HomeMy WebLinkAboutBuilding Permit #934-16 - 60 RUSSELL STREET 3/4/2013ON �D W BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit Nok/l 4LI '
Date Issued:
RTANT:
LOCATION
Date Received
must complete all items on this
�e.� .< Z-�—
N I� � Print
PROPERTY OWNER is o A-1,1 L)
Print 100 Year Structure yes 0
MAP 074 PARCEL:XYZ ZONINGIDISTRICT: Historic District yes no
0
Machine Shop Village yes f)
TYPE OF IMPROVEMENT
PROPOSEDUSE
Residential
Non- Residential
0 New Building
0 One family
0 Addition
0 Two or more family
0 Industrial
0 Alteration
No. of units:
0 Commercial
0 Repair, replacement
0 Assessory Bldg
0 Others:
0 Demolition
0 Other
0 Septic, 0 Well,
E! Floodplain 0 Wetlands
0 Watefshedi District
0 Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
,0,&
0 214
Identification - Please Type or Print Clearly
OWNER: Name: Nl(�Iojq� Phone: q76`4_21-522-7
Address: 66
Contractor Name:
Email:
Address:
Supervisor's Construction License:
Home ImDrovement License:
ARCH ITECT/ENGI NEER
NO 411 A (Qc, ve r. M A 619LI5
hone:
Exp. Date:
Date:
Phone:
Address: Reg. No.
FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED C041 -RASED ON $1 PER S.F.
Total Project Cost: $ V, -I --,1 0 q�_ FEE:
' A) .2,;d F& —
Check No.: Receipt No.(
NOTE: Persons contracting with unregistered contractors do not have access to the g"ruaranityfund
Plans Submitted El Plans Waived El Certified Plot Plan 11 Stamped Plans El
TYPE OFSHWERAGE DISPOSAL
Sewer
Publhic Sewer El
[
Tanning/Massage/Body Art El
Swimming Pools 0
well El
Tobacco Sales El
Food Packaging/Sales El
Private (septic tank, etc. El
Permanent Dumpster on Site El
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On
COMMENTS
Signature
CONSERVATION Reviewed on Sianature
COMMENTS
HEALTH Reviewed on Sianature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/ Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIJ R E D E P A RT, M E N T T 6'm P k
Aj- jDump§ter on site yes
n
a t'! 2" St,
Fire do
tme
A,
COMM"EINTS,
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.$10041000 fine
NOTES and DATA — (For department use)
L3 Notified for pickup Call —Email
Date Time Contact Name
Doc.Building Peimit Revised 2014
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
4� Copy of Contract
4� Floor Plan Or Proposed Interior Work
Engineering Affidavits for Engineered products
OTE: 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
,6 Photo Copy of H.I.C. And C.S.L. Licenses
Copy Of Contract
Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (if Applicable)
Mass check Energy Compliance Report (If Applicable)
Engineering Affidavits for Engineered pro ucts
TE: 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
2012 IECC Energy code
Engineering Affidavits for Engineered products
E: 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
Doe: Building Permit Revised 2014
Location '
No Date '
/
TOWN OF NORTH ANDOVER
Certificate ofOccupancy
Building/Frame Permit Fee
FoundotionPermitFee $__-__'~
Other Permit Fee $_----_
TOTAL $-----_'�
~�
Building Inspector
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Gerald A. Brown
Inspector of Buildings
Please prin
TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
1600 Osgood Street, Building 20, Suite 2035
North Andover, Massachusetts 0 1845
HOMEOWNER LICENSE EXEMPTION
BUIDING PERMIT APPLICATION
DATE: 31& , po i (,
JOB LOCATION: (n Sile-H
Number Street Address
Telephone (978) 688-9545
Fax (978) 688-9542
Map/Lot
HOMEOWNER N,c�alo� 71�orctckfho NJA 979-123-52,97
Name Home Phone ' Work Phone
PRESENT MAILING ADDRESS
I i 5t. Nrpi Anh,-c #1 A 0 � 2 L) �
City Town State Zip Code
The current exemption for "homeowners" was extended to include -owner �occnpied dwellings of one or two family
dwellings and to allow such homeowners to engage an individual for hire who does not possess a license, provide
that the owner acts as supervisor.
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 dwelling, attached or detached structures accessory to such use and/or farm structures. A
person who constructs more than one home in a two-year period shall not be considered a homeowner. (780 CMR
Section I I O.R5.1.2)
The undersigned "homeowner" assumes responsibility for compliance with 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
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements.
HOMEOWNERS SIGNATURE _,�/ dlf,04��
APPROVAL OF BUILDING OFFICIAL
Revised 8.2015
Form Homeowners Exemption
BOARD OF APPEALS 688-9541 cONsERvATi6N 688-9530 HEALTH 688-9540 PLANNING 688-9535
The Commonwealth ofHassachusetts
E_- Qa Department ofindustrialAccidents
I Congress Street, SWte 100
Boston, MA 02114-2017
www. mass. grovIdia
vit: Builder5/Contrletors/FIeqtriciaiislPlWbers.
