HomeMy WebLinkAboutBuilding Permit #701 - 59 CHURCH STREET 6/16/2009TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One family
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
Repair, replacement
Assessory Bldg
Others:
Demolition
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
D,ES RIPTIOCN O�F\WOO�tK 1' BE PUFORMED;
ujoaoaJ
Iden 'ficat' Pl ase Type or Print Clearly)
OWNER: Name: (Z- Phone:
Address:GI U�(,� L• 0 �7
4
CONTRACTOR Name: Phone:
Address:
Supervisor's Construction License:
Home Improvement License:
ARCHITECT/ENGINEER
Exp. Date:
. Date:
Phone:
Address: Reg. No.
FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ 10 00 • Dy — �) 00, 00 FEE: $ 3 �—
Check No.: \ g- Z Receipt No. --'-2 Z 2
NOTE: Persons contracting yith unre i to ed co tractors do not have access to the guaranty fund
Signature of Agent/Owner. G>?' Signature of contractor
Location C h v `2
No. 7-() Date
TOWN OF NORTH ANDOVER
�O w
� A
+ Certificate of Occupancy $
.�"•
it
�sJ�cMustt�' Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $ •
TOTAL $
Check #1 2,0
r�
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:
FIRE DEPARTMENT - Temp Dumpster on site
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Located 384 Usgood street
yes no
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 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
o 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)
o 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 DEPARTNIENTMITORM07
Revised 2.2008
n
E9*
O
F=4
O
z
c c
o �
C H
a A CS
CL.Cc
c
� z o
CA
0 L
y EQ
7: m c
'r O
V :.s
Q
N
E�
7 15 m
u �
p� C
N R
mm
L
N
N
y • 0 3
cC12
;= C C
y O O
*4'E"
m
V.
av� m
Ql
m
o o
C3 y O LO
Z
• O Of
.3 C O c
Q 60 y CL C •O
= m CD N
V2 O ev L m
WLU
O D C�
LU
L 'E v v •N O
CL C -7
n o� OF
g
_ cco aoy� O
F.— _ 0-a�m
H
O
LLI
0
C4
19
W
W
W
CA
w°
cna
cn
co
b
w°
x
bo
C2
C
U
cdv
w
go
W
x
tw
a
w
0
Z4
W
a
x
to
a2
cn
w
�
`
x
biD0
w
W
�,
cA
o
2
cn
v
Q
cn
O
F=4
O
z
c c
o �
C H
a A CS
CL.Cc
c
� z o
CA
0 L
y EQ
7: m c
'r O
V :.s
Q
N
E�
7 15 m
u �
p� C
N R
mm
L
N
N
y • 0 3
cC12
;= C C
y O O
*4'E"
m
V.
av� m
Ql
m
o o
C3 y O LO
Z
• O Of
.3 C O c
Q 60 y CL C •O
= m CD N
V2 O ev L m
WLU
O D C�
LU
L 'E v v •N O
CL C -7
n o� OF
g
_ cco aoy� O
F.— _ 0-a�m
H
O
LLI
0
C4
19
W
W
W
CA
W
JZ F
O
u i
u 0
a
NCIO w�
O
F=4
O
z
c c
o �
C H
a A CS
CL.Cc
c
� z o
CA
0 L
y EQ
7: m c
'r O
V :.s
Q
N
E�
7 15 m
u �
p� C
N R
mm
L
N
N
y • 0 3
cC12
;= C C
y O O
*4'E"
m
V.
av� m
Ql
m
o o
C3 y O LO
Z
• O Of
.3 C O c
Q 60 y CL C •O
= m CD N
V2 O ev L m
WLU
O D C�
LU
L 'E v v •N O
CL C -7
n o� OF
g
_ cco aoy� O
F.— _ 0-a�m
H
O
LLI
0
C4
19
W
W
W
CA
Gerald A Brown
Inspector of Buildings
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
Please print
uw�
HATE: J � � goo?
JOB LOCATION: ,5 Nug-C14 �'Nl ) t—
N U eet Address M*q of
HOMEOWNER
Name Home Phone Work Phone
PRESENT MAILING ADDRESS
City Town StateZipCode
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)
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 constricts 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 un
minimum inspection procedures and�Ireqdrmnents and
xequftenents• 11 .
HOMEOWNERS
n
APPROVAL OF BUR DING OFFICIAL
Revised 10.2005
Form Homwwaw F.xamptim
the Town of North Andover Building Department
9 will Comply with said procedures and
BOARD OF \PPE:\I.S A-39-9541 C0NSER\'.1TI0N,6x8-9530 HE.\L•I'H 698-9540 PL.LVNI\G (M-95.15
The Commorrruealth ofMassachusetts
Department of Industrial Accidents
Office of Investigations
600 ITashin;ton Street
Boston, MA 02111
www nwss gov/dia .
Workers' Campensation lmkrance Affidavit: Builders/Contractors/Eiectricians/Piambers
1101ic Et Information
Name (Business/Orguization//In/d' ividual):_
Address: �i— / l� 2 Ci
City/State/Zip:
k! f
�eo
Phone
Are you as employer? Cheek.the appropriate box:
L ❑ I° am a employer with
4. ❑ I am a general contractor and I
employees (fun and/or part-time).*
2. ❑ I am..a. sole proprietor or
have hired the sub -contractors
listed
partner_
ship and have no employees
on the attached sheet,
These stili -contractors have
working for me in any capacity,
[No workers' comp. insurance
workers' comp. insurance.
5. ❑ We are a corporation and its
requ red.]
3. I an a homeowner doing all work
officers have a xercised their
right of exemption per MGL
myselt~ [NO•workin' comp.
c. 152, § 1(4), and we have no
insurance -required.] .t
.emplayses. [No workers'
comp. insurance required. ]
TYPe of project (requires:
6. Now construction
7. ❑ Remodeling
g• ❑ Demolition
9. I] Btulding addition
I Q.❑ EIOctrical repairs or additions
11.❑ PIumbing repairs or additions
12.❑ Roof repairs
ME] .Other
•Arty appiioatR that tdteeics iron'# I must also lilt
out the section blow rhowit:g their worked' compensation poitty mformahon
t Iiomeawnera who submit this affidavit indicating they ate doing all work and than has outside conttacters must
ICaatractots ilial check this box must attached an add,:tioaW shat show' . submit a nein afttdavit indicating succi.
mg the name of the sub -contractors and their workers' cot -4
ant a}t
pcic! irt
enpuyecat isproviung:works' compensation f nnaion.
infor»atorrcr�PYe
Below is Use policy amtjob site .
Insurance Company Name:
Policy # or Self -ins. Lie. #
Expiration Date:
Job Site Address:
Ciiy/Ststmr ip:
Attach a copy of the workers' 'campensation policy declaration page (showing the policy number and expiration date}. .
Failure to secu a coverage as required. under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine u.Tp to $1,500,00 and/or one-year imprisonment; as well 8S civil penalties in the faun 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
Investigations of the DIA for insurance coverage verification,
I do hereby cerci r�nder the
pe� tyre the infor»>amon Provided above is &ue and eonrct
Dare U /C. ad
Wkiad use only. Do not write is this area, to be compietad or town o
by mecca(
City or Town: Permit/License #
Issuing Autbotity (circle one):
1. Board of Health 2. Building Department 3. City/Tow u Cleric 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person• Phone #:
Information a nd Instructions
Massachusetts General Laws chapter 152 requires all emp Icy= 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'fbmgoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or tnrstee 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 shat not because of such employment be deemed to be an employer."
MGL chapter 152, 925C(6) also states that "every state ow- local licensing agency shall wkbhold the issuance or
renewal of a license or permit to operate a business or to construct bulldings in the commonwealth for any
applicant who has not produced acceptable evidence air compliance with the insurance coverage required"
Additionally, MOL chapter I52, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the porformanee of public work until evidence of compliancx with the insunmce
requirements of this chapter have been presented to the carttracting authority."
ApplicenEa ..
Please fill out the workers' compensation, affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub -cont actors) name(s), addrms(es) artd phone numbers) along with their certificates) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employers other than the
members or partners, arc not required to carry workers' co=npensation insurance. Ifan LLC or LLP does have
employees, a policy is required. Be advised that this afndmvit 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 rete rnmd to the city or town that the application for the permit or license is being requested, notth 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 nu rmber. listed below. Self-insured corrrpanies should enter theft
salf-insurance'license number on the appropriate tine.
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 yoir to fill out in the event the Office of Investigations has to contact you regarding the applicrrt
Please be sure to fill in the permit/license number which Will be used as a ref --=c: number. In addition, an applicant
that must submit multiple permit/iiconse 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 starnped 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. 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 pers6n is NOT.required to complete this affidavit
The Office of Invesiisptions 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 Depalnent's address, telephone and fax number.
The Commonwe<h of Massachusetts
Department of industrial Aacidmts
Office of Investigations
600 Washington Street
Boston, MA 02111
TeL # 617-72.7-4900 Ext 406 or I-877-MA.SSAFE
Fax # 617-727-7749
Revised 5-26-(15 WvAv-mass.gov/dia