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Home My WebLink AboutBuilding Permit #6 - 54 COVENTRY LANE 7/1/2009 BUILDING PERMITo "°DT bgti TOWN OF NORTH ANDOVER 0 �L4� �° o A APPLICATION FOR PLAN EXAMINATION Permit NO: /_� Date Received Esq ADR4TeD IpP��Oj SSACHUS� Date Issued: IN[ ORTANT: Applicant must complete all items on this page LOCATION ' PnntoK�b PROPERTY OWNER Print MAP NO: PARCEL:. ZONING DISTRICT: -Historic District yes cov Machine Shop Village yes o TYPE OF IMPROVEMENT PROPOSED USE Res i Non- Residential New Building VA10 �nr mil Addi ' more family Industrial Iteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: hal s de tific tion Please Type or Print Clearly) OWNER: Name: Phone:NZZ Address: CONTRACTOR Name: _C)VJt% ✓-- Phone: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: 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: $TVS )o '1/ FEE: $_ Check No.: 7"7 3 Receipt No.:c9 — NOTE: Persons contractingV* gunreXisred contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor Location1 C d✓G"` `�" No. Date ( O �oRTM TOWN OF NORTH ANQ.QVER • ; ,' Certificate of Occupancy $ ' �'�s ^°•tt�' MU5 Building/Frame Permit Fee $ 4C Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # I �3 3 2 2 '1 `/ 2 Building Inspector 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 Reviewed on Signature COMMENTS 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 j FIRE DEPARTMENT -Temp Dumpster on site yes no Located at 124 Main Street 1 Fire Department signature/date COMMENTS L 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 j ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 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) ❑ 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 a ❑ 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 NORTH Town of 4Andover _ L No. 09dower, Mass., ' • Q C LAKE COC MIC KE WICK V ORATED C2 BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR Ird THIS CERTIFIES THAT .L Foundation has permission to ere c buildings on ....... ....... I . .............. .... ..�.�.. .h./ .......... Rough to be occupied as.... ..... „.�.. Chimney provided that the person accepting this permit shall in every respect conf terms of the ap ation on file in 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 36 • PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR. UNLESS CONSTRU STARTS Rough .................. ............................................... ............................ Service BUILDING INSPECTOR 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. The common wealthof Massachusetts De artme rzt o #� _f'industrial Accidents Office of investigations . .aa ` 600 Nlashi beton Street �'� Boston, MA 02111 c� www mass gov/dia . Workers' Compensation Insetrance Affidavit: Builders/C A piicant nformation ontractors/Eieatricians/PiQmbers I Please Print Lme-bl Name(Business/brgsnizatiorAndividual} Address: .-City/State/Zip; Phone Are you as employer?Cheek the appropriate box: I•Q I am a employer with 4. ❑ I am a general contractor and I Type of project(reqotmd): employees(full and/or part-time).* have hired the suircorttracors b' ❑New c coon . 2.Q I am..a.sole proprietor or partner- listed an the attached sheet? 7• odeling ship and have no employees' These subcontractors have working me in any opacity. workers' comp.insurance. g' Q Demolition [No ricers'comp.insurance.. 5. ❑ Weare a corporationand its a 9• Q Building addition reds officers have exercised their l0•Q Electrical repairs or additions 3. am a homeowner da' ung all work right of exemption MGL 11. Pn l� m se ❑Plumbing y I£ [No•warker� comp. c, 152, §1(4),'and we have no r ' oraddrtrorrs insurance required.]t -employees o wofke& 12•Q Roof repairs COMP. iszstusncerequired.] 13.Q.Other 't+ny applicant that checks bur:#t must also Mi out the section below showing their workers'bom t homeowner¢who submit this eft itlavit indicei'ing theyare dein an pensetiori Policy Mtonnatfoa ;Contractors that check this box must g work and then hila outside connectors must submit a new affidavit indi ' ettrehed an sdditioasl alias showing•the name of the sub-cmrtractors5 such and their workers'cc.:P.PcTic;rrtnrniedon. I alit aS2 e !Jl ,r titian ' � � y rspnovid"ut :workers co g ens aitort mP lnsur ante or infor»rafion. f m1'employees. Below is the policy and,%ob site . Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: C' 'f Attach a copy of the workers+com � �'K' �iv cl Failure to ecla.ratiou page(showing the policy number and expiration date}. secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of fine up to$1,5X00 and/or one-year imprisonment,as well las civil penalties in the fonru of a STOP WORK ORDER criminal lpna nes of a 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 Investigations of the DIA for insurance coverage verification. I do herebycerci nder the pains o .e fp dury tftat thein nrtnation provided above is true and corm,c Sr tZtre: Date: Phone#: r�ciat use only. Do not write in this area,to be compicted b or town o y ff� City or Tower; Per atit/Licrnse# Issuitrg Authotify(circle one): -------------- I. Board of Health Z Building Department 3.City/Town Cleric 4. Electrical Inspector S. Plumbing Inspector b.Other Contact Person• Phone#: I I i Information a i1d Instructions Massachusetts General Laws chapter 152 requires all emp foyers 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'fomping engaged in a joint enterprise,and includir-ig the legal representatives of a deceased employer,or the receiver ortmstee-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 os-local 6eensing agency shall withhold the issuance or renewal of a license or permit to operate a business or ito construct buildings in the commonwealth for any applicant who has not produced acceptable evideuce.of compliance with the insurance coverage required." Additionally, MOL chapter 152,§25C(7)states"Neither the cornmenwealth nor any of its politicttl 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 compi�mtely,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 eertificate(s)of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,arc not pito carry workers'ccsrnpensation insurance. If-an LLC or UP does have empioyees,a policy is required. Be advised that this affid- vit may be submitted to the Department of Industrial .Accidents for confirmation of insurance coverage.. Also'Ese 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,notthe Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' oocnpensation policy,please-can the Departn Department at the nruber.listed below, Self-insured companies-should enter their self-insuraii=e license number on the'approp=iate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department hes 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 wrilI 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 Addr-ess"the applicant should write"all locations in (city or town)."A copy of-the affidavit that has been officially siamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file fur fatem permits or licenses. A new affidavit must be filled out each year. When 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 poison is NOT,mquired 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 Departrnent of Industrial Accidtents Office of Investigations 600 Washington Street Boston, IIIA 02111 TeL #617-7274900�i=406 or -9 - I 77 MASSAFE Revised 5-26-05 Fax 4 617-727-7744 www.mass.govldia MO�TM TOWN OF NORTH ANDOVER • �_ * : o� OFFICE OF p BUILDING DEPARTMENT *�* ; 1600 Osgood Street Building 20, Suite 2-36 s�cwusttty North Andover,Massachusetts 01845 Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION Please print DATE: JOB LOCATION: —..,.Sq ra Number. Street AddressS&A-4 Mapes HOMEOWNER V . Name Home Phone Work Phone PRESENT MAILING ADDRESSelf y rA City Town Statep Code The current exemption for"homeowner was extended to include owner ' and to ailaw such homeowners to an indivi ��dwellings to two units or less engage dust 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 Persons)who owns a parcel of Iand on which helshe resides or intends to reside,on which then is,or is intended to be,a one or two family structures. A person who oonstzucts man 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 helshe muierstmuls the Town of North Andover Building Department insmrnrmumPon Ps and and he/ will Iy with saidprocedures and requirements. HOMEOWNERS SIGNATURE . APPROVAL OF BUILDING OFFICIAL Revised 10.2W5 Form Homeowners EmmPtion ROARD OF \PPEAIS 6Rg-95 11 CO.\SERVXFIOA G:4R-9530 IiE.11.aii 4R8-95 3 PI_A\IN ING 6W9535 Y K