HomeMy WebLinkAboutBuilding Permit #665-13 - 523 OSGOOD STREET 4/11/2013TOWN OF NORTH ANDOVER
77APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION'. s
PROPERTY OWNERe}a2t1.
Pnnt' 100. Year, OWStructure% yes.
MARNO PARCEL: ZONING, DISTRICT: Historic District yes`'
Machine Shop Village yes
no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
ne family
❑ Addition
❑ Two or more family
industrial
Iteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ S.eptic: ❑Well
❑ Floodplain o Wetlands
❑ Watershed District, -
iiWater/Sewer..
`DESCRIPTION OF WORK TO BE PERFORMED: `
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
ArlrirPSG
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.
bc>
Total Project Cost: $ 7 c � FEE: $ �5
Check No.: Receipt No.:
NOTE: Persons contracting witkunregisle(ed contractors do not have access to the guaranty fund
Signature _ofAgent/Owiier; __--nature. of.coritractor,
Plans Submitted ❑ Plans 6ived ❑ 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
COMMENTS
HEALTH
COMMENTS
Reviewed
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
LimNit
Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Towi., ]Engineer: Signature:
Located 384 Os ood Street
FIRE DEPARTMENT = Temp Dumpster on site yes_ no
Located at 124=Mair"Street a�'� Y`� , `r '
Fire Deparr`tment signature/date�`"r
Y P
COMMENTS 6.
r -
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
E,. Fb N 'I 1AL-aW
D Notified for pickup - Date
Doc.Building Permit Revised 2010
Building Department
The fohowing 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)
a 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 appal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be subm;tted with the building application
Doc: Doc.Building Permit Revised 2012
Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
$ 79000.00
m
$ -
$
84.00
Plumbing Fee
$
10.50
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
10.50
Total fees collected
$
205.00
523 Osgood Street
665-13 on 4/11/2013
4x16 addition on existing porch
PLOT PLAN
401 SOUTH BROADWAY LAWRENCE,
NORTHERN MA TASSOCIATES,) INC. 3335 FAX: 978 837-3336
MORTGAGOR:
STEPHEN DUFRESNE
DEED REF.
1968/151
LOCATION:
523 OSGOOD ST/AKA 0 STEVENS ST
PLAN REF.
#5958
CITY,STATE.
NORTH ANDOVER, MA
SCALE:
1"=60'
DATE:
4/10/13
JOB #:
0
CERTIFIED TO:.
Flood hazard zone has been determined by scale and
is not necessarily accurate. Until definitive plans
are issued by HUD and/or a vertical control survey
is performed, precise elevations cannot be determined.
NOTE: This mortgage Inspection was prepared
specifically jbr mortgage purpose only and b ri i� QF
is not to be relied upon as a land or property '(H
ZIZ
line survey, used for recording, preparing
descriptions, or construction No corners were JOHNset. Building location and offsets are
approximately located on ground and fI
are shown specifically fir zoning determination eP�0
only and are not to be used to establish property a
lines. The matters shown hereon are based on
client—furnished injbrnation and may be subject
to further out—sales, takings, easements and rights
of way, and other matters of record and preser ive�4 'OS
a
or other rights. Northern Associates, Inc. assumes no �ri
responsibility herein to land owner or occupant,
accepts no responsibility jbr damages resulting from saidsa
reliance by anyone other than the said mortgagee and it3 its assigns
in connection with its proposed mortgage financing to sao said tno, gator.
J.¢ mortgage inspection was prepared in accordance
with the Technical Standards for Mortgage Loan
Inspections as adopted by the Massachusetts Board of
Registration of Professional Engineers and Land
Surveyors 250 CMR 605.
1 further state that in my professional opinion that
the structures shown conlbrn with the local zoning horizontal
dimensional setback requirements at the time of construction er
are exempt under previsions of M.G.L. CH. 40—A Sec. 7.
O I. Property/House is not in Flood Hazard.
Cl 2. Property/House is in a Flood Hazard Area.
O 3. Injbrmation is insufffcent to determine Flood Hazard
Flood Hazard determined from latest Federal Flood
Insurance Rate Map Panel
Date Zone
,
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, AM 02111
,• www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: S-,�3
City/State/Zip: Phone #: 33 _q6 3(_1
kre you an employer? Check the appropriate box:
❑ I am a employer with
4. ❑ I am a general contractor and I
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.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
❑ I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. [] Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
iy applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information.
omeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
ntractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
w an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
grmation.
urance Company
icy # or Self -ins. Lid. #: Expiration Date:,
Site Address: City/State/Zip:_
ach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
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
ip to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
estigations of the DIA for insurance coverage verification.
P hereby certt& #rider thepains andp/enalties ofperjury that the information pro vided abo ve is trite and correct.
)fficial use only. Do not write in this area, to be completed by city or town official.
;ity or Town:
Permit/License
ssuing Authority (circle one):
. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
Other
'.nnfnef Parenn• PhnnP V-
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 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 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 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' compensation 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 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 (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
J.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,
?lease do not hesitate to give us a call.
'he Department's address, telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 021.11
TeX. ## 617-7274900 ext 406 or 1.877--MASSAFE
Rau #f Al 7_777_7749
GeraldA. Brown
Inspector ofBuildings
TOWN OF NORTH ANDOVER
OFFICE OF
BLUDING DEPARTMENT
•.600 Osgood Street Building 20, -Suite 2-36
North Andover, Massachusetts 01845
Telephone (97$) 688-9545
Fax (978) 688-9542
HC)MMOWNER•LICENSE EXEMPTION
BUDDING PERMIT APPLICATION
Please print
DATE:
SOB LOCAnbn 5�3
. ev
Number Str..t Address —
Map/Lot
IXOME. OWNER
23'-� 3 9O3C�
Name Home Phone
Work Phone
PRESENT MAILING ADDRESSr-�
State- Zip Code
The current exemption for "homeowners" was extended to Include owner-occ6pied dwellings to two units or less and
to allow such homeoy-�rers to engage ancividuai•for hire who does not possess a 7 cense, provided that the owner
acts as supervisor). State Building (Code Section 108.3.5.7)
DEFINITION OF HOMEOWNER
Persons) 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 construct
considered a homeowner. s more thatone home Ina two-year period shall not be
The undersigned "homeowner" assumes responsibility for compliances with the State Building Code and other
Applicable codes, by-laws, rules and regulations, t
The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department
minimum inspection procedures and requirem
requirements, ents and that he/she will comply with,said procedures and
,
HOMEOWNERS SIGNATURE Q
APPROVAL OF BUILDING OFFICIAL
Revised 7.2009
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530
HEALTH 688-9540
PLANNING 688-9535
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Location
No. 6& D a t e
Check o5w
26276
TOWN OF NORTH ANDOVER
Certificate of Occupancy,
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee
TOTAL
Building Inspector