HomeMy WebLinkAboutBuilding Permit #861 - 58 PETERS STREET 6/5/2012BUILDING PERMIT
TOWN OF NORTH ANDOVER M1 • -< - p
APPLICATION FOR PLAN EXAMINATION * ;
Permit Nn U Date Received ase A0 Argo
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
[Addition
❑ Two or more family,
❑ Industrial
❑ Alteration
No. of units:
[Vcommercial
❑ Repair,. replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
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ARCHITECT/ENGINEER Ywin Tir' i`r�/6 Phone:,-og^ Fr 4960
Address: S
FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ .;tan 0, FEE: $ D -LA �
Check No.: 3-1 2-- Receipt_ No.--. 253Jr1
NOTE: Persons contracting -with uArygistpred contractors do not have access to the guaranty fund
a/V
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan 19""' Stamped Plans N
TYPE OF SEWE", GE DISPOSAL
G40 �1,i �_.,
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
PLANNING & DEVELOPMENT
COMMENTS
DATE A PR VED
DATE REJECTED DAT APPROVED
ACONSERVATION ❑ ❑ 7 ��
COMMENTS MV\ -Q
DATE REJECTED DATE APPROVED
HEALTH ❑ ❑
COMMENTS L12- z C c c n> d r -k- A,-�
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Drivewav Permit
Located at 384 Osgood Street
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
DoC.Building Permit Revised 2007
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
❑ 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 2.2007
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Location
No. 16 Date (PArA7,
Check #-3'1 \ &2-
25359
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee
Foundation Permit Fee $
Other Permit Fee
TOTAL
Building Inspector
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Page I of I
http://sz0006.wc.mail.comcast.netlservicelhomel—INIAConstructionLicence.jpg?auth=co&l... 4/19/2012
The Commonwealth ofMassachusetts
Department oflndustrialAccidents
Office of Investigations
600 Washington Street
s�
Boston, MA 02111
www,massgov/dia
Workers' Compensation Insurance Affidavit: EuildersiContlractors/Electricians/PIumbers
mlicant ynfnrmn inn
Name
Address:3
City/State/Zip :sG�Q ��
a �'A oa»?
S •_
Phone #: .' $ —(�' -! 02 S'dQ
Are you an employer? Check the appropriate box:
1.51
am a employer with 13_
4. '
❑ I am a general contractor and I
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or
have hired the sub -contractors
listed
partner-
on the attached sheget. I
ship and have no employees
These sub -contractors have
working for me in any capacity,
[No workers' comp, insurance
workers' comp. insurance.
5. El We are a corporation and its
required.]
3. ❑ I am a homeowner doing
.officers have exercised their
all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, §1(4), and we have no
insurance required,]r
employees. [No workers'
comp, insurance re aired ]
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. F1 Roofrepairs
13.❑ Other
*Any applicant that checks box #1 must also fill out the section below showing their workers, compensation policy mformation, I
i Homeowners who submit this affidavit indicating they are doing all work and then hire outside con
#Contractors that check this box must attached an additional sheet showing the name of the sub-ctractors must submit a new affidavit indicating such.
ontractors and their workers' comp, policy information.
information,
lam an employer that isproviding workers' compensation insurance for my employees Belo w is the policy ancl job site
Insurance Company Name: S p � l / Tno,Veler (z
Policy # or Self -ins. Lie. #: D TA C R_- R - 9�B' K
�� — �"
P - ( ORExpirationDate:�7�J�
Job Site Address: J $ }�' r AA ,
City/State/Zip: A, Ah
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required uhder 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 ofthis statement may be forwarded to the Office of
Investigations of the DIA, for insurance coverage verification.
r do Hereby certify under the pains and pen/aJlties ofperjury that the information provided above is true and correct.
=W�W,K"
SO R�
vffrcrac use ondy, DO not write in this area, to be completed by city or town offcial.
City or Town: 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 insurancd 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 ceriificate(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 cavy workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial
Accidents for confirmation ofinsurance 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 D eparEment 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.
PIease 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 (ifnecessary) 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 pe
yrmits 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 NOTrequired 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 Co,-monwc-awa of M assachusetts
i?epaiiixien$ o£Zndustrial Accidents
Ofte of ]hmtigattons
600 Washhigton Street
Boston; MA- 0211 X
Tei. # 617-727-4900 ext 406 or 1,877 mASSAFE
Revised 5-26-05 Fax # 617,727-7749
WWw.ln.as.s govjdia