HomeMy WebLinkAboutBuilding Permit #722 - 6 Berkley Road 6/22/2009Permit NO: 7,g 2
Date Issued: �0 v
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
U
TYPE OF IMPROVEMENT
PROPOSEDD-LISE
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
Septics 1l1/ell `
Floodplain Wetlands
Watershed °District
Water/Sewer
,..
DESCRIPTION OF WORK TO BE PREFORMED:
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t�rS
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Identification Please Type or Print Clearly)
OWNER: Name: Phone:
Address:
ARCHITECT/ENGINEE
Address:
Phone:
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: $ ' 0 Ori FEE: $ �/� D a
Check No.: -7 Receipt No.: ,�� y y
NOTE: Persons contracting with unregisteredcractors do not have access to the guaranty fund
"-I✓✓ �� —
Location r �f f L F//f el
t �� D
No. 2 Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
'�s':��°„E<�• Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # 1-11-
22"1 44 e"I
B/din inspector
I ..
Plans Submitted
Plans Waived Certified Plot Plan Stamped Plans
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`TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/Massage/Body Art
Swimming Pools
71 4 ,
1Weil
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
I CONSERVATION
I COMMENTS
II 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
I.
11 Conservation Decision:
Comments
'Water & Sewer Connection/Signature & Date Driveway Permit
`DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT Temp Dumpster n site yes
'no -
Located gat 1 24 Main Street- ti
Fire Department signature/date 7- s
�01
E r-.nKAKAFti- _R
Dimension
Number of Stories:
Total land area, sq. ft.:
Total square feet of floor area, based on Exterior, dimensions.
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 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
'I t ❑ 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
i
❑ 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)
LiEngineering Affidavits for Engineered products
NOu f: 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
j ❑ Workers Comp Affidavit
o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
E 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
all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
it the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
ist be submitted with the building application
Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2008
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TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
1600 Osgood Sbvd Building 20, Suite 2-36
North Andover, Massachusetts 01845
Gerald A. Brown Telephone (978) 699-9545
InspwW of Buildings a. Fax '(978) 688-9542
HOMEOWNER LICENSE EXEMPTION
Please urint
DATE: -
JOB LOCATION: elev
V 7 3
Ntaiw Street Address M*11&
HOMEOWNER /_0 w 4r -C- err,
-
Name Home Phone I walk Phone
PRESENT MAILING ADDRESS
Ci ty toym State Zip tode
The current exemption for "homeowners" was extended to include owner-o=ipied dwellings to two mots or less
and to allow swk homeowners to engage an individual for bin who does not possess a license, provided that the
owner acts as supervisor). State Building (Code &zwm 108.3.5.1)
DEFINMON OF HOMMArNER,
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" M511MOS rc4*nsft* for complimoes with the State Building Code and other
Applicable codes, by-laws, rules and regulations.
The undersigned "homeowner" certifies that Wshe understands the Town of North Andover Building Department.
inspection procedures and rapirenizats and that he/she will comply with said procedures and
requirements.
HOMEOWNERS SIGNATURE.
I
APPROVAL OF BUILDING
Rid 10.2005
Form Homeowners F=mpfion
BOARD OF \.PPE. -U -S 689-9541 C0NSERV-):F10.N698-953n ITE -U-111688-95 .1 PLANINNIG (4g-9535
Date.
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that . licl.x.l ... 10,19 0.
has permission to perform ..... .
plumbing in the buildings of AR\
at..6 ... F. -r I �_q.orth Andover, Mass.
Fee. ...... Lic. No.//O.�.f ... ........ .......
�ILUMBING ll�ZC.4j
Check #
8119
1
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Location
Owners Name
Date
Permit #
Amount
Type of Occupancy /�J
New Renovation Replacement E] Plans Submitted Yes ❑ No ❑
1WMIRES
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(Print or type) J 9�0 I ie -+-J Xy#-
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Installing Company Name 1� `Yt 7
Check one: Certificate
❑ Corp.
Partner.
ri Firm/Co.
