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Home My WebLink AboutBuilding Permit #478-15 - 524 MAIN STREET 11/13/2014BUILDING PERMIT?r y.: _ 0A TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION xx Permit NO: U i6 Date Received 0 • Ana•41 Date Issued: �9SSAc Hus�� i I� IMPORTANT: Applicant must complete all items on this page LOCATION SJ (S2 !g &1Ae',,y J61A�. ! V� /a/—.2�u� ,�- � . G�Z Print PROPERTY OWNER i Print . MAP NO: V1_PARCEL: ZONING DISTRICT: Historic District Machine Shop Village TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Buildingne family ❑ Addition ❑ Two or more family 0 Industrial ❑ Alteration No. of units: ❑ Commercial epair, replacement 0 Assessory Bldg 0 Others: ❑ Demolition 0 Other 0 Septic ❑ Well Q Floodplain ❑ Wetlands 0 Watershed District ❑ Water/Sewer OWNER: Name:_ Address: M, CONTRACTOR Name: Identification Please Type or Print Clearly) Ph( /A/ Phone: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ��?,9>z Gi,*,9'.3✓ 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: $ FEE: $ Check No.: gai Receipt No.: Z�2-(p1 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 3ignature,of Agent/Owner ►® re of contractor .�z .tee Plans Submitted ❑ Plans Waived ❑ 41 Certified Plot Plan ❑ _x 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 ❑ t�, THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments F 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 here/date ONIMENTS Qt -GP 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 NU I t5 and UA I A — (For department use ❑ Notified for pickup Call Emai Date Doc.Building Permit Revised 2014 Time Contact Name 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/Cross Section/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 2014 4+ - IM, QLU x Ila' OC9 D O mC L O LL E +0+ O_ Ln � U z z �_ m C 7 LLL = d' U c6 LL xx O z z J d bD 7 K I.L.. 0 Z Q U J W 7 cr i> Ln N LL oC 0 u z z :3 w LL z LU x a a C LU °c 6L L m Zcu N N O Ln i� O C) LU U) Z 0 m E-- H E Z U Cl) DC 0 . U) a z o W � U CD� a W J m a= 0 C 7 O N d t 4- O z O Q J 0 E w O � O � m m co O � CL tQ O � Cc Cc J O O za N C The Commonwealth ofMassachusetts - Department of InilusfriralAccitlents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass gov/clia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organizationgndividual):. City/State/Zip xy/l Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑ New construction employees (full and/or part-time).* 2. El am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. 7• El Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition Irking for me in any capacity. workers' comp. insurance. 5. ❑ We are a corporation and its 9. F1 Building addition o workers' comp. insurance officers have exercised their 10.❑ Electrical repairs or additions required.] 3. t6 I am a homeowner doing all work right of exemption per MGL 11.C1 Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required] � � employees. [No workers' 13.0 Other comp. insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. i -Homeowners who submit this affidavit indicating they tie doing allwork and then hire outside contractors must submit anew affidavit indicating such. ?Contractors that checkthis boa: must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that isproviding workers' compensation insurance for my employees. Below is the policy and job site information. 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 page (showing the policy number and expiration date). Failure to secure coverage as required under 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 tine of up to $250.00 a day against 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 certo under iliepains andpenalt"perjury that the information provided above is true and correct. 161 Official use only. Do not write in this area, to he completed by city or town official. City or Town: PermitiLicense # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. EIectrical Inspector 5. Plumbing Inspector 6. Other 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 person in the service of another under any contract ofhire,- express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other Iegal 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 employes." MGL chapter 152, §25C(6) also states that "every state or local lie-ensing 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 -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. B e advised that this affidavit may be submitted to the Department of Industrial Accidents fo; confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be retained 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 suture permits or licenses. Anew 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 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 abd fax number: Tho Commonwalth of Massachusetts Dopartmeiit ofl dust ial Aacidwts Office ofInvestigationa 60 Wasbii gtoa Street Boston, MA 02111 Too, # 61 7-7-2.7-4900 ext 406 ox 1-877-MASSAFI E Revised 5 -26 -os `ay,617-727-7749 www.ulass,govldla 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 HOMEOWNER LICENSE EXEMPTION Telephone (978) 688-9545 Fax (978)688-9542 JOB LOCATION: ;: 'j k,,'/V Number Street Address Map/Lot HOMEOWNER Name Homi)Phone Work Phone � n PRESENT MAILING ADDRESS A4 11L Z�a /2Y a l /� � S - 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) -,.2.-z 44 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 10.2005 Foran Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVA'T'ION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Location`— 1 I' No. 6 — 1 Date { 3 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 2626? Building Inspector