HomeMy WebLinkAboutBuilding Permit #471 - 59-61 PARK STREET 3/6/2009BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION I
Permit NO: Date Received
Date Issued: ` v
IM ORTANT: Applicant must complete all items on this page ic
LOCATION - 1 q r)<,
Print S'C�
PROPERTY OWNER °��►'� /V-
►45,.A 2( Cmc' Print
MAP NO: ' PARC L � Z KING DISTRICT: Historic District yes
Baal. tope Machine Shop Village yes
v Atte.+ ,6
16 0
o �
4L i ey
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One family
Addition
Two or more family
Industrial
Alteration Vl*"
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:
(C CCVA-'--L-S�t A02)l4►nCal Sah wOL-11 Fla PCO vit , ,if/ew C-ePg'tt'cC
Identification Please Type or Print Clearly)'
OWNER: Name: S`i� ��� S'lg`� Phone: 773
Address: SS F22"LeT kk LA c)2
/40-/a -, of ew s
CONTRACTOR Name: 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: $ 2 Li. a 0 FEE: $ a
Check No.: -� I d I Receipt No.: a ld6--�Oe
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
;Signature of Agent/owner Signature of contractor
C
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
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE REJECTED DATE APPROVED
Reviewed on Signature
Reviewed on Signature
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 yes,
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Locatea 364 Usgooa Street
no
Dimension
Number of Stories: 3 Total square feet of floor area, based on Exterior dimensions. YOX So
Total land area, sq. ft.: 1 3 3S'8
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes
i.
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
o 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)
o Building Permit Application
o 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 Application
Revised 2.2008
Location �� & =
No. L-- Date - 4 .01
N°RTM
TOWN OF NORTH ANDOVER
o R
;
Certificate Occupancy
$
;
��
of
s"•^°' E<�
+cNus
Building/Frame Permit Fee
$�
Foundation Permit Fee
$
Other Permit Fee
$
TOTAL
$
V 1
Check #
21 b,� k
V Building Inspector
-� The Commonwealth of Mj?ssachuseft
Department
of Ind
Depart
ustrial Accidents.
KI Office Of Investigations
600 Washington Street
Boston MA 02111
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Workers' Compensation Insurance -Affidavit: Blinders/Contractors/EleciriciateslPlumbers
apiica.nt Information
..�aa� r rani LE`glbl
Name (Business/Organization/individual): S �I.u,K
Address: S Sy�°S�
City/Stat✓/Zip: .�/��� ,�i v,
C c ` x14 f Phone 7 6- Ck 3 —! i 6�
Are you an employer? Check the appropriate box:
1. ❑ 1 am a employer with 4. ❑ I am a general c
employees (full and/or part-time).*
2. ❑ 1 am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
)Qeqred.]
a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
ontractor and I
have hired the sub -contractors
Iisted ort the attached sheet I
These su,b_contractors have
workers' comp. insurance.
❑ We are a corporation and its
officers have exercised.their
right of exemption per MGL
c. I52, § 1. (4), and we have no
employees, [No workers'
comp, insurance re . d
Type of project (required):
6. ❑ New construction
7. modeling .
8. ❑ Demolition
9• ❑ Building addition
10:❑ Electrical repairs or additions
l 1.❑ Plumbing repairs or additions
12:❑ Roof repairs
quire ] 1.3•7 Other
*Any appii ant.that checks box # 1 .must also fill out the section below showing their workers' compensation policy information.
t.
riomeowuers wliu suUinil .flits &iudexit iudicatirfg L`�ey ere uuiii� : t=.r;.r k olid then hire outside coniraciors ✓nasi submit a new arnuavit irdi� ting s ch.
xContractors Thal check this box must attached an additional sheet showing the name of the s. „��tors and their whoa n affi avir .., :_____.•-
mm,
•••,� cowtoyer rnar cs provutine workers' compensation insurance for +�' employees. Below is the oft -J .._.... �.,,...
information p cy and job site
Insurance Company Name:
Policy # or Self -.ins. Lic. #:
Expiration Date:
.lob Site Address:
_ City/State/Zip:
Attach s 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 11,500.00 and/or one-year imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 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 cartO, under the pains and penalties of perjury that the information provided above is true and correct
q7e - 603-116-4
Official use on'p. Do not write in. this areg to be completed by city or town off
City or Town:
_ Permit/License #
Issuing Authority (circle one):
1. Board of health 2. Building Department 3. City/Town
6. Other Clerk 4. Electrical Inspector S. Plumbing Inspector
Contact Person:
Phone *-.
Information a.nd 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 "..very 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 includiTi.g 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 bean employer."
MGL chapter 162, §25C(6) also states that "every state a r 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 mf 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 -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' compensation insurance. If an LLC or LLP does have _
employees, a policy is required. Be advised that this affil-avit 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 reg&-rdi si the iam, or if you are required to obtain a workers'
compensation policy; please call the Department at the nmim- ber.listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officiais
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 permitAicense number which will be used as a reference number. In addition, an applicant
that must submit multiple pennitthcense applications in ariy 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. Nhlbem 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 burnleaves 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 Wash-ington Street
Boston, MA 02111
Tel. 4 617-727-4900 e= 406 or 1-977-MASSAF'E
Revised 6-26=05
Fax # 617-727-7749
vAV%kr.mass.govldia
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+ NORTh
TOWN OF NORTH ANDOVER
o`t,,
OFFICE OF
BUILDING DEPARTMENT
1600 Osgood Street Building 20, Suite 2-36
�,S •••.o ^`tom
North Andover, Massachusetts 01845
Gerald A. Brown Telephone (978) 688-9545
Inspector of Buildings Fax (978) 688-9542
HOMEOWNER LICENSE EXEMPTION
Please vfint
DATE:
JOB LOCATION:
Number Street Addressp/1,�
HOMEOWNER 6w h �i . ? �7v 6 — b S �
Name Home hone Work Phone
PRESENT MAILING ADDRESS S�S �� f LR 1, Q /�
City Town State Zip Code
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 helshe resides or intends to reside, on which there is, or is intended
to be, a one or two family structures. A person who constructs 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 understands the Town of North Andover Building Department
minimwn inspection procedures and requirements and that he/she' ill with said procedures and
requirements.
HOMEOWNERS SIGNATUI
APPROVAL OF BUILDING
Revised 10.2005
Form Howwwru><s E=ption
ROARDOF \PPEALS 688')541 CONSER\'.VRO\ 6.,188-9530 ITE.11.;P f 688-9540 PLANNING 688-9535