Name of Licensed Plumber:
Insurance Coverage: Indicatethit type of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity ❑ Bond ❑
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
threeinsurance
Signature I
Owner 1:1 Agent ❑
I hereby certify that all of the details and information I have submitted (or en ed) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installatio p rf, e un t Issu r this application will be in
compliance with all pertinent provisions of the Massachusetts S ate m 'ng Cod a hap e of the General Laws.
By: Tigna ureo is e u er
Type of Plu Bing License
Title
City/Town /icense um er Master Journeyman 13APPROVED (OFFICE USE ONLY
V
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The Common►vealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 NMashing-bn Street
Boston, MA 02111
f s WWW MaSLgorldia
Workers' Compensation Insitrance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Infar>gation Please Print Legibly
Name (Business/Drpnirdtion/individaal): I
City/State/Zip:
Phone #:-.�gQ j_l�
Type of Project (required):
6. ❑ New construction .
7. ❑ Remodeling
8. Q Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑.Other
Homeowners who submit this affidavit indicating they are doing all work end then ham outside c ntmctm must submit new affidavit indicating such.
=Contrnctors that check this box mustattached an additional shear showing the name of the sub-cantmctors and their workers' cer.:p. polite • irfamwion.
I ant an employer that is providing: workerscompensatwn insurance for my employees. Below is the policy rind job site
information.
Insurance Company Name:
Policy 4 or Self -ins. Lic, 4:
Expiration Date:
Job Site Address: City/State/Zip:
Attach a 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 $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 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
o. fPerlrrry that the information provided above is hme agd correct
use only. Do not write m this area, to be completed by city or town official
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2 - Building Department 3. City/Town Clerk 4. Electri
6. Other cal Inspector 5. Plumbing Inspector
Contact Person:
Phone #.
Are you an employer? Cheek.the appropriate box:
1 ❑ I am a employer with
4. ❑ I am a general contractor and I
ployees (full and/or part-time).*
have hired the sub -contractors
2. I am.a:sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These subs -contractors have
working for me .in any capacity,
[No workers' comp. insurance
workers' comp. insurance.
5. ❑ 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.] t
employees. [No workers'
comp. insurance required_]
;Ally applicant that Checks bos: # l must also fill out the section below showing their workats' nom sat'
Type of Project (required):
6. ❑ New construction .
7. ❑ Remodeling
8. Q Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑.Other
Homeowners who submit this affidavit indicating they are doing all work end then ham outside c ntmctm must submit new affidavit indicating such.
=Contrnctors that check this box mustattached an additional shear showing the name of the sub-cantmctors and their workers' cer.:p. polite • irfamwion.
I ant an employer that is providing: workerscompensatwn insurance for my employees. Below is the policy rind job site
information.
Insurance Company Name:
Policy 4 or Self -ins. Lic, 4:
Expiration Date:
Job Site Address: City/State/Zip:
Attach a 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 $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 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
o. fPerlrrry that the information provided above is hme agd correct
use only. Do not write m this area, to be completed by city or town official
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2 - Building Department 3. City/Town Clerk 4. Electri
6. Other cal Inspector 5. Plumbing Inspector
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 apa-tments 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 busioesi or'*o construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence.of 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 insuranet
requirements of this chapter have been presented to the contracting authority." \�
Applicants J
Please fill out the workers'- compensation• affidavit compimtely, by checking the boxes that appiy.to your situation and, if
necessary, supply sub=contractors) name(s), addresses) 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 affidavit 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 retumed 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 mnrnber listed below. Sel{ hw�„pd ch**epaniPs �he�sld enr� +41e;r
self insurance license number on the*appropri 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 you to fill out in the event the Office of Investigations has to contact you regarding the applicarrt.
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 writs "all locations in (city or
town)." A copy ofthe 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 compiete this affidavit
The Office of Investigations would Bice 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 Washington Street
Boston, MA 02111
TeL 9 617-727-4900 ext 406 or 1-977-MASSAFE
Fax 4 617-727-7749
Revised 5-26-05 www.mass.gov/dia