HomeMy WebLinkAboutBuilding Permit #625 - 60 LEANNE DRIVE 5/15/2009BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO:
Date Issued:
IMPORTANT:
Pplicant must
I/I A
ZONING DIST]
Y.
Date Received
10
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New BuildingOne
fam�brefamily
Addition
Industrial
Alteration
No. of units:
Commercial
epair, replacement
Assessory Bldg
Others:
Demolition
Other
'Septic Well
Floodplain, etlands.
VVatershed'District `
Nater /Sewer _
r
OWNER: Name:
IPTION,OF ARK TO BE PREFORMED:
Please Type or Print Clearly)
Ph
Jr '
ARCHITECT/ENGINEER Phon
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: $ S ® ® C) FEE: $ J
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
. 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 SECTIONSTOR OFFICE USE -ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS _
CONSERVATION
COMMENTS
' HEALTH .
c
COMMENTS
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:
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
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
a 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 2.2008
Locatio 1"o
No. e�A-- Date 7
AORTN TOWN OF NORTH ANDOVER
Certificate of Occupancy $
14-t Building/Frame Permit Fee $ M
4
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
22U4 1
Building Inspector
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The Commonwealth of Massachusetts
k1 ! Department of industrial Accidents
Office of Investi rations
600 Iflashington Street
Vj a �' Boston, MA 02111
t www_mms gov/dia .
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers
501iCant Infnrrnafinn
Name (Businessiorganizafion/individual):_
Address:
City
Phone #: .
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ❑ 1 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 sheet t
ship and have no employees
These suis -contractors have
working for me .in any capacity,
[No workers' comp, insurance
workers' comp. insurance.
5. ❑ We are a corporation and its
reqmre
officers have exercised their
3. 1 am a homeowner doing 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_)
Type of project (required):
6. ❑ N onstrtructioir
7. Remodeling
8. D Demoiition
9. [] Building addition
10.0 Electrical repairs or additions
11 -11 Plumbing repairs or additions
12.❑ Roof repairs
13.❑.Other
*Any appfi-In that checks ba# I must also 8A out the section below --,g their workers' 6ompensafiOni
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside c nnactors must licy rubmit aan- affidavit indicating such.
4contractors that check this box mug strsched an additional shoot showing the name of the sub -contractors and their workers' temp. pclic, infiln don.
t am an employer that is promdmg:workers' compensation insurance for nV employeM Below is the policy and job site .
information.
Insurance Company Name.
Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address: City/State/Zip:
Failure to s
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration dated .
ecure 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 $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 11 hereby cerdry under enalties of perjury that the information provided aboye is trite and correct
OffJciat use only. Do not write in this area, to be complPMed by city or town off daL
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
Lntact Person: Phone #•
Information and Instructions
Massachusetts General Laws chapter 152 requires all emp l oyers 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 ortnastee 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 o,.r- local licensing agency shall withhold the issuance or
renewal of 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 insurance'coverage required"
Additionally, MGL chapter 152, §25C(7) states "Neither dile 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 orthis chapter have been presented to the cor &acting 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 cavy 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 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'
compensation policy, please -call the Department at the nurnber listed below. Self-insured companies should enter their ;
self-insurance"lieense number on the appropriate line.
City or Town Officials
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 permit/license number which vvilI 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 write "all locations in (city or
town)." A copy of file affidavit that has bem 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 fume 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 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 Departineni's address, telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Ras ton, MA 02111
TeL # 617-7274900 ext 406 or 1-8.77-MASSAFE
Fax 4 617-727-7749
Revised 5-26-x5 www.mass.gov/dia
t Noerp TOWN OF NORTH ANDOVER
o`''�•e ,`,�� OFFICE OF
w
BUILDING DEPARTMENT
1600 Osgood Street Building 20, Suite 2-36
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:_
Number Street Address
HOMEOWNER
Name ' Home Phone
PRESENT MAILING ADDRESS
City Town
State
17�/f/-el, 7-z- -177Z
Work Phone
)f 1
Zip Code
The current exemption for "horreownef-" was e5ile-nded W include owner•„vcuyied dwellings to two unit; pia r.�s
and to allow such homeowners to engage an individual for hire who does not possess a hcense, provided that the
owner acts as supervisor). State Building (Code $ecction 108.3.5.1)
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of tend 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 constructs more that one home in a two-year period shall not
be considered a homeowner.
The undersigned "homeowner" assnm,es responsibility for compliances with the State Building Code and other
Applicable codes, by-laws, nrles and regulations.
The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department
inspection procedures and rapremeuts and that �ewill comply with said procedures and
HOMEOWNERS
A
APPROVAL OF BUILDING OFFICIAL
Revised 10.2005
Foam Homeowners Eumpfm
is
BOARD OF \PPE:U.S 698-9541 CC)NSERV.):F1Ot 688-9530
11E_kLM 699-9540 1 1 PLANNING rg8-9535