I -
workere compensation Insurance Affida 1jNGAUTj1OFJTY-
TO BE FILED WITH TBE FER'�ffT Pkase Print Leqbl
db_)
Mormation
Name (Business/Oigabizationadividal):
Address* �h Eisst1l S4mJ
City/State/Zip- N,0�- An4vt(, A 61N(, Phone#:
Are you an emp�oy�r? C4eck tfie appropriate box:
art -time,).*
1.0 1 am a employer Vith___��MP'oy .. (f"11 andlor P
2. 1 am a sole proprietor or partnership and have no employees Working for me in
any capacity. LNo -workers' comP. insurance required.]
3.��Iru h vner doing all -Work mYselt tNo workers' comp. insurance required.] T I
I am: meo g contractors to conduct all work on my property. I will
4. homeowner and va be hirin
ensure that all contractors either hay., workers' oMpensation insurance or are sole
proprietors withn'o',161611ployees.
listed on the attached sheet.
5.Fj I am a general contractor and I have hired the sub-0011tra tos . t
These sub-contrat�,�'��e'� �6pioyees and have workers comp. msurance-
6. n We are a corpor?,tigii PPa its ojEdc6rs have exercised their right of 'exemption Per MGL c-
� erupldye�, LNO -workers, comp. insurance required.]
15? sla) andWehaii6ji
5 Z,2� �
Type ofzproject(Tequired),
7. ' '
�-066nstr6diion
,e
,in dez,
9. Demolition
10 Building addition
11.[] Elec�rical wpPirs or additiggs
12,Ep r-umDing repairs or additions
13% Fj Ro6f roair6
14.r] 0fl1er_____.
. I I below showing their workers' compensation policy information-'
0 Idavit indicating such -
*Any applicant that ch0�-ksb6k,4pid�t fill out the section
-9 all work Pd the- hire outside, contractors must submit a now aff
or not fhoseentigeg, have
I Homeowners who subinit-this artA�a�jt indicating they are dOi
tContractors that check ihis �lol� must attached hu additional sheet showing the name of the sub -contractors and state whqther
" " ' have employees, they must pro -vide their workers' COMP. Policy number -
employees. If the sub -contractors
orkeps' compensation insurancefor my eynP16yees. Below is thepolicy and)oh slt�
lam an employer tizat isproviding-W
information.
Insurance CompanY Namc):.
Policy # or Self -ins. Lie.
Expiration Date:.
Job Site Address, City/State/Zip:
Attach a copy of the wol:kers' compepsation policy declaration page (showing the policy number and expiratiou date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a ab 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 $250.00 a
day against the violator. A copy of this statement May be, forwarded to the Office of fuvestigdtiOns Of the DIA for insurance
coverage verification. fp erju ry t1z at t1i e inform ation provided ah ova is tru e an d correct
7do he�reb
v cV�dfy under thepains andpenalfies o
17
- to he completed by city or town officiaL
fficial use only. Do not -write in t1lis area,
0j,
City or Town:
Permit/License #.
issuing Authority (circle One):
1. Board of Health 2. Building I)epartment 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Phone 9:
Contact
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their ej#X6y�es.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contra'ct ofw�,
express or implied, oral or written."
An employer is'deffibd as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in ajoint enf&prise, and including the legal representatives of a deceased employer, or the
receiv6k'6r, trusidd dan individual, partnership, association or other legal entity, employing emplbypp§. - However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupian"t' o'f 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 b6 deemed to be an employer. -
MGL c i hapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of alicense or permit to op6rate a business or to construct buildings in the commonwealth for any
applicant,wh(j has not produced -acceptable evidence of compliance with the insurance coverage ieq'uired."
Additionally, MGL chapter 152, §25C(l) states "Neither the commonwealth nor any of its political subdivisions shall
enter intp any contract for the performance of'public work until acceptable evidence of compliance with the insurance
requirements of th i I s chapter have been presented to the contracting authority."
Applicants
Pleasb fill out the Workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
nec6sary, supply sub'contractor(s) 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 orLLP do,&S have
employees, a policy is required. 1�e advised that this affidavit maybe submitted to the Department of Industrial
Accidents for confirmationof 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 requ�steq, not the Department of
IndustrialAccident's. 'Should you have any" questions regarding the law or if you are req*ed to obtain aw'6rkers'
compensatioA policy, please call the Department at the number listed below. Self-insured companies s�o�ld enter their
self-insurane'o license 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 ofInvestigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
thai must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy infbimation (if necessary) and under "fob 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 now 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 NOT required to complete this affidavit.
The Department's address, telephone and fbx number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston, AIA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-NUSSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia