HomeMy WebLinkAboutBuilding Permit #652 - 53 WEYLAND CIRCLE 4/27/2010BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION.
Permit NO:Date Received
Date Issued:l—)
I
IMPORTANT: Applicant must complete all items on this nage
LOCATI
Print
PROPERTY OWNER(Or tC
Print
MAP 210 PARCEL: ZONING DISTRICT: Historic District
!Machine ShoD'
yes
no
TYPE OF IMPROVEMENT
PROPOSED USE
Residen '
Non- Residential
New Building
Addition
Two or more family
Industrial
eration)
No. of units:
Commercial—
Re'pair, replacement
Assessory Bldg
Others:
Demolition
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
UtSGKIP I ION OF WORK TO BE PREFORMED:
L) y • f ep I4 c e rAc:VL—;
OWNER: Name: J,w
Address: 573 LL-�e-
CONTRACTOR Name:
[dentificatkn Please Type orrint Clearly)
'e S -+- �a,... CSI L
Q,�- c CJ
SP/-
611
JP/- M
A
Phor
:03-
W 03-)-377
S 12
� �3S
Supervisor's Construction Licenser J Exp. Date:S I
Home Improvement License: Exp. Dae: 7/--./71`;a 11
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: $ o�� , COO .0 FEE: $ 3
Check No.: Receipt No': g4cC
NOTE: Persons co tracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner Signature of contract
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
r
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
7
COMMEN', S
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:
uocatea su4 usgooa street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
COMMENTS
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
Doc.Building Permit Revised 2010
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/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
Ej 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 2008
Location
No. Date
2 2 0
TOWN OF NORTH ANDOVER
Certificate of Occupancy
$
Building/Frame Permit Fee
$
MU
Foundation Permit Fee
$
Other Permit Fee
$
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The Commonwealth of Massachusetts
Department o f Industrial _accidents
Dice Of rnvestigations
600 Washington Street
Boston, MA 02111
wwW-PnasWorkers' Compensation Insurance Affidavit g ov/�a
�licant Informajon Builders/Contractors
Name (Business/organization/individual):_
Address:
M.
(.'v
City/State/Zip: ,v 2-a b7�
3 7 Phone #: eel'()7-77 0-�10 3 5'
Are you an emplo erg Ch It
1.
J ec the appropriate boa:
I am a employer with 4. ❑ I am a general
_
(full and/or part-time).*
contractor and I
have hired the sub -contractors
2.�%employees
l am a sole proprietor or partner-
and have no employees
P
listed onhip
the attached sheet t
Y
working for in any capacity,
These subcontractors have
workers c
� comp. in
'surance.
[No workers' comp..
insurance
.
5. ❑ We are a corporation and its
3: ❑required j
I am a homeowner doing all
officers have exercised their
work
myself; [No workers' comp.
insurance
right of exemption per MGL
. 152, § 1(4), and we have no
cc.to
required.] t
ees.
P Y [No workers
comp ms
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
urance regwred ] f 13 Other
Any applicant that checks box #i must also GIl vut ice secfipn below • shot �W.. fW
I�omeowners who submit this affidavit indicating i��, are doing all work and wort a s' com, ,...,.tea; jn Y L•c, i ,.ccrmahon_
'Contractors that check this box must attached an additional sheet showingthe hirr outside contractors must submit a new affidavit indicating such.
r_
name of the sub -contractors and their wnri,—
•— G"W"'yer mar is providing workers' compensadon insurance for my employees Below is the it —ul�un,
information' Policy and job site
Insurance Company Name: Y"�144(d
Policy # or Self -ins. Lic. #: S /o L4 / D 3 3 nl f►''
Expiration Date: Z (b Q J0
Job Site Address: S-3 c -,e lee /-
City/State/Zip: 1(�o AtoLx w,,�
Attach a copy of the workers' compensation policy declaration page (showing Failure to secure coverage as required under Section 25A ofMGL c. 152 can lead to the policy
impnumber
and
of crimi expiration date).
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WO
Penalties of a
of up to $250.00 a day against the violator. Be advised that a co RK ORDER and a fine
Investigations of the DIA for insurance coverage verification.PY of statement may be forwarded to the Office of
7'4- L..__c
.V `'" "Jy " and enalties
OfPer u
P J rJ dist the information. provided above is true and correct
afimo• _ �7
Official use only. Do not write in this area, to be completed by city or town ffC
City or Town:
Permit/I-icense #
Issuing Authority (circle one):
1. Board of Health 2. Binding Department
6. Other
City/Town Clerk 4. Electrical Inspector 5. Plumbiab inspector
Contact Person:
Phone:
Information an- d 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 o3- 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 lural 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 co=mpliance 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 unrl 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' comp enation 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 inurance coverage. .Also be siure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the pert or license is being requested, not the .Departa:ent. of
Industrial Accidents. Should you have any questions regardintg 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 Ince to thank you in advance for your cooperation and should you have any question,
please do not hesitate to give us a call
The Department's address, telephone .and,fax number.... .
T'he Commonwealth of Massachusetl:s.
Dq%artment of Industrial Accidents
Office of Inrestigations
600 Washington Street
Boston, MA 0.2111
Tel. # 617-72.7-4g¢0 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fv. # 617-72.7-7749
v 1vc=ur.maSs.-�Ov/dia.