HomeMy WebLinkAboutBuilding Permit #533 - 53 MARTIN AVENUE 1/30/2007Permit NO: � MY
Date Issued: "
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
IMPORTANT: Applicant must complete all items on this page
LOCATION ✓ �"� A V 1 T "
/1) / Print �� c,
PROPERTY
Print
MAP NO.: PARCEL: ZONING DISTRICT:
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Residential
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TYPE OF IMPROVEMENT
- - ---
PROPOSED USE
Residential
Non- Residential
❑ New Building
XOne family
❑ Addition
[I Two or more family
❑Industrial
❑ Alteration
No. of units:
Repair, replacement
❑ Assessory Bldg
❑ Commercial
❑ Demolition
❑ Moving (relocation)
❑ Other
❑ Others:
❑ Foundation only
DESCRIPTION UIP W UK& t U tir, rKnr vxivinli
b, `- /_ ( /' .L- -4e 'k, ,I, liiL+ln Ain
OWNER: Name:
Address: 5,'3
Identification Please Type or Print Clearly)
CONTRACTOR Name:
C-
I
Address:
Supervisor's Construction License:
Exp. Date:
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Name: Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT. $12.00 PER $100.00 OF THE TOTAL ESTIMATED 170ST BASED ON $125.00 PER S.F.
Total Project Cost :$ s �® FEE:$ Y O
Check No.: �3 7 Receipt No.:
Page 1 of 4
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
Addition Or Decks
❑ Building Permit Application
❑ 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)
❑ Mass check Energy Compliance Report (If Applicable)
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
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:BPFORM05
Page 4 of 4
TYPE OF SEWERAGE DISPOSAL
Art E]Public
Swimming Pools ❑
Sewer F1Tanning/Massage/Body
Well
Tobacco Sales ❑
Food Packaging/Sales El❑
❑
Permanent Dumpster on Site ❑
Private (septic tank, etc.
Electric Meter_Jocation to
project = "
NU'1'E: Persons contracting with unregistered contractors do not have access to the guaran
Signature of Agent/Owner Signature of contractor
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT ❑
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE REJECTED
DATE REJECTED
11
I
DATE REJECTED
i
FIRE DEPARTMENT - Temp Dumpster on site
Fire Department signature/date
COMMENTS
0
C
0
DATE APPROVED
DATE APPROVED
DATE APPROVED
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
Comments
Water & Sewer Connection/Signature & Date Driveway Permit
Building Setback (ft.)
Front Yard
Side Yard
Rear Yard
Required
Provided
Required
Provides
Required
Provided
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
-NUPE's and DATA — (For department use)
Page 3 of 4
Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM05
Created IMC. Jan.2006
Location 5-3 /?)C�a 4fv
No. S Dates -�-
NORT1y TOWN OF NORTH ANDOVER
Certificate of Occupancy $
'�sJACNUS <� Building/Frame Permit Fee $ r2.10
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ '
Check #
19958
(Q -
Building Inspector
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...,,1 TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
1600 Osgood Street Building 20, Suite 2-64
U5tt�y forth .kndover, Massachusetts 01345
Gerald A. Brown
Inspector of Buildings
Telephone (91S) 6,SS_9j=
HOME0WNER LICENSE E`CE%iPTION Fax (978) 6,04-54
DATE: 3 0 Q
JOB LOCATION:
Number Street Address
HO,IMEO�y'NER L5-erk?gd.e ,
Nameb4/ f
Home Phone --
PRESENT MAILING ADDRESS
Map, Lot
86 73.2 a
Work Phone
City Town v(g��
State Zip Code
The current exemption for "homeowners" was extended to include owner -occupied dwellings to two units
e
to allow such homeowners to engage an individual for hire who does not possess a license, provided that th
acts as supervisor). .State Building (Code Section 108.3.5.1) or less and
owner
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which the
be, a one or two family structures. A person who constructs more that one home in a two-year
a erect a homeowner, re is, or is intended to
wo year period shall not be
The undersigned "homeowner" assumes responsibility for compliances with the State B
Applicable codes, by-laws, rules and regulations. Building Code and other
The undersigned "homeowner" certifies that he, she understands the Town of North Andover BuildingDe
minimum inspection procedures and requirements and that he.'she will comply with said roced
requirements. Department
P urns and
110MEOWNERS SIG,NATLRE
\PPROVw. OF RUII.DING OFFiCI.XL
i�'ntt Hnnu•„„It,,t.,• Ic,.��.c�'tir.n
1 I.. . t..
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
N
600 Washington Street
t Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name (Business/Organization/Individual):
City/State/Zip: Ndo - djf-e0' � 1il - Phone.#: 2 <;o C
Are you an employer? Check the appropriate box:
1. El am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ( 1 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.
employees and have workers'
[No workers' comp. insurance
comp. insurance.t
5. ❑ We are a corporation and its
required.]
3. ❑ 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.l
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
*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 are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing 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 fine
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
Investieations of the DIA for insurance coveraee verification.
I do hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct:
Signature: __ ___ Date:_
Phone #:
use only. Do not write in this area,
City or Town:
or town official.
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical 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 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
(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 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
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext.406 or 1-877-MASSAFE
--- - Fav# -617=727=7749
Revised 11-22-06
www.mass.gov/dia
Contract
Agreement for rehabilitation work to be performed in the kitchen and
bathroom at 53 Martin Ave. North Andover. Owner of the property
Bernadette Dubois agrees to allow Paul Dubois to perform all construction
work and supervise all contractors.
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Bernadette Dubois (owner)
Si ed � � &�, 5;; , !-/,, �7�z, �, � -
Date / O C7
Paul Dubois
Si ed 1�2 )� -
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