HomeMy WebLinkAboutBuilding Permit #170-11 - 523 OSGOOD STREET 8/26/2010 BUILDING-PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received b �u �Olp 4 �� �• ^'
o ACIR40S
Date Issued:
IMPORTANT:Applicant must complete all items on this page
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TYPE OF IMPROVEMENT PROPOSED USE
New Building
Residential Non- Residential
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ne famil
Addition Two or more family Industrial
Iteration No. of units: Commercial
Repair, replacement Assessory Bldg Others:
Demolition Other
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DESCRIPTION OF WORK TO BE PREFORMED:""
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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.
Total Project Cost: $ (,?Oa�ea FEE:
Check No.: 21q Receipt No.: 3�
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty_fund
�:ana
�[=.T
on rad or ktr ` _
-n ture< fe r
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 Dum ster on Site
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THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED-
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Signature
a
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
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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
Doe.Building Penrvt Revised 2010
I
Building Department
The following is*a fist 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
o 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
0 1..ei 01 leu r-ropose-d Plot 111an.-
❑ 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
I
II
°F NORTH TOWN OF NORTH ANDOVER
oOFFICE OF
' BUILDING DEPARTMENT
* 1600 Osgood Street Building 20, Suite 2-36
�.9�DA1TlD•�^'yt� North Andover Massachusetts 01845
SSACHU9�i
Gerald A.Brown Telephone(978)688-9545
Inspector of Buildings Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
BUIDING PERMIT APPLICATION
Please print
DATE: �c, 2ol b
JOB LOCATION:
Number SSttreetn Address Map/Lot
HOMEOWNER 7y s 435
Name Home Phone Work Phone
PRESENT MAILING ADDRESSv��
✓-�n�d� ►m C51�'�-S
City Town stwt, 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
m' .
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 685-9530 HEALTH 688-9540 PLANNING 688-9535
The Comnmonweizith of Massachusetts
Department o f rndastal Accidents
Office Of Investigations
6.00 Washin
_ ;ton Street
Boston, 1114 0211,
www.nzrasS-gov/dia
Workers' Compensation Insurance Affidavit;: Builders/Contractors/Electricians/Plumbers
An licant Information
PIease Print Legibly
Name (Business/Organization/Individual):
Address: 00
City/State/Zip: vn, ®�g'CJ� phone#: �17� t�66
��3s
Are you an employer?Check the appropriate boa:
L❑ I am a employer with 4. ❑ I am a general contractor and I Type of project(required): .
•❑ employees(full and/or part-time).* have hired the sub-contractors 6 ❑New construction
I am a sole proprietor or partner_ listed on the attached sheet �• ❑Remodeling
ship and have no employees These mob-contractors have
working for me in any capacity. workers comp. 8. Demolition
[No workers'com . ' 5. 0 � P insurance.
p insurance We are a corporation and its 9 (]Building addition
required) officers have exercised their 10 ❑Electrical repairs 3. I am a homeowner doing all work right of„ °r�tr0�
Px4),and per MGL 11. Plumbing repairs or additions
myself. [No workers'comp. C. 152,§1(4) and we have no ❑
insurance required.] t employees. [No workers 12-[1Roof repairs
comp.insur=ce required.] 13.[] Other
c=n3' p?iccaatthat h bo::.-i m.s!aso RU cu!Etre Se om :ov!
FIameowners who submit this a"��_="='a'or+^s'
affidavit indicating thea'a=dcirg aL wcrk and
+Contractors that shed;this box must attached an additional sheet showing ��hire oxide contra n4 snbmii x new affidavit indicating such.
a the name of the sub-contractors and their workers'comp.policy information.
infoo rmation,
I an employer that is providing workers,compensation insurance for my employees. Below is thepolicy and job site
Insurance Company Name:
Policy#or Self-ins.Lie.#:
Expiration Date:
Job Site Address:
City/State/Zip:
Attach a copy of the workers' compensation policy declaration Pa.e(showing
Failure to secure coverage as required under Section 254 ofM the policy number-and expiration date).
fine up to$1,500.00 and/or one-year imprisonment,as sell Glc' 152 can lead to the imposition of criminal penalties of a
Of up to$250.00 a day against the violator. Be advised that a co penalties
m the form of a STOP WORK ORDER and a fine
Investigations of the D Py°f this statement may IA for insurance y be forwarded e cov ded
coverage to the
� verification. Office of
I do hereby cerfi•fy er the p and enalfies a er ,
.fP iu? thQ1 the information.provided above '
Siffiature: �
rs true and correct
/ - _
Phone#:
[Other
only. Do not write in this area, to be completed by city or town officurl
n:
Permitucense#
hority(circle one):
I.
Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.plumbing
b Inspector
sort:
Phone :
Information am d Instructions
Massachusetts General Laws chapter 152 requires all employs to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,associ,a,tion, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise,and including tiae legal representatives of a deceased employer, or the
receiver or trustee of an individual,partnership, association o$other legal entity,employing employers. However the
owner of a dwelling house having not more than three apartn1 cuts and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maint�--Mance,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 co3mpliance 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 m-il 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=cation 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 mt-arn—cd to the city ar town that the application for the Derr mit'or license us being requested,not the DepaSty:y:lT.of
Industrial Accidents. Should you haveany eue:stions regarding the law or if you are mqji ea 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.Whe m 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 hike to than 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..fag number__
The Commonwmlth of Massachusetts
Department of industrial Accidents
Office Qf JxNestigations
600 Washutptan Street
Bastion,IVLA 021.11.
Tel. 617-72.7-4900 =4-06 or 1-9-7-1VLASSAFE
Revised 5_26-05
Fax 7 617-72.7-7/749
MrVirtTi-Mass._a ov/Cha.
NORTH
01" 0Andover
01
�10 dover, Mass.,LAK
�
COCHICHEWICK y�.
�oRATE D PPy
S BOARD OF HEALTH
Food/Kitchen
Septic System
PERMIT T D
BUILDING INSPECTOR
THIS CERTIFIES THAT..... .. -1. .... ...............:...... - ............................................................... Foundation
has permission to erect........................................ buildings on ... ............ .. ...... ......... ...--.......................... Rough
(J lii.� ' Chimney
to be occupied as................. . .. ...... ....... .. .. . . . .'4....................:®.........................................................
provided that the person accepting this emi�sa eve res ect conform to the terms of thea lication on file inP P P 9 Pevery P application Final
this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of
Buildings in the Town of North Andover. PLUMBING INSPECTOR
-VIOLATION of the Zoning or Building Regulations-Voids this Permit. Rough
Final
3� PERMIT EXPIRES IN 6 MONTHS
ELECTRICAL INSPECTOR
UNLESS CONS U ON ARTS Rough
......... ................... ......... ........ ...... ......... .......................
.... Service
BUILD TOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
SEE REVERSE SIDE Smoke Det.