HomeMy WebLinkAboutBuilding Permit #710 - 523 OSGOOD STREET 4/5/2012BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
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Permit N0: Date Received-���-
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TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
N New Building
�KDne family
❑ Addition
b Two or more family.
industrial
❑ Alteration
No. of units:
D Commercial
❑ Repair re lacemen
❑ Assessory Bldg
❑ Others:
❑ Demolition
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❑ Other
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DESCRIPTION OF WORK TO BE PREFORMED:
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OWNER: Name:
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Address Q%3 Os cx�,� S�tc-O-�
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ARCHITECT/ENGINEER Phone:
Address: Reg. No
FEE SCHEDULE: BULDING PER+MIIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED &i'
COST BASED ON $125.00 PER S.F. ,Q- Total Project Cost: $ q f 0� 11 1 a 0 — FEE: $ _G X r _57
"
1 11. W i
Check No.:
L- Receipt No.: S-1
NOTE: Persons contracting wijh unregistered contractors do not have access to the guaranty fund
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 ❑ Y
COMMENTS W oc--I� ��2(� ®s2� J�br� �. �00\
HEALTH ❑
COMMENTS
DATE REJECTED DATE APPROVED
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.s100-s1000 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
o 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
a Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
o 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
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)
o Building Permit Application
o Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ 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
❑ 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 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
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y The Commonwealth of Massachusetts -
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization4ndividual):
Address:_'
City/State/Zip: /1 AA f rkA Phone #: 7 76'` ? 33_ g7O3(�
Are you an employer? Check the appropriate box:
Type of project (required):
1. ❑ I am a employer with
4. ElI am a general contractor and T
6. New construction `
❑
employees (full and/ox part-time). *
2. ❑ I am a sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet. t
7• ❑ Remodeling
ship and'have no employees
These sub -contractors have
8. ❑ Demolition
working for me in any capacity.
workers' comp. insurance.
g, ❑ Building addition
[No workers' comp. insurance
5. ❑ We are a corporation and its
10. F1 Electrical repairs or additions
,� xequired.]
3. Lvd I am a homeowner doing all work
officers have exercised their
right of exemption per MGL
11.❑ Plumbing repairs or additions
myself. [No workers' comp.
c. 152, § 1(4), and we have no
12. ❑ Roof repairs
insurance required.] i
employees. [No workers'
13.❑Other
comp. insurance required.]
'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.
.1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company N
Policy # or Self ins. MG. #:
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 fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I'do hereby cert1Cy�iiXer the pains and ppnaIdes ofperjury that the inform a tio n pro vided above is true and correct.
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License
M, IIWFMM
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other - -
Contact Person: Phone #:
Informati®n and Instructi®n
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 j oint 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 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 Us 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 fox 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 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 (ifnecessary) 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 p* 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 Commonwealth ofMassochusetts
Dep.aftent of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA. 021 It
`Fel, # 617-727,4900 Qyt 406 ox 1-877,MA.SSAFB
Revised 5-26-05 Fax # 617^727-7749
www.Mass.g0VA'a
Gerald A. Brown
Inspector of Buildings
Please print
TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
1600 Osgood Street Building 20, -Suite 2-36
North Andover, Massachusetts 01845
Telephone (978) 688-9545
Fax (978) 688-9542
HOMEOWNER•LICENSE EXEMPTION
GUIDING PERMIT APPLICATION
DATE:__�/-z f ef, � �%IZ
JOB LOCATION:
Number
IJOMEOWNER
Name
PRESENT MAILING ADDRESS
R-\ G &Ve r
Ui-ty Taj} M.
D-w6d_ SV -
Street Address
oU
Home Phone
StaYte .
Map%Lot
i7fl- X33- 70
Work Phone
0l��lS
Zip Code
The current exemption for "homeowners" was extended to include owner -occupied dwellings to itivo units or less and
to allow such ho neon=vers to engage an iadividual•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 Qwns 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 mmnevli,rPc .-A
requirement._
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Revised 7.2009
Form Homeowners Exemption
130ARD OF APPEALS 688-9541
CONSERVATION 685-9530F
HEALTH 688-9540 PLANNING 688-9535
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CERTIFIED TO:.ENTERPRI5E \
Flood hazard zone has been determined by scale 'N�11
and is not necessarily accurate.Until definitive plans \
are issued by BUD and/or a vertical control survey
is perfarmed,precise elevations cannot be determined.
NOTE: This mortgage Inspection was prepared This mortgage inspection was prepared in accordance
s yy mortgage purpose only and with the Technical Standards jbr Mortgage loan
i ��be "at" upon as a land or property �+ d , ; Inspedtons as adopted by the Massachusetts Board Of
line survey/ used jbr recording, preparing deed r� Registration of ProJhssionat Engineers and Land
descriptions, or construction. No corners were �� �+ Su 250 CMR 605.
set. Builth location and of
are a ���� �q I further state that in my projhssionat opinion that
approximately y located on ground and JOHN G the structures shown conjbrm with the local zoning horizontal
are shown specifically jbr zoning determination W; n` dimensional setback requirements at the time of construction or
only and are not to be used to establish property I J' �-A F are ezenpt under previsioru of JLG.I. CB t0—A Sec. 7.
lines. Tho matters shown hereon are based on Q H SSELl. y f
client—furnished infi"nation and may be subject 3 71 OTI. Pmperty/House is not in Flood Hazar&
to further out—sales, takings, easements and right O 2. Ind Properly/House
se to i asat� Hoz rd Arem
Flood Hazard
of way, and other matters of record and preserpt Jb ff+c
or other rights. Northern Associates. Inc. assumes no �,,�� : oZ-
responsibility herein to land owner or occupant, � 1�1' t`J Flood Hazard determined Joon latest Federal Mood
accepts no responsibility jbr damages resulting Insurance Rate Yap Asnet��'
Horn � o
reliance by anyone other than the said mortgagee and % z2,09
in connection with its proposed mortgage financsng to said mortgagor. / c
Date 1516n - oZ - 93 Zona
Location
No. Date �----
Check # 1
25160
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $��
Foundation Permit Fee $_
Other Permit Fee $
TOTAL $
Building Inspector