sole listed proprietor or partner- on the attached sheet ship and have no employees These sub -contractors have working forme in any capacity. employees and have workers' [No workers.' comp, insurance comp. insurance.$ 5. We are a corporation and its 3Xrequired.] I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no . employees. [No workers' comp, insurance required;] *Any applicant that checks box #1 must also fill out the section below showing their workers' t Type of project (required):.` 6. ❑ New construction 7. Remodeling . 8. ❑ Demolition 9. ❑ Building -addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13.0 Other Harneowriers who submit this affidavit indicating they are doing all work and then hire outside carcompensation Policy information. +ContractOrS that check this box must attached an additional sheet showin the n tors must submit a new affidavit indicating such. employees. If the sub-contractors.have to ge of the sub-cantractors and sate whether or not those entities have emp Yees, they must provide their workers, comp; policy number, • information. n coyer rear is ovutIng workers' compensation insurance for my employees. Below is the policy.and job site Insurance Company Name: Policy # or Self -ins. Lic. #:, Job Site Addre attach a copy Expiration Date: ------------ City/State/Zip: workers' compensation policy declaration page (showing the polic}� number and expiration date). Failure. to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of fine up to $1,500.00 and/or one-year � � . criminal penalties -of a y imprisonmen as well as civil penalties 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 maybe forwarde&to the Office of Investigations of the DIA for insurance coverave verifinarin., Ido hereby certify under the pains •and penalties of perjury that the information provided above is true and correct Silonatar`e: area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Departm 6; Other ent 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector 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 pesrson 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 "ever state or local licensing agency shall withhold the issuance or renewal of a license or permit to•bperattem 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, §25CO) states'"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for. the performance of public work unitil 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(g) 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,orif 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. 4. 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 sureto fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permittlicense 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 io any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is I -40T 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: The Commonwealth of Massachusetts D!egarbment of Industrial Accidents Office of Investigations 640 Washington Street Boston, MA 02111 Tel. # 6:17-727-4900 ext.4.06 or 1-877 -MASSAFE ` Revised 11-X22-06 Fax # 617-727-7749 .mass.gov/dia s£96-889 WQXINZ ^Id Ut"C6-899IfET "311 UtiS6 8sy \QI I.\",12135\()J It -S6-889 S -I\ add\ A) Gds U11 W3 UMMOMOH UM3 sooz•ot IUL 'Ifr'IJLd30 9mcmna JO WAOIid" H2I UVNJIS SUWMOMOH pm d Pm'siva�aaannbai qdmw Wa aris!q VM Pus SX=mdm pm sa rgwwd wqoa&m mmutuim M=gM*U ftVIMS iMeopud qUoN 30 UtAO.L MR SpuEnuoPua appq W soup= .mmoa wq. poa8=pua OU saogeln8ai pue sRm `sn q f4 `S= oI4milddV saq;o Pm QWJ SUIPImS OMS M IMA swmq&m Joi 14rpcL aod= sa mse Sao wq,, pou2p&Ww oU Jaw+soamog a pompe= aq Wu nags pouad ieaf.- ons 8 m smog mo req; atom spngsaoo ogb uosiad V •sa n=m Apmej onq ao ouo a `oq of papam o st so `m a>mv gocgns uo V= o; spwm io svi= ogspq gowa uo Puel3o pond a smw oqm (s)uowj Va"C KOH 30 NOLLIN a (I •S•£'8oi aoums opal Bulwa ams *(=ospuwm se save "Umo M Wqt PoPLuud `as=n a ssassod lou scop ogtn W% io; FW!AV t ae aMUO 01 siaunsoamoq goes Molle 01 pue SMI m Sims ot►i o; 9ftWmp paidn000-iaubo apalam 01 papuMa sena �SWMAO*mog„ w3 uogdmm mu= ate. aPo'J diz UAWJ f4� SSHUG(IV rJAII'IIm ,1 Nasaud OuNd voM =Id DoH 2WN b -V N Wff"OMXOH viovw SMM PWS nq=N 0 Wolsdooll Sof MOI cMHX HSNMI'I ZI NM MKOH ZV96-899 (8LO Xed SM -889 (8LO auogdala L 5ti810 SWMgMSM `ianopud tPON 9£-Z S `OZPi. 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